Beatrice, Artie, Phil, and Abby discuss the meaning and history of "the social determinants of health"—all of the social and political factors that impact individual and population health beyond what healthcare traditionally focuses on—and what becomes possible when we recognize that health is political.

This episode was originally a patron exclusive (Original air date: 08/15/22). If you enjoy this episode consider supporting the show at patreon.com/deathpanelpod to get access to all of our second weekly bonus episodes that come out every Monday in the patron feed.

Please Note: transcript is from original airing, timestamps correspond with the beginning of the original episode, which starts at 00:01:16 on the unlocked version.

Artie’s Introduction in Unlocked Version: Hey everyone, Artie here with a quick note that Bea and I’s book Health Communism will finally be officially out next week, this coming Tuesday, October 18th. So, if you haven’t already pre-ordered a copy, please do. Pre-orders are a huge help to first time authors like us, and we can’t wait for everyone to get their hands on this book. Which brings me to the second thing, since Health Communism is out this week, we wanted to share with you the episode we did on what are called the “Social Determinants of Health [(or, SDoH)]” which should be a great preamble to anyone about to read Health Communism, and which was previously locked to the patron feed. So if you enjoy this episode, consider becoming a patron at patreon.com/deathpanelpod get that book and we’ll see you with a brand new episode on Monday in the Patron feed.

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Abby Cartus  0:01  

That's the level of the public health intervention that is incentivized by kind of like the academic research apparatus. And it never, never never, because I mean, you can't, I could not say to the NIH, I'm going to accomplish like, I'm going to abolish the value form. You know what I mean? I'm going to accomplish a total overhaul of the political economy of the United States because my findings about inequalities and COVID deaths really seem to suggest that something is going wrong here.

Beatrice Adler-Bolton  0:55  

Welcome to the Death Panel. Patrons thank you so much for supporting the show. To become a Patron: www.patreon.com/deathpanelpod. We could not do any of this without you. If you'd like to help us out a little bit more. Share the show with your friends, post about your favorite episodes, pre-order Health Communism, or request it at your local library and follow us @DeathPanel_. 

So today Artie, Phil and I are joined by friend of the Panel and longtime Death Panel correspondent Abby Cartus. Abby is a perinatal epidemiologist and a postdoctoral research associate at Brown University School of Public Health, working with the People Place and Health Collective. Abby, welcome back to the show.

Abby Cartus  1:30  

Thanks, I need to get a shorter title. I feel like that took two minutes to read out.

Phil Rocco  1:37  

Abby Cartus.

Beatrice Adler-Bolton  1:38  

Yeah, it is always a little bit of a mouthful, but I never mind. So last week, the United States' CDC issued new guidance that further rolled back its recommendations for non pharmaceutical COVID protections. And we will be covering the changes in the guidance later on this week in the public episode. But in many ways, this change itself is also an important part of the broader context for today's episode, which is about the social determinants of health. Because one of the key points that the CDC has offered as justification for these new loosened guidelines is that they are trying to reflect complex and shifting social factors. And of course, trying to center quote-unquote equity, meaning that rather [than] put pressure on society to make sure people have access to what they need to protect themselves and their community, if and when they get sick. The CDC has opted to shift the guidance to reflect the fact that many in our society, categorically do not and will not have access to things like testing paid leave the extra cash to buy masks, filtration, a place to isolate or quarantine away from the people in your house. And the federal government is not going to do shit about it. And it's an approach that centers equity in that it's a terrifying race to the bottom in the service of justifying the status quo. 

Phil Rocco  2:57  

One way of doing it. 

Beatrice Adler-Bolton  2:59  

Yeah, unfortunately, the common way of doing it, as we'll get into, and this argument is using a theoretical framework that we mentioned often on Death Panel to do this, which is the 'social determinants of health.' So it's kind of funny that the timing worked out this way, because we've been planning this episode for a while. And the justification and framework of the CDC guideline changes, and I think the way that it's being sold to the public, really sort of is one of the best examples of  how this term is not a sort of neutral or innocuous term in and of itself, there are so many complex meanings just within what the social determinants of health are, and how it can be used. So I think it's really good for us to just sort of stop and lay the groundwork and talk about what we mean when we say the social determinants of health.

Artie Vierkant  3:48  

Yeah, in a lot of ways, I think this conversation has been in the making for a long time, social determinants of health are a term that we throw out a lot. But I think what you're saying is a really good point in terms of the context, at least in this particular moment, when this thing is happening, because you know, the CDC, for example, is not directly saying, "Oh, blah blah blah the social determinants of health." But essentially, what you're saying, Bea, is that all of the things that they are pointing to are saying—all this sort of non pharmaceutical intervention stuff, although social determinants of health, as it were—are bad. Are bad.

Phil Rocco  4:23  

Yes.

Abby Cartus  4:23  

Like, all of the social factors impacting health in the United States are bad. And so in the context of those things, just being bad and us not wanting to exercise any political activity to do anything about that. Really, therefore, here is the new guidance that just sort of accepts things.

Phil Rocco  4:41  

That's not my department. Yeah. But it's, you know, the funny thing about this and I'm, I'm glad you brought that up, and I'm really happy that we're we have Abby to like, help us sort of historicize this because every single time, I've encountered people using the term social determinants of health that really left an impression on me. It always seemed to be instrumental and strategic in this way that I was like, "Oh, I thought that social determinants of health had this kind of origins in social medicine and thinking about conditions of work, and housing, and environment." But all of the times I remember most significantly hearing people use it were like 1) Seema Verma at CMS saying that by forcing people to work in exchange for Medicaid, putting work requirements, that was somehow doing something about the social determinants were like, improving the social determinants of health. 2) I remember going to a conference in Texas, where United Healthcare was saying that, like, you know, what, you can't write prescriptions for shoes, but we're getting into the housing market. 

Abby Cartus  5:49  

Yep. 

Phil Rocco  5:50  

And, then 3) I remember going to a conference in—where else but... Wilkinsburg, Pennsylvania—hosted by the Department of Health and Human Services, where the people who were most talking about social determinants of health were real estate developers... 

Artie Vierkant  6:04  

Oh, my god.

Phil Rocco  6:04  

...who were talking about how, by creating healthy communities, they were, like, their, the central purpose was improving property values. So, before we even get into what the term is, or the history of it, or the way that it's been sort of poisoned. It just occurs to me that those are the ways it always has been [used]. People using it as a way of deflecting attention from the fact that we, the United States, provide so little in terms of social support for anybody. 

