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of Pages 14 ARTICLE IN PRESS

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Health Policy xxx (2008) xxxxxx

Barriers to addressing the social determinants of health:

Insights from the Canadian experience
Dennis Raphael a, , Ann Curry-Stevens b , Toba Bryant c
a School of Health Policy and Management, York University, 4700 Keele Street, Toronto, Canada M3J 1P3
b School of Social Work, Portland State University, Portland, OR, USA
c Department of Sociology, York University, Toronto, Canada

Abstract

Despite Canadas reputation as a leader in health promotion and population health, implementation of public policies in
support of the social determinants of health has been woefully inadequate. The continuing presence of income, housing, and
food insecurity has led to Canada being the subject of a series of rebukes from the United Nations for failing to address child
and family poverty, discrimination against women and Aboriginal groups, and most recently the crisis of homelessness and
housing insecurity. In this article we consider some of the reasons why this might be the case. These include the epistemological
dominance of positivist approaches to the health sciences, the ideology of individualism prevalent in North America, and the
increasing influence on public policy of the marketplace. Various models of public policy provide pathways by which these
barriers can be surmounted. Considering that the International Commission on the Social Determinants of Health will soon be
releasing its findings and recommendations, such an analysis seems especially timely for understanding both the Canadian scene
and developments in other nations.
2008 Elsevier Ireland Ltd. All rights reserved.

Keywords: Social determinants of health; Public policy; Politics and ideology

1. Introduction subject of a series of rebukes from the United Nations

Despite Canadas reputation as a leader in devel-
oping and promoting health promotion and population
health concepts, implementation of public policies in
support of health has been woefully inadequate [1]. The
continuing presence of income, housing, and food inse-
curity among Canadians has led to Canada being the
Corresponding author. Tel.: +1 416 736 2100x22134.
E-mail address: draphael@yorku.ca (D. Raphael).
for failing to address child and family poverty, dis-
crimination against women and Aboriginal groups, and
most recently the crisis of homelessness and housing
insecurity [2].
The contrast between words and actions has also
been apparent in the area of the social determinants
of health [3]. Canadas rich history of policy decla-
rations regarding the importance of public policy for
addressing the economic and social conditions under-
lying health has contributed to the social determinants

0168-8510/$ see front matter 2008 Elsevier Ireland Ltd. All rights reserved.
doi:10.1016/j.healthpol.2008.03.015

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2 D. Raphael et al. / Health Policy xxx (2008) xxxxxx

of health concept [46]. Canadians have managed two

of the International Commission on the Social Deter- Box 1
minants of Healths knowledge hubs early childhood Reports from the Commission on the
and globalization and health and Canadians have Social Determinants of Health
made significant contributions to various aspects of the Early Child Development:
Commissions mandate [7]. Final report of the Early Child Develop-
Yet on the ground, living conditions continue to ment Knowledge Network
deteriorate for many Canadians [2,3,8]. As just one Globalisation:
example, Statistics Canada recently reported that over Final report of the Globalisation Knowl-
the past 10 years the only group of Canadians show- edge Network
ing income gains has been the top 20% whose incomes Health Systems:
have increased substantially [9]. The incomes of the Final report of the Health Systems Knowl-
other 80% of Canadian have stagnated. Analyses of edge Networks
Canadian failures to address the social determinants Urban Settings:
of housing, employment security, food security, social Final report of the Urban Settings Knowl-
exclusion, and poverty among others are available edge Network
[10]. Employment Conditions:
Considering the accumulating knowledge of the Final report of the Employment Conditions
importance of the social determinants of health and Knowledge Network
Canadas reputation for considering these issues on a Women and Gender Equity:
conceptual level, how can we explain Canadas pub- Final report of the Women and Gender
lic policy failure to address these issues? And what Equity Knowledge Network
are the implications of this analysis for other nations Measurement and Evidence:
attempts to implement a social determinants of health Final report of the Measurement and Evi-
approach to public policy? In this paper we consider dence Knowledge Network
two key questions. Considering what is known about These and other reports
these social determinants of health and their importance and papers are available at
for promoting the health of Canadians, why does there http://www.who.int/social determinants/en/.
seem to be so little action being undertaken to improve
them? and (b) What are the means by which such pub-
lic policy action in support of health can be brought play in having a concept such as the social determi-
about? Such an analysis seems especially timely as the nants of health taken seriously [1113]. What are the
Commission on the Social Determinants of Health is ideas about health and illness the ideologies held
making available its sets of reports and recommenda- by health professionals, the public, and policymakers
tions (see Box 1 ). What might be the barriers to having concerning the sources of health and causes of dis-
its findings and recommendations accepted in Canada ease? How do these ideas influence receptivity to a
and elsewhere? social determinants of health approach to promoting
health?
This analysis is important as there are numerous
2. Identifying the issues aspects of a social determinants of health approach
that are foreign to traditional ways of thinking about
Our analysis considers issues that are only spo- health issues in North America. Some of these aspects
radically discussed in the health sciences literature include (a) how issues in the health sciences in gen-
but appear especially important to implementing a eral, and in epidemiology in particular, are generally
social determinants of health agenda. The first issue conceived and acted upon; (b) the role that the belief
considers the role that professional and societal dis- in individualism and individual responsibility play in
courses ways that health professionals, the public, North American society; and (c) the increasing market
and policymakers understand and consider an issue orientation of North American society and how this

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emphasis weakens support for a social determinants of
health approach to promoting health.
The second issue is concerned with what is known
about the policy change process in Canada and other
developed nations. There are varying approaches to
understanding the policy change process [14]. The
pluralist approach sees policy development as driven
primarily by the quality of ideas in the public policy
arena such that those judged as beneficial and useful
will be translated into policies by governing authorities.
The materialist approach is that policy development is
driven primarily by powerful interests who assure their
concerns receive rather more attention than those not
so situated. In Canadian society these powerful inter-
ests are usually based in the economic market sector
and have powerful partners in the political arena.
The pluralist approach suggests the need for further
research, knowledge dissemination, and public policy
advocacy with the aim of convincing policymakers to
enact health-supporting public policy [15]. The mate-
rialist model suggests the need for developing strong
social and political movements with the aim of forcing
policymakers to enact health-supporting public policy.
The third issue is the increasing influence of neo-
liberal market-oriented ideology upon the making of
Canadian public policy [16]. The last two decades has
seen a diminishing role of the State in citizen provision
of resources. This has been associated with program
reductions, limiting eligibility for a range of benefits,
and a shifting of influence towards the business sec-
tor rather than institutions associated with civil society
[17]. Such shifts have been associated with public pol-
icymaking that has little to say about strengthening the
social determinants of health [10,18]. We consider each
of these in turn followed by suggestions on how these
influences can be neutralized such that public policy
in support of the social determinants of health can be
developed.
3. Ideology, health discourses, and the social
determinants of health
Most of the public probably believes that academic
disciplines such as the health sciences and their applied
expressions, public health agencies and governmental
health ministries, carry out their activities based on
objective facts drawn from empirical research stud-
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3
ies. Within this framework we would understand the
health fields current preoccupation with biomedical
advances and with what sociologist Nettleton [12] calls
the holy trinity of risk of tobacco, diet, and physi-
cal activity as reflecting the accumulated evidence that
these domains are the primary determinants of citi-
zens health status in developed nations. We would also
understand the profound neglect by the health sciences,
public health, and governmental health authorities of
the social determinants of health in Canada as reflect-
ing a lack of evidence these issues play an important
role in determining the health status of Canadians.
Clearly, the pervasive evidence that has accumulated
concerning the importance of the social determinants
of health does not support this argument [1922]. There
must be more to this neglect of the social determinants
of health than meets the eye and indeed, numerous
hypotheses are available to inform this analysis. The
first concerns the nature that is the focus and the ana-
lytical tools available of research and action in the
health sciences in general and epidemiology in partic-
ular.
The characteristics of traditional health sciences and
epidemiological approaches that are problematic have
been identified [11,2326]. These include (a) reliance
on quantitative and statistical approaches to under-
standing health and its determinants; (b) a tendency
towards viewing the sources of health and illness as
emanating from individual dispositions and actions
rather than resulting from the influence of societal
structures; (c) a professed commitment to objectivity
or what is termed a non-normative approach to health
issues; and (d) a profound de-politicizing of health
issues. All of these reflect an adherence to positivist
science as the preferred means of understanding health
and its determinants [27].
The health sciences in general and epidemiology
in particular are a reflection of what has been termed
positivist science [27]. Sometimes known as empiri-
cist science, positivist science is based on a natural
sciences approach associated with the rise of physics,
chemistry, and biology as areas of study. It is focused
on the concrete and observable. It has also been called
a reductionist approach whereby effort is expended to
identify specific variables that can be placed into statis-
tical equations in order to identify putative causes and
effects. While positivist science has led to impressive
advances in the natural sciences, its application to the
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4 D. Raphael et al. / Health Policy xxx (2008) xxxxxx
fields of the health sciences and other areas of social
inquiry has been problematic [24,28].
When applied to the health and social sciences, pos-
itivist science generally avoids dealing with aspects
of broader environments [29,30]. In the medical field
it leads to a focus upon cells, body organs, and bod-
ily systems by biomedical researchers and a focus on
behavioural risk factors by health sciences researchers
[23,31]. The study of environments and the politi-
cal, economic, and social forces that shape the quality
of these environments is generally neglected [25,32].
Examination of, and attention to environments and the
public policies that shape these environments includ-
ing the social determinants of health is uncommon
[33]. Positivist-oriented health and social science also
avoids analysis of the abstract, implying the study of the
underlying economic, political, and social structures
of society are beyond its analytical and methodolog-
ical grasp [29,34]. The role of politics and political
ideology in shaping these environments therefore, is