Artie Vierkant  6:37  

Yeah. 

Phil Rocco  6:38  

And like all of the things, he talked about Bea, paid leave, and everything like that, I've almost never heard people in these sorts of moments, like, use that in conjunction with social determinants of health. And instead, it's always, you know, in some cases, it's even shaded into the way that people use it, into behavioral control. And, you know, employers—who shall remain nameless—giving out pedometers to their employees in exchange for a little break on their insurance premiums. So like, you know, I sort of want to get into like, one, where does this term like come from, but to what explains the fact that to the extent that it's used, it's often used in these incredibly instrumentalized and very duplicitous ways?

Artie Vierkant  7:24  

Well, I think by way of explaining that, let me just really quickly, I guess, offer, if we can move back a click and do a bit of that definition work. Actually, I know that Bea has, I think, a good definition of social determinants of health to throw out for us, as far as I know. But I'll offer one that comes from sort of one of these liberal compromised versions of social determinants of health. So here's, here's one definition of social determinants of health just to sort of get the ball rolling. And then we can talk about, you know, uses, misuses, and I think really why we think the term is important actually. And a good use of the term is actually very politically effective, or can lead us to very politically effective places. But here's sort of a one definition of the term, quote: "...social determinants of health include where you live, the state of your housing, the food you have access to, your transportation options, how much education you've received, your financial security, and more. For example, if your living conditions mean, you don't have nearby access to healthy food, or affordable transportation to a better grocery store, don't have access to a safe place to exercise, and can't get much sleep because of your living conditions, you are much more likely to eat poorly become stressed, get sick, and wind up in an emergency room," unquote. And that definition comes from an article titled, wait for it, "Addressing Social Drivers of Health is a Big Opportunity for Health Entrepreneurs."

Beatrice Adler-Bolton  8:50  

It takes a structural analysis and says, "And the problem is that, you know, you are becoming stressed, you are becoming tired, you're becoming sick..." Not like, oh, you know, society is making you sick and extracting from you to the point that you are a husk? You know?

Abby Cartus  9:07  

Yeah, well, but this really interests me. This use of the social determinants framework, because I mean, it's all true. You know, if you live in crowded housing, you're much more likely to contract COVID-19, or spread it to someone in your household. But the social determinants framework, we have to understand that science is kind of a social process, and the social determinants framework gets deployed in, for example, public health in ways that accord with, you know, kind of the political economy of public health and stuff. So I'm sorry, that this is kind of like an abstruse, like, run up to what I'm really trying to say. But what I'm really trying to say is that, while the framework of social determinants is an important one, it has really old roots in social medicine. Its function, certainly within public health, and it sounds like in other fields as well, is to kind of arrest the inquiry at a specific structural level. So like in public health, it's very common that it's like, oh, well, we're looking at housing just as kind of a disaggregated, disarticulated risk factor that people are self reporting. And we're loading it into a regression model and seeing what comes out. And yeah, it seems like people that have, you know, insecure unstable housing, however we measure that, seem to have worse, worse health outcomes, but it never gets to the point of, but why is it that some people live in substandard housing? You know, why is it that not everyone has, quote, unquote, access to living wages as the Healthy People 2020 document, you know, it correctly identifies a living wage as an important social determinant of health, but it doesn't go far enough into really interrogating the political economic structure. So that's kind of where I see the social determinants. It has this polymorphic meaning but how it's often used in the social sciences. And yeah, like "health entrepreneurship," or whatever. It serves kind of a, it's almost like a contradictory function, right? Like it has the social determinants framework has this immense power to extend the inquiry of, you know, the health sciences all the way back to, you know, the fundamental political economy of the state. But it's also very often instrumentalized, to just be like, well, if doctors could prescribe housing, if we could increase, you know, the green space in this really disinvested urban neighborhood by like, some marginal amount, then, you know, we're addressing the social determinants of health. And it's like, ehhhhh [laughs] not really.

Beatrice Adler-Bolton  11:33  

Umhmm.

Artie Vierkant  11:33  

Well, that's why I think it's appropriate to start with saying, there's kind of the version that you'll hear about it from random liberals or normie public health people or something like that, which often, I think, as you're saying, I like to think of this as, it reduces it to sort of they point to the problem, or they point to symptoms of certain problems that like, for instance, there's, there's a great Vicente Navarro line, for example, that talks about this. And again, I guess this gets us into some of the more expansive readings of social determinants of health as an idea, but that I think distills this limitation that you're talking about very concretely, which is Navarro says, "...it is not inequalities that kill but those who benefit from the inequalities that kill."

Beatrice Adler-Bolton  12:17  

Yeah, absolutely. Which is why I think I want to actually just sort of start us at the most base level with the World Health Organization's definition of what social determinants of health are, because it's really tied up into the way that health is framed in this very sort of international context as a policy goal is a kind of collaborative, charity oriented goal. And I think it's really important to sort of understand that the very base level concept in and of itself, as we've been discussing, is a kind of open framework, there are not necessarily values, political values, or political economic values that are embedded into it. But depending on who is using it, social determinants of health does come to embody various values, some of which are very harmful. So at the sort of most base level, the WHO's definition is that the social determinants of health are, quote, "the conditions in which people are born, grow live, work and age," and the quote "fundamental drivers of these conditions," which in many ways conceptually reflects the sort of definition of health that is in the WHO constitution, which says, quote, "health is a state of complete physical, mental and social well being and not merely the absence of disease or infirmity." So basically, health, you know, quote, unquote, health is not just about medical care, it's about your entire life and social determinants of health are not in and of themselves inherently good or bad they are, as is in the name, determinants. So it's all of the things sort of social, structural, environmental, political, that affect the conditions of your life, either positive or negative. And while this term as we're saying is sort of relatively recent, what it's supposed to reflect is this idea that the only way to really, truly improve health is to improve the health of the collective body at a kind of population level, which, you know, would require deep investigations into the social origins of illness, conditions in the workplace, conditions in the environment, all the things that sort of make us sick or assign us to slow death. And for a long time in I think a lot of ways and maybe also in name only, addressing the quote unquote, social determinants of health and trying to improve them has been the stated goal of public health for a very long time, sort of pre dating this being formalized as a concept and I think one of the biggest problems, as we've been saying, is the fact that for so long, the approach that many especially liberal organizations, charities, researchers, people like the WHO, the approach that many have taken has been to attempt to improve the social determinants of health without addressing these underlying fundamental drivers, like the fundamentally political things that they actually are.