especially uncommon though excellent examples do
exist [3539].
Another important aspect of positivist science is its
professed commitment to objectivity [27]. This leads
to researchers and workers being unwilling to make
what are termed normative judgments as to what
should be as opposed to describing what is. This
professed commitment to objectivity and avoidance of
normative judgments is a pretense as all health science
researchers and public health workers identify their
clear commitments to promoting treatment regimens
to improve biomedical markers and to reduce the so-
called risk behaviours such as tobacco and excessive
alcohol use, physical inactivity, and diets lacking fruits
and vegetables. These commitments to the importance
of biomedical markers and behavioural risk factors and
the neglect of broader issues is so strong as to consti-
tute in itself a normative ideology of what is a health
issue and what is not [11,17]. This is by any analy-
sis not an objective approach to understanding and
promoting health.
The professed commitment to objectivity therefore,
serves as a means to avoid consideration of broader
issues concerned with political, economic, and social
issues. Also unlikely to be discussed is how the class
biases of health researchers and workers come to influ-
ence what is conceived as being either within or
outside the realm of health sciences inquiry [40].
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A perceived threat to career prospects that may arise
by raising broader issues associated with the social
determinants of health is also not to be dismissed
[41]. Extensive discussions of how these issues shape
the health sciences and public health sectors appar-
ent unwillingness to consider a social determinants of
health approach are available [4143].
Within the traditional health sciences approach,
health problems remain individualized, localized, de-
socialized, and de-politicized [17]. Notice that such
an approach is congruent with conservative and
neo-liberal political ideologywhereby social prob-
lems are being continually framed as individual
ones rather than societal ones (e.g., unemployment,
poverty and racism, etc.). Policy solutions under
conservative and neo-liberal ideologies are residual
and de-socialized. Problems are responded to one-
person-at-a-time through targeted clinical, social work,
psychological, or criminal justice interventions and
responses. While traditional health science approaches
may not be overtly conservative in orientation, they are
congruent with such an ideology and serve to justify the
retreat of governments around the world from invest-
ing in the collective health and well being of citizens
[17,33,4447].
4. Individualism and the social determinants of
health
The second barrier to having a social determinants of
health approach taken seriously by professionals, the
public, and governmental policymakers is the North
American commitment to the ideas of individualism
and individual responsibility as opposed to commu-
nal responsibility [17]. Individualism is the belief that
ones place in the social hierarchy their occupational
class, income and wealth, and power and prestige as
well as the effects of such placement such as health
and disease status comes about through ones own
efforts [48]. At the very minimum it leads to plac-
ing the locus of responsibility for ones health status
within the motivations and behaviours of the individual
rather than health status being a result of how a soci-
ety organizes its distribution of a variety of resources.
The importance of individualism to understanding how
the determinants of health are conceptualized has been
thoughtfully explored by Hofrichter:
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Individualism, a powerful philosophy and practice in
North American, limits the public space for social
movement activism. By transforming public issues
into private matters of lifestyle, self-empowerment,
and assertiveness, individualism precludes organized
efforts to spur social change. It fits perfectly with a
declining welfare state and also influences responses
to health inequities. From this perspective, each person
is self-interested and possessed of a fixed, competitive
human nature. Everyone has choice and the potential
for upward mobility through hard workignoring how
we develop through the process of living in society.
Individualism presumes that individuals exist in paral-
lel with society instead of being formed by society [17,
p. 28].
Individualism in health has numerous effects in rela-
tion to the social determinants of health. First, it leads
to a strong bias towards understanding health prob-
lems as individual problems rather than societal ones.
Second, it specifies the cause of the health problem
as residing within faulty biomedical markers, specific
individual motivations, and risk behaviours that are
somehow under individual control. Third, it specifies
that improving health will result from modifying these
markers, motivations, and behaviours. Fourth, it says
little about reorganizing society and its structure in the
service of health. Fifth, it says even less about how
such societal structures could be modified. This clearly
represents a commitment to the cultural/behavioural
approach to health inequalities [49].
An alternative paradigm for understanding health
and its mainsprings is available. Sociologists and social
epidemiologists working in the historical material-
ist tradition have long attempted to illuminate how
various modes of production, especially in capital-
ist societies, influence the distribution of economic,
social, and political resources within the population,
thereby influencing health (see Ref. [50]). Despite
this long-standing tradition, these analyses concerning
the structural determinants of health and their clear
impacts on health remain outside the mainstream
of current discourse on determinants of health among
policymakers and health researchers in Canada. It is
unclear whether the efforts associated with the Inter-
national Commission on the Social Determinants of
Health can reverse this tendency.
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5. Increasing market orientation of Canadian
society
Finally, the increasing market orientation of Cana-
dian society weakens support for a social determinants
of health approach to promoting health [16,45,51]. The
rise of capitalism and the market economy grew in
tandem with a strong belief in individualism and the
ability of the individual to control ones destiny [52].
The uncritical belief in this ideology was associated
with the rise of market-oriented societies which saw
little role for governmental or State intervention in the
market place and in the provision of various forms of
security for its citizens. At its heyday such a belief
saw the rise of tremendous inequalities in wealth and
health in Victorian England, for example, and more
recently during the 1930s and since the 1970s in many
developed nations [53].
The rise of differing forms of welfare states in
Europe during the 19th century was a response to these
excesses of laissez-faire capitalism [52]. In continen-
tal Europe a conservative form of the welfare state
arose whose main concern was with reducing unrest
and promoting a modicum of security for citizens. The
dominant ideological inspiration of this type of welfare
state has been identified as Solidarity achieved through
social stability, wage stability, and social integration
[54].
In Scandinavia the social democratic welfare
state arose which saw active promotion of equal-
ity and human rights and the provision of citizen
security across the life span [55]. There, the dom-
inant ideological inspiration is Equality achieved
through the reduction of poverty, inequality, and
unemployment [54]. The third form of the welfare
state the liberal was the weakest of all and
Canada falls within this group. In the liberal wel-
fare state the dominant ideological inspiration is
Liberty achieved through minimizing governmental
interventions, and minimizing so-called disincen-
tives to work such as social programs and
supports.
Eikermo and Bambra provide an overview of some
key welfare state concepts that are especially rele-
vant for the analysis of state receptivity to social
determinants of health concepts [56]. These include
decommodification: The extent to which individu-
als and families can maintain a normal and socially
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6 D. Raphael et al. / Health Policy xxx (2008) xxxxxx
acceptable standard of living regardless of their mar-
ket performance (p. 4); defamilisation: the degree
to which individual adults can uphold a socially
acceptable standard of living independently of fam-
ily relationships, either through paid work or through
social security provisions (p. 4); and welfare state
retrenchment which refers to the political backlash that
led to welfare state reforms and cuts to social expen-
diture and usually involved increased privatization and
marketization of health and social services.
It is the liberal welfare states of which Canada, the
USA, UK, Ireland, Australia, and New Zealand are the
usually examples where the degree of decommodifi-
cation and defamilisation is usually the lowest and the
extent of welfare state retrenchment has been the high-
est. Bambra recent work that has critiqued and gone
beyond the three-world model of Esping-Andersen has
served to reinforce the distinction between liberal and
social democratic welfare regimes [57].
Of particular note is that while no less than twelve
welfare state typologies have been presented by Bam-
bra, in six of the seven that have included Canada,
Canada is found in the group similar to the so-called
liberal welfare state: liberal, basic security, or liberal
Anglo-Saxon. In the seven that have included the US,
the US is always found in these groups. Similar findings
are seen for the UK and Ireland, with less consistency
for New Zealand and Australia. And the Scandi-
navian nations of Finland, Denmark, Sweden, and
Norway are almost always identified in the so-named
social democratic, encompassing, Nordic, or services
groups.
The liberal welfare state and its associated ide-
ology provide barren soil for a well-developed
social determinants of health approach. Within such
an approach, liberty and its close neighbour, self-
determination, become available only to a narrow band
of the populationthose who have sufficient financial
resources and cultural capital to define their own liv-
ing conditions [58]. Liberty and self-determination are
out-of-reach for much of the population.
Scholarship has specified the mechanisms by which
these differing forms of the welfare states developed
and how their trajectories shape the making of public
policy [52]. Importantly, these differing forms of the
welfare state have been shown to be related to clear dif-
ferences in the quality of numerous social determinants
of health and population health outcomes [59,60].
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Even so, the end of the Second World War saw a
clear desire by all nation states to avoid the economic
and social conditions that gave rise to totalitarian-
ism [16]. Attention to promoting citizen security was
increased across all developed nations such that by the
1970s the Canadian welfare state was seen by some as
rivalling that of Sweden at the time.
Yet the rise of what has been termed neo-liberalism
or a retreat from government intervention in the mar-
ketplace has threatened these social reforms [16,45].
This has especially been the case in the liberal politi-
cal economies such as Canada, the USA, and the UK.
Neo-liberalism refers to the dominance of markets and
the market model. According to Coburn [88], the pri-
mary tenets of neo-liberalism are: (1) markets are the
best and most efficient allocators of resources in pro-
duction and distribution; (2) societies are composed
of autonomous individuals (producers and consumers)
motivated chiefly or entirely by material or economic
considerations; (3) competition is the major market
vehicle for innovations. Such ideology sees little space