Artie Vierkant  15:06  

Like capitalism.

Abby Cartus  15:07  

Yeah, capitalism. 

Beatrice Adler-Bolton  15:09  

Right.

Phil Rocco  15:09  

Yeah. Right. It's like we can deal with the things that happen outside of the clinical space, as long as they don't, you know, come into contact with anything that challenges or deals with directly, even in research terms, politics or institutions, I often think about, like, you know, people trying to get grants to study these things like, oh, no, you can't study that relationship. That's too political, the NIH will not fund that. Like there are these boundaries inscribed even in like the research infrastructure that prevent you from that prevent the sort of the profession, I guess, so to speak, from doing some of this research

Beatrice Adler-Bolton  15:48  

Well, right. And I mean, I think this, the framework of social determinants of health has really been largely appropriated as a kind of sanitized equity mission, where the mission is actually to center equity by depoliticizing inequality, which is why I think ultimately, this is, you know, the social determinants of health, even though in a way, this is the WHO's primary mission, right, this is like in their goal is towards bettering the collective health of the world, we can never expect an organization like the WHO to solve, you know, the negative social determinants of health, because these profound attempts to make social determinants of health apolitical, you know, they make the message more palatable, maybe. But, you know, ultimately, it's just hiding the way the world truly is. And there's nothing that we can do to actually address the sort of structural drivers of slow death, and sickness, and suffering, and illness, and inequality, if we refuse to admit that these things are actually real, and that they're driven by real dynamics, political, economic ones that go way beyond the kind of framework that we like to approach public health or medicine and science as this kind of neutral playing ground that's beyond politics in some kind of way.

Abby Cartus  17:04  

Yeah, I think a lot of what you're saying, and a lot of what Phil is saying, just about kind of like the structure of doing science is so important here, because you know, it's fine. It's fine. In fact, I think it's encouraged at this point to write grants and to do work that are engaging with the social determinants of health, but what you can't do, what's not allowed is to attach any kind of normative significance to what those social determinants mean, you know what I mean? So it's fine to just document inequalities, or as, as we say, in public health, euphemistically, "disparities," it's fine to catalog health disparities by whatever index of social causation, you might want to choose, housing, wages, my personal favorites, socio-economic status as a substitute for class. You know, it's fine to do that. But it has to be confined to this level, where you're just kind of chasing the social determinants around the track and documenting the fallout from them. Because both politically and scientifically, at the level of working as an epidemiologist, every day, it is frowned upon to insist that your findings regarding social determinants implies specific political actions, particularly if those actions are redistributive in nature. 

Beatrice Adler-Bolton  18:30  

[Laughs]

Abby Cartus  18:31  

And then at the level of working as an individual scientist, it's difficult to make the connection between an individual social determinant, you know, the consequence of our fucked up political economy and the political economy itself, because your work is very constrained. The types of interventions, as Phil mentioned, to suggest anything about the about the social determinants of health, you have to do it in the framework of a quote, unquote, intervention, you know, public health intervention, and in order to be fundable, that intervention to improve on the social determinants of health has to be kept at the level of something that's achievable within the material boundaries, have an NIH grant, you know, you get five years, you get a finite amount of money. And you have to make the case that by studying this, we're going to come, you know, we're going to be able to inform an intervention to improve the social determinants of health and it's not surprising that what often shakes out of that is really uninspiring stuff, you know, what I mean? So, if the prob if the social determinant is you know, living in a food desert, the interventions are often something like maybe a one off partnership with one or two corner stores to offer more healthy items like fruits and vegetables like close to the register, you know what I mean? Like, that's the level of the public health intervention that is incentivized by kind of like the academic research apparatus, and it never, never, never. Because I mean, you can't, I could not like in good faith, say to the NIH, like, I'm going to accomplish, like, I'm going to abolish the value form, you know what I mean? I'm going to push for a total overhaul of the political economy of the United States, because my findings about, you know, inequalities and COVID deaths really seem to suggest that something is going wrong here. Like, there's no, there's no way that you could do that. And so, again, you know, science being a social process, like the way that social determinants research shakes out is very, very constrained by just the political economy of doing science itself, I think.

Artie Vierkant  20:35  

Right. I mean, but I think this is why it's important and interesting to sort of interrogate the term itself, social determinants of health, both how it's used now, as we kind of have talked about a little bit already, but also how it or similar terms have been used before, because obviously, as you're saying, you know, if you, if you're, for instance, like a scientist doing a study, or an academic of any kind doing a study and saying, you know, through this work, I am going to, as you said, like abolish the value forum, through my paper or whatever, that's not going to achieve that goal. But also, obviously, it has these, you know, these ideas can be really leveraged and used to understand the world and to understand, and to, you know, push for changes in the world. 

Abby Cartus  21:18  

Oh, totally. 

Artie Vierkant  21:18  

And to that end, I think it's interesting to think about social determinants of health. And again, some of this lineage of people who have talked about this more expansively, I know that for instance, Abby, you and I were talking actually, yesterday about this shortly how it's funny, there just seems to be this. It's like there's this ebb and flow throughout the recent history of the last couple of centuries of sort of health and public health literature where people sort of come in and they will have, you know, relatively class conscious or Marxist leanings or something, and they will say, they'll make big statements about the social and political determinants of health, and then that discourse will sort of just die out for a little while come back at regular occurrences. For instance, in the 19th century, Rudolf Virchow writing, essentially about class power, politics, and the social determinants of health in the context of a cholera outbreak in Berlin, again in the 19th century, writes, quote, "Is it not clear that our struggle is a social one? That our job," as again, as public health people, or people talking about these issues,” at least, "that our job is not to write instructions to upset the consumers of melons and salmon, of cakes and ice cream..."

Phil Rocco  22:33  

Ha!

Artie Vierkant  22:33  

"...in short, the comfortable bourgeoisie, but it is to create institutions to protect the poor, who have no soft bread, no good meat, no warm clothing, and no bed and who through their work cannot subsist on rice, soup, and chamomile tea. May the rich remember, during the winter, when they sit in front of their hot stoves, and give Christmas apples to their little ones, that the ship hands who brought the coal and the apples died from cholera? It is so sad that 1000s always must die in misery so that a few 100 may live well." unquote.