for governmental action in strengthening the social
determinants of health.
Conservative and social democratic political
economies have been more able to resist these forces
than liberal political economies [61]. Consistent with
this view, it has been argued that Canadian society
is moving more and more towards that of the most
extreme liberal welfare state, the United States [51]. It
should therefore not be surprising that implementation
of a social determinants of health approach has been
lacking in Canada [1]. Those attempting to raise these
issues through the provision of evidence and policy
options run smack into resistance driven by ideologi-
cal beliefs concerning the nature of society as well as
concrete pressures to resist such an agenda. Some of
these concrete forces become clearer in the following
examination of how public policy is made in nations
such as Canada.
6. Understanding policy change
Another key issue is the policy change process in
Canada and other developed nations. There are varying
approaches to understanding the policy change process
[14]. The pluralist approach sees policy development
as driven primarily by the quality of ideas in the pub-
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lic policy arena such that those judged as beneficial
and useful will be translated into policies by govern-
ing authorities. An alternative materialist approach is
that policy development is driven primarily by pow-
erful interests who assure that their concerns receive
rather more attention than those not so situated.
Each approach provides differing explanations for
understanding the present situation and each proposes
different means of moving such an agenda forward.
As noted the social determinants of health appear to
be underdeveloped in Canada and other liberal welfare
states such as the US and UK nations as compared to
most other developed nations. This is especially the
case in relation to the social democratic nations. Much
of this has to do with public policies that determine how
the resources of the nation are to be distributed among
the population.
6.1. Pluralist view
The pluralist view is that public policy deci-
sions result from governments and other policymakers
choosing public policy directions based on the compe-
tition of ideas in the public arena [14]. This competition
of ideas according to this view is facilitated by various
interest groups who lobby governments to accept their
position. Pluralists recognize that there may not be a
level playing field in these lobbying attempts with polit-
ical, economic, and social elites having an upper hand.
Nevertheless the pluralist approach assumes that the
governmental policymaking process is generally open
and those with the better ideas will come to see their
views adopted by governments.
Additionally, pluralists assume that policymaking
is a democratic and rational process whereby the best
ideas are put into practice. Individuals, communities,
agencies, organized groups, labour and business all
have a place at the policymaking table. Canadian gov-
ernments are not seen as being the handmaiden of the
elites. Rather they strive to implement the Canadian
constitutional principles of peace, order, and good gov-
ernment by implementing reasonable public policy. If
Canada lags behind in social determinants of health
supportive policy, it requires education of policymak-
ers and lobbying of these same policymakers with the
expectation that with the right knowledge dissemina-
tion, translation, or exchange, these health supportive
policies will come to pass. The pluralist view argues
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7
therefore that advocates of the social determinants of
health view need to get organized and have their voices
heard by policymakers. Ongoing consciousness rais-
ing, advocacy and lobbying and building coalitions will
achieve policy change.
Taking this view at face value, we would expect
that all of the policy recommendations presented by
various Canadian writers would be of interest to policy-
makers [6266]. The only problem is that these policy
options have been presented numerous times over the
past decade to policymakers, their benefits have been
outlined repeatedly, yet no action seems forthcoming.
For example Raphael and Curry-Stevens suggested a
number of options that would strengthen the social
determinants of health (see Table 1).
Yet, there is little evidence that any of these recom-
mendations have been taken seriously. Why is this the
case? Perhaps we need an alternate model of policy
change to explain the current situation and point the
way forward. The materialist model provides such an
alternative.
6.2. The materialist view
The materialist view is that governments in capital-
ist societies such as Canada enact policies that serve
the interests of economic elites [14]. These elites are
the owners and managers of large corporations whose
primary goals are to maximize profits, provide grow-
ing profits to shareholders, and institute public policies
that keep business costs down. These interests are also
likely to lobby for minimal governmental intervention
in business practices and to resist business regulation
and progressive labour legislation [67]. Lowering cor-
porate and income taxes is also an important policy
objective. Since taxes are required to fund govern-
mental services, economic interests frequently call for
reduction in program spending to allow tax decreases.
Business interests generally oppose moves that enable
workers to form unions that would see the realiza-
tion of collective bargaining. Collective bargaining is
related to the receipt of higher wages, stronger benefits
and increased employment security for union members.
Canada has come through a generation of governments
retreating from their role in supporting its most vulner-
able citizens, and even much of the middle class.
Canadians have seen a dramatic set of cuts to pro-
gressive taxes such as income tax and corporate taxes,
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8 D. Raphael et al. / Health Policy xxx (2008) xxxxxx