Beatrice Adler-Bolton  23:03  

Right. And I think, you know, this is why we try and assert that these frameworks which seek to locate the problem with public health, or the problem with medicine, as it having become politicized beyond belief is really actually one of the sort of biggest distractions that happens in this arena, because it's actually the removal of the political context that takes this critique that can be so powerful and renders it basically only useful to elite capture and reproducing the status quo and seeking to sort of justify and almost take these negative social determinants of health and just as we're saying, sort of naturalize them as the way things are. Which is why I want to just quickly bring in another quote from pharmacist, epidemiologists and health services researcher, Danya Qato. This is from Danya's 2020 essay called "Public Health and the Promise of Palestine" in the Journal of Palestine Studies, which I think offers a kind of approach to social determinants of health, which is more in line with the way that we try and use it on the show when we're using it. We're trying to force, I think, the sort of lens of politicization back on to some of these frameworks. So Danya writes, quote, "As an interdisciplinary field of inquiry, public health, unlike clinical medicine, is interested in the prevention of disease and the promotion of health in populations, rather than in the treatment of disease in individuals. If we accept here the definition of health articulated by the World Health Organization, as, quote, 'a state of complete physical, mental and social well being and not merely the absence of disease,' we understand that both individual and public health are determined predominantly by the structural and political context within which medical care is received. Defined in epidemiology as determinants, these include the environmental, economic and social contexts within which people work, eat, play, love, struggle and live. In other words, public health is political in as much as our social and economic contexts are political," and I would add, there's really no way to separate the two. But as you're saying, Abby, essentially what we've oriented our entire sort of knowledge reproduction structure around is around denying the political aspect of the social determinants of health.

Abby Cartus  25:22  

Yeah, totally. So, you know, we alluded to this earlier, but the social determinants framework really grows out of a much older framework that is more commonly referred to as "social medicine." This is the history of social medicine is the thing that gets kind of cyclically, you know, forgotten and rediscovered, with each successive generation of, you know, grad students in public health and whoever else. Social medicine really has its origins in industrial revolution Europe. Engles is one of the first, which I mean is interesting, because I don't think Engels focused too much on health specifically, throughout his career, but Engels really wrote kind of the foundational text in social medicine with "On the Condition of the Working Classes in England." He was one of the first, maybe the first person to I mean, we could do a whole podcast episode just about black lung, but he was one of the first people to identify black lung as an occupational disease among coal miners...

Artie Vierkant  26:30  

By a long time too.

Abby Cartus  26:32  

By a long time. So, you know, Engels really observed that the conditions of the working classes in England were very poor as a result of the conditions of the Industrial Revolution, people being essentially forced to work for wages, living in extremely substandard and unhealthy housing, being crowded together, doing repetitive and dangerous work in unventilated environments, and so on and so forth. And that's kind of where that inquiry of Engles is were kind of the term I mean, he coined the term "social murder," which I'm sure has been mentioned on this podcast before.

Artie Vierkant  27:12  

We did the episode about it with Nate Holdren, actually.

Abby Cartus  27:14  

Yes, yeah. Now, I don't know if Rudolph Virchow, I don't know how you pronounce his last name, because it's German. And I think that's weird. But Rudolph Virchow was like a cellular pathologist in Germany, he was sort of a contemporary of Engles. And he really developed—he's one of the sort of other founding figures of what we now understand as social medicine, based on work that he did during I believe it was an outbreak of typhoid, in a region of what is currently Poland. And again, you know, very similar to Engels, Virchow observed that the social conditions that people found themselves in were really contributing to their susceptibility to typhoid. And to that to the outcomes that they were experiencing with typhoid. We had talked about Salvador Allende, who was the president of Chile, until the 1973 coup. He is another very important figure in the history of social medicine as is Che Guevara, who was trained as a physician, and wrote, I believe, like his Motorcycle Diaries of his motorcycle tour of South America is basically a social medicine text, as are several texts of Allende's. So, you know, I've kind of jumped from the 1800s all the way through to basically contemporary times, but this idea that social conditions are sort of primarily responsible for population health is very old. And you know, this is not something that's not known. I always get very frustrated with you know, people like Josh Barro, you know, who are like, [mocking] "Well, you just want to use your public health knowledge as a way to obtain your political ends." [serious] And it's like, you dumbass. This is all well established, I didn't invent this idea just to piss you off, you know what I mean? 

Artie Vierkant  29:02  

Right. 

Abby Cartus  29:03  

But yeah, so there have been successive movements to address the social determinants of health comprehensively. The World Health Organization, at the conclusion of World War II was moving in the direction of addressing the social determinants of health, obviously, lots of stuff happened in the post-war period. And one of the things that happened was that the balance of resources and political might and political authority shifted from the World Health Organization to the World Bank. And so for example, there was a 1978 conference at Alma Ata in Kazakhstan, which was, I mean, and this is referenced, you'll learn about this, if you go to grad school for public health, it was kind of like the social determinants conference and it's like, okay, what are the things that that we need to do in order to improve child infant mortality, and to ensure a healthier outcomes, essentially what that conference converged on was this idea of universal primary care, very much a prevention approach. But unfortunately, I feel like the political economy of the world was moving in a direction that was not amenable to that. And the relative power of the World Bank meant that a lot of the development programs and a lot of the health programs undertaken by these international agencies were actually undertaken through the World Bank, which had maybe different value structures, certainly different stakeholders. And they kind of alighted on this idea of like, oh, just selective primary care, which is just a beautiful turn of phrase to me, but they're kind of was, you know, a somewhat global, a somewhat coordinated, international focus on the social determinants of health from, you know, what I think is more of a social medicine type of perspective, that was engaged, you know, with, with political considerations of, you know, wealth distribution, and political equality and things like that. But as we know, you know, the world we're living in is not the world that has addressed all the social determinants of health. And I really think that the influence of the World Bank and neoliberalization, and kind of structural adjustment in a lot of, as we say, you know, developing countries, a lot of the interventions that were intended to improve on the material and social conditions that affect health, ended up getting tied to these to these World Bank programs, essentially. And, again, as is kind of, in parallel to like the structure of, of science in the US, I think a lot of what happened is like, the World Bank is run by economists, they want to see program evaluation they like, again, like there's a preference for articulating and understanding the social determinants of health in this kind of disaggregated, disarticulated way that can be easily sort of measured and reported to governments that are funding the body or whatever. So neoliberalism, global neoliberalism, and the acceleration of neoliberal capitalism, in the last, I don't know, 50 years has really kind of torpedoed not only the sort of like, preventive public health practice, but it's also sort of, I think, served to sever the social determinants themselves from the fundamental causes of why the social determinants are the way they are.

Beatrice Adler-Bolton  32:45  

Absolutely. And I would only just sort of add that one of the important things too, I think, is that when this kind of idea of like selective primary health care was proposed in relation to the original framework, which was kind of like the original framework of social determinants of health, that the WHO was working with, recognize that we needed to that like the world's the quote, unquote, the world's economy, would actually be impacted in a positive way if we took care of the world's poor in some sense. And that was kind of like the sort of unifying mission and framework. And by the time you sort of get to the late 70s, what you have with this selective primary health care model that sort of comes in to replace the original, quote, unquote, inefficient goal of, you know, providing the world's poor with the basic needs of survival...

Artie Vierkant  33:36  

...inefficient goal of changing the political economy...

Beatrice Adler-Bolton  33:38  

...this was this selective Primary Health Care framework, which was sort of like, okay, well, what if we just made sure that all the people in this locality have treatment for this one disease? You know, you see this in a lot of like, the kind of UNICEF programs that you saw in the 80s and 90s, where you would have people going in just: "Oh, we're just treating malaria. Oh, we're just treating typhoid here" and these kinds of approaches to public health care that... 

Abby Cartus  34:04  

Top down technological. 

Beatrice Adler-Bolton  34:06  

Exactly, yeah. And like very...

Phil Rocco  34:08  

"One weird trick." 

Beatrice Adler-Bolton  34:09  

And they're kind of the interventions that require the least amount of input and involvement from the people who are being intervened upon Right? This is very much like a sort of one sided framework. And this selective Primary Health Care framework was literally proposed as being more financially palatable, more pragmatic, and more politically unthreatening. So that's like a really important point, which is that yeah, part of why Social Determinants of Health has been defanged is because the context of social medicine is a politically threatening context.

Artie Vierkant  34:42  

Exactly. That's very important because all of these things, all these changes that you're talking about, they do a lot of work to sort of, you know, pretended to depoliticize health, which as we've said, you know, you can't, like health and politics are inextricable. But I think this sort of turn that we're talking about where neoliberalism sort of intersects with social determinants of health and the WHO agenda. And stuff like this gets sort of translated into all of these health policies, like really across the world, the center of aro has a very to the point, sort of eight point rundown of this, actually, that I think just just listing these things might actually sound very familiar to anyone who has, for instance, been listening to our COVID coverage for a long time, and has heard a lot of the complaints that we've had about the way that health is articulated in a political sense in the United States. But he says, for example, quote, "Translation of neoliberal policies in the health sector has created a new policy environment that emphasizes one, the need to reduce public responsibility for the health of populations to the need to increase choice and markets. Three, the need to transform national health services into insurance based healthcare systems for the need to privatize medical care, five, a discourse in which patients are referred to as clients and planning is replaced by markets, six individuals personal responsibility for their own health improvements, seven an understanding of health promotion as behavioral change, and eight, the need for individuals to increase their personal responsibility by adding social capital to their endowment." 

Beatrice Adler-Bolton  36:28  

COVID response? 

Abby Cartus  36:29  

Yeah, I want to point out this is from 2009. Yeah, you know, like, this is not like this wasn't written last year, this stuff is out there. 

Phil Rocco  36:38  

You know, it occurs to me that from the time that the WHO and UNICEF are bringing in these concepts of social determinants of health explicitly, there are huge stakes in what you talk about as a social determinants, social determinants health, that you can manipulate or change. Because once you start talking about it as something that you can manipulate or change, then that is an implicate like, because we're talking about things that are outside of the domain of formal care and the clinic, then that input necessarily implicates the political economy. So the fact that in the 80s, you know, that this Alma Ata conference, states that they're studying or the regimes that they're studying, are, in fact, places like China, Kerala in India, which is sort of like a communist state in India, Cuba, that by talking about, oh, the fact that these countries are, you know, producing a basic level of health, that seems surprising, given the relatively low per capita GDP, you start having to like talk more explicitly, about the fact that there are things that a simple sort of one off intervention isn't going to change, because the political context and the institutions, and the power of the working class is so different in these different countries from the ones that you might imagine, they're like trying to, you know, export, the capitalist version of public health too so like, one way of thinking about is that what we're seeing with COVID, and the things that seem shocking, that public health people are saying now and the sort of individuation that seems like such an abandonment of like the public health ethos is like, that's a transformation that's been long underway. 

Artie Vierkant  38:37  

Yeah. 

Phil Rocco  38:38  

And that now we're finally like the, you know, the imperial metropole, is now finally seeing people having to state that more explicitly, because the contradictions are emerging here, too.

Beatrice Adler-Bolton  38:53  

Right. Absolutely. And I think one of the things that there's not a lot of like total recognition on is the fact that so often throughout, I would say, this sort of recent history of of social medicine and this approach to how are we going to sort of better world health through public private capitalist interventions has really been about kind of taking findings about the social determinants and finding ways to, I guess, leverage or sort of read those findings as reading into health not fitting under this sort of framework of like existing within a social context, but as existing within this sort of, like individual lifestyle choice context. And so what's, you know, what's actually been happening since the 60s and 70s, right, is that we've seen these findings about social contexts and about political context, basically taken up through elite capture and transformed into evidentiary support for the kind of like reduce state responsibility for health that we're seeing right now in the COVID response or the kind of behavioral individualistic frameworks that we see, you know, basically send hundreds of millions of people into health bankruptcy rather than give them the care that they need. And these are like, you know, the kind of discrete decisions that also, you know, the ways that social determinants of health can be used is also to basically make these discrete decisions look like a kind of act of cosmic destiny, right? That really, it's not a social and political process that is depriving people of healthcare in the United States. It's really just that, you know, we have a fraught political environment and health has been politicized. And all of these bad health outcomes are just such a train wreck, and, and we've got to do something so people can help themselves, right. And that's a framework that looks at very real political observations about the social determinants of health, and strips the politics out of it, in order to essentially, you know, support the neoliberal individualization of health as a consumer commodity good. 

Abby Cartus  40:59  

Yeah, well said.