Table 1
Policy options to support the social determinants of health
Policies to reduce the incidence of poverty
Raise the minimum wage to a living wage
Improve pay equity
Restore and improve income supports for those unable to gain employment
Provide a guaranteed minimum income
Policies to reduce social exclusion
Enforce legislation that protects the rights of minority groups, particularly concerning employment rights and anti-discrimination
Ensure that families have sufficient income to provide their children with the means of attaining healthy development
Reduce inequalities in income and wealth within the population, through progressive taxation of income and inherited wealth
Assure access to educational, training, and employment opportunities, especially for those such as the long-term unemployed
Remove barriers to health and social services which will involve under-standing where and why such barriers exist
Provide adequate follow up support for those leaving institutional care
Create housing policies that provide enough affordable housing of reasonable standard
Institute employment policies that preserve and create jobs
Direct attention to the health needs of immigrants and to the unfavourable socioeconomic position of many groups, including the particular
difficulties many New Canadians face in accessing health and other care services
Policies to restore and enhance Canadas social infrastructure
Restore health and service program spending to the average level of OECD nations
Develop a national housing strategy and allocate an additional 1% of federal spending for affordable housing
Provide a national day care program
Provide a national pharmacare program
Restore eligibility and level of employment benefits to previous levels
Require that provincial social assistance programs are accessible and funded at levels to assure health
Assure that supports are available to support Canadians through critical life transitions [63, p. 349,351]

and a correlated rise in regressive taxes such as the
Goods and Services Tax. We have also seen massive
cuts to income support programs such as social assis-
tance (in most provinces) and unemployment insur-
ance. On the program side, extensive cuts have been
made to public housing, education, mental health and
violence against women services [51]. Failed promises
in child care and supports for the homeless reveal
that even when gains are made through social move-
ments, governments can undo them through an array of
means. Labour legislation has been rolled back in many
provinces, undoing gains made in the post-war era.
Economic interests are able to influence govern-
ments through a variety of processes. First, they are able
to influence government through their ability to shift
investment capital from location to location. A gov-
ernment that institutes non-business friendly policies
could see business and investment leaving the juris-
diction. Second, lending agencies whose interests are
consistent with business can raise borrowing rates for
debt-ridden jurisdictions that institute what they see as
problematic policies. Third, the people who have the
financial resources to consider running for the domi-
nant political parties may either come from the business
class and/or hold similar values. These individuals can-
not only expect to receive financial support for their
runs at political office, but can also be assured of
employment opportunities within these same sectors
if they fail to be re-elected or upon their retirement
from public office [2].
Increasing income and wealth inequality and the
weakening of social infrastructure result from the con-
centration of wealth and power within a nation with
attendant weakening of civil society [33,68]. What is
to be done? The materialist model suggests organizing
the population to oppose and defeat the powerful inter-
ests that influence governments to maintain inequality
[15]. These defeats can occur in the workplace through
greater union organizing and the promotion of class
solidarity. These defeats can occur in the electoral and
parliamentary arena by the ascendance of working class
power.
This would come about by achieving greater equity
in political power [69]. This can be achieved by restor-
ing programs and services and reintroducing more
progressive income tax rates. Independent unions are