Phil Rocco  41:02  

And so I mean, and that's actually, as health becomes this consumer good, it becomes even less likely, I think, you know, all else equal, that you're going to see social determinants style interventions, go back into the domains that that exists, like outside of formal healthcare, because once healthcare becomes a consumer good, it becomes a way of generating all of this capital and thinking about all of the sort of the complexes of healthcare that now dominate, so many cities and like dominate the economy of so many cities in the United States. And elsewhere, as you have a population that is, you know, increasingly facing illness, and illness that is generated by their social conditions, policymakers now have, you know, it's like the thumb is on the scale of investing in that system, and then calling whatever they do their social determinants, and not investing further in things like social supports, in better workplace regulations, or conditions of work. But once you have this like profit center, where you can begin to generate all this, this capital, then you're gonna say, Well, you know, maybe the hospital is going to, like buy some housing or something, or like the health system is going to, like buy some housing, like and that social determinants. So like, we're going to, like, invest in like the bike share program in the city, and like that social determines, and but ultimately, what you cannot do, you know, all else equal, I mean, there's, there are contradictions that can be exploited here, also, but like what you can't do under this kind of regime talk about the fact that we like that so many social supports have disappeared, that the US is like a singular kind of country in terms of not having paid leave, all of that stuff becomes so off the equilibrium path of politics.

Beatrice Adler-Bolton  43:06  

Right, right. And I think the thing that's really important that I don't know if we've actually said out loud is the fact that that political framework and the political reality that we live in, right that that in and of itself, that limiting perspective that Phil's talking about, that is a major social determinant of health, that is a negative one that is preventing us from doing things like standing up programs in the United States that could actually equitably distribute resources like a kind of American NHS. And it's interesting that so many of the thinkers who have engaged with these ideas, from the perspective of recognizing that politics is incredibly necessary to this type of analysis, if you actually want it to be liberatory. Those people have really, I think, gone much further than challenging, you know, medicalization, or the sort of financialization or any of these other aspects. And they've said that, really more than anything else, one of the sort of social determinants that would be required to overhaul the political economy of health is actual sort of community empowerment is making people who are policy makers actually accountable to people who experience the negative consequences about their decisions not to benefit poor people or not to try and make the lives of everyone free from negative social determinants of health. And so this is one of those kinds of key frameworks where you have a lot of people who are working with these ideas from a perspective that's really actually trying to orient its critique towards industry towards capitalism and towards wealth inequality, that you have this kind of idea of an NHS or a system and systems for planning and provisioning care and making sure that we distribute care not just to everyone but also to people geographically speaking, is a key priority and I think it kind of looks away from this market ideology. That, for so many, is the only way that we're sort of acceptably allowed to talk about health care, which is within the sort of realm of making small, small little changes to the markets in order to tone down some of the pain and make them a little bit more fair and favorable. But ultimately, the market itself runs counter to these kinds of ideas that would support more positive social determinants of health that would allow for more liberatory approaches to public health and medicine, but in and of itself, like the fact of the matter, that this is kind of off the table that ruins lives and makes people sick.

Artie Vierkant  45:39  

Well, and I think this is why it's important to think about and view this in a really long term historical context to I mean, in some ways, if you think about all the contestation that has happened over health, because, you know, again, we have to say very clearly, again health is itself, a social construct health as a politically constructed term in the first place. And we can see, I think if you look back at the long arc, obviously, we could go much further back and talk about how, not to be all guy talking about Greek history on a podcast or whatever, but like, pre Hippocrates or something, the idea of health is "Oh, like, Gods smited you with disease or something," and it's some sort of, which obviously, connects to I think some of the moral, moral failing frameworks or whatever that we hear still today, all the time. Then ironically, if we want to talk about social medicine, Hippocrates, like his whole deal, so much of the thing about how they defined health is like fifth century BC, is talking about here's a program for what you should eat, how long of a walk, you should go on every day, how much you should make sure to rest so long as you're not one of the people who is compelled to labor. Because it's always a class thing, obviously, even at the beginning. And you know, how many bowel movements you should have literally. But that all sounds like social determinants stuff, are you comfortable? Are you resting enough? And then we've talked a lot about the 19th century, a lot here. But on into the 18th century, for example, you have all this stuff, on one hand, there are certain people, I can't remember the name of this individual off the top of my head, but who basically, I don't think this idea is well advised, but who kind of writes about a totalitarian police state of health, basically, to protect the public's health, which is I think there's a reason that, you know, people like us wouldn't necessarily draw him as a comparison for the...

Abby Cartus  47:35  

Which Vinay Prasad thinks is actually happening...

Artie Vierkant  47:40  

But then, you know, around the same time, you have what, like Rousseau and other people writing about how health as a matter of education, and like the educated individual, because you know, it's the enlightenment, or whatever the educated individual is going to, you know, take it upon themselves to, you know, whatever, you know, the story, it's the same, it's the same shit. And then, we mentioned Virchow, like, the typhus thing that Abby was talking about, there's this great line from that, which again, just resonates with all the things, this entire arc of what we've been talking about. I think it all resonates with narratives that we'll hear surrounding COVID. Virchow in the 19th century encounters resistance to his proclamations that we have to think about health, population health, and individual health as component of population health, in terms of its social and political context. And he describes the resistance to this as, quote, "Our politics were those of prophylaxis. Our opponents prefer those of palliation," as in thinking about things like palliative care, or whatever, as in, you know, the bad thing happens to the disease, the now diseased body or whatever person gets typhus person gets COVID. And then the best we can offer them is palliation, you know, is easing their suffering, using their, like, inevitable and or morally brought upon themselves suffering or whatever. And so, it's, again, you know, it's a long arc, but I think the, what I'm trying to get at here is basically I think it's really important that we always interrogate not only this political and social construction of health and the things like the social determinants of health, but also the degree to which health is very obviously, even as a concept something that is wielded politically.

Abby Cartus  49:26  

So as we've been talking, I've been kind of thinking of an example from Pittsburgh, which regular listeners will know is my hometown. There's a lot of Pittsburgh representation on this pod, which I appreciate.

Phil Rocco  49:40  

Yes.

Abby Cartus  49:42  

So this story is about the lead crisis—like the water lead crisis—in Pittsburgh a few years ago. And I don't know if this is widely known, but a few years ago, I want to say it was like 2015 or 2016. Some kind of routine water like home water quality monitoring revealed lead. Scary, large. There's no safe amount of lead. But you know lead well over the so called "action limits" in the drinking water of several residences in Pittsburgh. And on the one hand, this is a social determinant story at a very basic level, right people who live in older housing that are more likely to have lead service lines coming off the main into their houses. They're more likely to be poor, they're more likely to be Black people in Pittsburgh that live in this older housing, a very clear example of how your housing can affect your health. I think there's also another layer to the story that is kind of underappreciated, and gets to some of the deeper considerations about, you know, the social determinants of health and social medicine and how threatening, like a real social determinants analysis is to, for example, let's say capitalism. So, Pittsburgh is in Western Pennsylvania, and it is located in the Marcellus Shale, which shale is the type of rock underground that traps bubbles of natural gas. And, I mean, if you've been in the US at all, for the past 10 years, you're probably familiar with fracking, which is this process of fracturing that rock to release the gas, so it's kind of very intensive extractive work, I guess, and it requires a lot of water. And that water has to have a lot of, you know, very heavy metals, very toxic chemicals in it. There are, you know, some regulations about how that water can be stored, you know, once it's been used and is toxic, those regulations are not perfect. Fracking water gets into the municipal water supply of Pittsburgh, it seems fairly frequently, at least at this time of a few years ago, I can't speak to the present day. So this, this frack water is kind of leaching out of the pits that it's stored in once it's been used, you know, all over Western Pennsylvania. And, consequently, the municipal drinking water in Pittsburgh ended up being full of heavy metals, you know, things like bromine. And those are now I'm sorry, that my water chemistry is not like totally up to date. So I'm going to do my best here...

Beatrice Adler-Bolton  52:28  

[Laughs]

Abby Cartus  52:28  

But the basic idea is that the normal sort of treatment, you know, with chlorine of the water, was promoting the formation of these compounds, brominated trihalomethanes or something, things that you don't really want in drinking water, because this water is so contaminated. So the normal sort of chlorination process was resulting in this, you know, byproduct, that's not really great. And so the Pittsburgh Municipal Water Authority, I forget what it is, but they changed some aspect of the treatment, some agent that they were using to treat the water. And that caused the water to corrode lead pipes. So anybody that had a lead service line, you know, the water that they were getting off of the off of the main was, was corrosive to their pipes, and was causing lead to leach into the drinking water. Now, so I think, you know, the, the straightforward, and I think this is what the city has done, the straightforward solution to this is simply to pay to replace all of those lead service lines. But I think that there is a kind of social medicine critique to be leveled, which is, you know, fracking, this intensive environmental degradation for extractive purposes, is harmful to health. And it's harmful to health in ways that aren't straightforward, that aren't straightforwardly predictable, right? Like they're very complex, like chains of causation that lead from opening up fracking, shale drilling around Pittsburgh to then this complicated chain of causation that led to lead contamination in drinking water. But, it's one thing to make a demand of the city and say, "Hey, I know you didn't cause this but you got to pay to replace these lines." And it's another thing to make a demand of the broader political economy and say, "Hey, why is the city of Pittsburgh essentially subsidizing? Or paying to clean up? The externality of all of these fracking companies? And why are we doing this? And why is this allowed?" Like, it's pretty clear that fracking has harmful consequences for health. So, I don't know if this has been useful, but I feel like it kind of illustrates the dual face of social determinants and you know, the less structural interpretation is not always a bad one. People getting their service lines replaced is a good outcome and I'm happy to see it happen. 

Artie Vierkant  55:00  

I think this point is really good, which is that in the absence of also stopping the fracking that caused the additional damage in the first place. Yeah, my politics are those.

Beatrice Adler-Bolton  55:15  

If we're gonna be pedantic: Are the service lines the fundamental underlying dynamic of the lead poisoning? Absolutely not. So addressing the surface lines is not in fact, improving the social determinants of health, it's improving one of the knock on components of the fundamental dynamic, not the dynamic itself...

Abby Cartus  55:34  

And our water, our air quality, are still really bad. Still, it's really bad in Pittsburgh.

Phil Rocco  55:40  

But this actually, I think, illustrates something about, and this isn't just a phenomenon of like health, health services research, it's it just happens to be the case that it adheres here, which is, when you talk about something like social determinants of health, it's such a, the way that the concept is like structured, it's so broad, that it ends up really allowing you to draw the boundaries of what you're going to treat as the cause as the main causal story to focus on... 

Abby Cartus  56:13  

Yeah. 

Phil Rocco  56:15  

...whatever way you want, which is why, people can say, "Oh, you're just sort of like wielding this politically." But the point is, that it almost always is the case that the social determinants of health that get treated in national "healthy population plans," are the ones that political leaders find politically prudent to care about, right? Which is why if you go and look at social determinants, there's all this, you know, research on how somehow insurers are going to bring in dealing with social determinants as a way of controlling their costs. And in fact, there's a lot of work within CMS (Centers for Medicare and Medicaid Services), like, "We're going to deal with social determinants as a means primarily of doing cost control." And the point is that we can talk about these things, here in the world, but to the extent that the institutions that we have for making decisions that have the authority, and that have the resources to define health to the extent that they are the way that they are, they're going to actually keep reproducing this knowledge regime that forces us down this path of thinking about social determinants in this really narrow way. I think that's like, the story you tell is kind of a good example of how that happens.

Abby Cartus  57:39  

Yeah, yeah. It's really important to kind of have these conversations, because I was talking to Artie a little bit about this yesterday, but I've been talking to some other, you know, colleagues, friends of mine, and I think that graduate school for public health people is really like, ignorance producing, more so than instilling specific skills it produces specific patterns of ignorance, and kind of delimits the acceptable boundaries of inquiry to things that are fundable or not overtly political and things like that. But the lesson, I don't know the lesson from social medicine from Engles, certainly, I would say from Marx, there's a lot of public health in Marx's writings as well. The lesson is that we're in a dialectical relationship with everything, you know, what I mean? Like, it's not possible to sever the social determinants of health from the political economic arrangement that produced them. It drives me up a wall with a lot of like policy oriented public health research is like, "Oh, we're just evaluating the effects of these policies." And it's like, well, but someone designed these policies, they didn't just come into being just like disparities. You know, I prefer the term inequalities, because inequalities are made, disparity sounds a little bit too passive. And I think that the value of the social determinants framework, if we can avoid the trap of, "Oh, how do we incent people to choose to live in richer neighborhoods?" Or, you know, "How do we empower doctors to prescribe edge years of education, you know, or job opportunities?" If we can avoid that, then there's nothing more powerful, I think, than a social medicine analysis, because it is foundational. And it does challenge the foundational not just the foundational assumptions, you know, in the rhetorical stuff. But it challenges the legitimacy of the very economic, political, and social structure of society. And it's kind of a running joke among a lot of people that are there, especially going through the process of education in public health. To be like, "Wow, it really is like, capitalism is the problem in every scenario, like there's no way out of this stuff besides total social revolution" and the task of educating people in public health is training them to not be able to see that I think.

Phil Rocco  1:00:18  

Right, because I think the typical gestalt is something like, "What is the least amount I would have to do in order to make a, you know, minimally acceptable, effective intervention?"

Abby Cartus  1:00:32  

"How can I show progress without pissing off anyone important?" 

Artie Vierkant  1:00:36  

"How can I write a slide deck that gets me a little treat?"

Phil Rocco  1:00:37  

But the thing is... it's not even. But I think the way that people conceptualize it, it's like, if those categories were in their heads, that would be a whole different question. 

Beatrice Adler-Bolton  1:00:46  

Right.

Phil Rocco  1:00:46  

But the point is, that it's actually shorn of all of those categories, right? You're not talking about power, you're not talking about any of that you're just thinking about, like, how do I do science? How do I do a public like, what is it to be a professional, blank, whatever that might be? And the whole logic of that is demonstrate that this sort of thing, this, this bobble, this widget, whatever is, is now like in the language of the Patient Centered Outcomes Research Institute (PCORI), is not only effective, but also will self sustained, that I will not need to fund it past the point of the grant that it will just go on. Like, that's the other criteria and in the arm for like, a lot of this, like PCORI work. And, and so once you're down that pathway, and that's what you consider to be the source and summit of your professional life, then you're not even thinking like, it's just it's impossible for you to even conceptualize what else it is you might do, or the fact that maybe the most effective work that you could do is, you know, being in solidarity, like working in solidarity with people who are most negatively affected, you're like, I'm going to, like produce my own research program, and everything about the sort of professional incentive structure moves you in that direction. But I think what you're saying Abby, is that to actually deal with social determinants of health, if that term means anything, requires actually completely rethinking what it is that people gain when they, you know, become epidemiologists and like public health researchers.

Artie Vierkant  1:02:24  

I mean, and I think this gives us kind of to the bigger point, which is that it's important not only to think about this, and how it can be used politically, but also I think, you know, to challenge the left a little bit to really fucking take this seriously, frankly, because I think, you know, this is one of the reasons I think that I keep returning almost to the framing that the social determinants of health show us that health is political—health is inseparable from politics, and is always political, not just politically constructed, but politically used. I mean, ill health is the threat that is used to discipline the labor force, it is like health is used as definitionally as a demarcation between the productive body and the unproductive body, right? I mean, and when health is abstracted as physical and cognitive capacity, it's also used to define who is and is not allowed to define themselves as part of society, right? Who has the ability to participate in civic and political life, right. And so, for example, the situation that he brought up with fracking and lead water lines is a fantastic one, because you can't attack those things like that. If all of that is true, right? If health as this existential concept is wielded in American politics, and politics, generally, I think, to demarcate basically positions of power or ability or whatever within the political economy, then we need to take very seriously the the broad, you know, again, population level impacts on health that things like that scenario have,

Beatrice Adler-Bolton  1:04:12  

Right and I hope that maybe the bottom line takeaway that people might have from this episode is to think about the social determinants of health not just as political or not just as ways to describe what constitutes health but as ways to name how the way that the state makes itself is marked on our lives, right? How the decisions that the state makes in order to construct itself. Those are our social determinants of health. It's also a way of naming how the state has an impact on slow death, on illness, on workplace accidents, on respiratory viruses. It's a much broader thing, but at most sort of at the most basic level, it's also a process of naming the state for what it is, which is something that extracts health. And that relies upon these extractive pathways. And I think it's really important to sort of take a step back and look at these concepts in the ways that we did in this episode, because not only is it sort of subject to elite capture, and it's important to talk about things the real way, but it also offers a kind of interesting framework to sort of rethink what research is for, and what health is, and what the state is, and what these determinants are. They're not forces of nature, they're not naturalized. These are the result of policy priorities, discrete decision making, and capital and social determinants of health. Yes, thst is one way to talk about health outcomes. But yes, on the other hand, it's another way to talk about how the state is made in order to affect certain health outcomes in certain populations, which I think is probably the best place to leave it for today.

Artie Vierkant  1:05:56  

Yeah, yeah.

Abby Cartus  1:05:57  

I have, as always one closing thought...

Artie Vierkant  1:05:59  

Do it...

Beatrice Adler-Bolton  1:06:00  

Go for it. 

Abby Cartus  1:06:00  

If you don't mind, 100% to everything that you're saying Bea. And I would also frame everything that you can name as a social determinant of health, wages, housing, whatever the case may be. Every one of those things is also a crack in the edifice of capitalism, right? And the story that we all understand, you know, the story that we're all taught to internalize about capitalism being maximally efficient, and maximally fair. Every social determinant, you know, represents a crack in that edifice. And that's a place that is a potential or, you know, an actual as the case may be site of struggle. It's a place where you can force your hands into the crack and try to like pry this system apart. So that's how I would encourage listeners to think about it.

Beatrice Adler-Bolton  1:06:47  

I think that's the place to leave it. Actually...

Abby Cartus  1:06:50  

Thanks for indulging me.

Beatrice Adler-Bolton  1:06:53  

Abby, as always, thank you so much for joining us. It's been an absolute pleasure. Thank you. And patrons thank you so much for supporting the show. We could not do any of this without you. To become a Patron: www.patreon.com/deathpanelpod. We could not do any of this without you. If you'd like to help us out a little bit more. Share the show with your friends, post about your favorite episodes, pre-order Health Communism, or request it at your local library and follow us @DeathPanel_. We'll catch you later in the week in the main feed...

Artie Vierkant  1:07:17  

...to talk about those CDC guidelines I know that everyone wants to hear about...

Beatrice Adler-Bolton  1:07:20  

Oh yes! And as always, Medicare for All now, solidarity forever, stay alive another week.

Transcript by Beatrice using her screenreader and auto-transcription software, apologies for any errors or typos. Slightly edited for clarity.