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the Canadian experience, Health Policy (2008), doi:10.1016/j.healthpol.2008.03.015
HEAP-2171; No. of Pages 14 ARTICLE IN PRESS
D. Raphael et al. / Health Policy xxx (2008) xxxxxx
a necessity as is legislation that strengthens the ability
of workers to organize. Re-regulating many industries
would reverse current trends towards the concentration
of power and wealth. Internationally, the development
and enforcement of agreements to provide adequate
working and living standards that would support and
promote health and wellbeing across national barriers
is essential.
The provision of a social wage government pro-
vided services that people need to live and develop their
ability to work is a way to restore the social infras-
tructure that has been so weakened in nations such
as Canada. Resistance to the privatization of public
services is essential.
7. Insights from UK inequalities in health
policy experience
While the UK is best seen as a liberal welfare state,
in 1997 a Labour government came to power on a
platform of reducing health inequalitiesa concept
somewhat related to the social determinants of health
concept in Canada. Two studies examined policymak-
ers and researchers views of how evidence on health
inequalities can be translated into policy [70,71]. To
briefly summarize, five types of evidence was seen as
persuasive to policymakers:
observational evidence showing the existence of a
problem;
narrative accounts of the impacts of policies from
the household perspective;
controlled evaluations;
natural policy experiments;
historical evidence [71].
These findings are consistent with recommenda-
tions made on how to raise the profile of the social
determinants of health in Canada [72,73]. Yet there
is a profound difference between the situation in the
UK and Canada and the US. In the UK governments
have endorsed policy positions that address these health
issues. In the latter two nations however, there is vir-
tually no public discourse on inequalities in health
or social determinants of health nor is there any dis-
cernible public policy action in these areas. In Smiths
parlance [74], while there have been some partial,
and fractured journeys of evidence into policy in the
Please cite this article in press as: Raphael D, et al., Barriers to addressing the social determinants of health: Insights from
the Canadian experience, Health Policy (2008), doi:10.1016/j.healthpol.2008.03.015
9
UK on health inequalities, in the Canada and the USA,
the vehicle has not even been allowed to get on the
road!
8. The way forward
Such an analysis suggests that what is neces-
sary to promote governmental receptivity to the
social determinants of health concept is the build-
ing of social and political movements in support of
health. In the UK such activity may have contributed
to the election of a government whose receptiv-
ity to these ideas is certainly greater than s the
case in Canada and the USA. Of note is that both
New Zealand and Australia usually recognized as
liberal welfare states have also elected Labour
governments. It may very well be that the growing
inequalities in income and wealth associated with
strongly conservative regimes contributed to these
events.
In Canada, the social determinants of health con-
cept has contributed to numerous activities that include
the Canadian Senate undertaking and reporting on an
inquiry into the social determinants of health [75]
and funding being made available to examine fac-
tors associated with health inequalities [73]. Numerous
Canadian social development and social justice advo-
cacy groups as well as public health units have taken
up the social determinants of health concept in support
of their activities [7682].
Yet, as compared to policy activity in the UK, virtu-
ally no public policy activity seems to be happening in
Canada [44]. There are few governments who appear
to be receptive to these concepts. In this section we
focus on what role health researchers and workers could
play to shift this situation. These three roles are educa-
tion, motivation, and activation in support of the social
determinants of health. These roles are about build-
ing the social and political supports by which public
policy in support of the social determinants of health
could be implemented. Each is considered in turn. As
noted, such action will require broadening of knowl-
edge paradigms in the health sciences, accepting the
political nature of health and its determinants, and con-
fronting many of the economic and social forces that
are opposed to governmental action in the service of
strengthening the social determinants of health.
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10 D. Raphael et al. / Health Policy xxx (2008) xxxxxx
8.1. Educate
In Canada and other nations governed by liberal
political economies and this is especially the case in the
US, the public remains woefully uninformed about the
social determinants of health [8991]. The population
has also been subject to continuous messaging as to the
benefits of a business-oriented laissez-faire approach to
governance [16]. What this messaging has not included
are the societal effects of this approach: increasing
income and wealth inequality, persistent poverty, and
a relatively poor population health profile [46]. These
effects are profound and objectively influence for the
worse the health and well-being of a majority of the
population [59].
There are hundreds if not thousands of Canadi-
ans whose occupations are concerned with the health
of the public. These workers could take advantage of
the citizenrys continuing concern with health and the
wealth of evidence of the importance of the social
determinants of health to begin offering an alterna-
tive message to the dominant biomedical and lifestyle
discourse. At a minimum health promoters can carry
out and publicize the findings from critical analy-
sis of the social determinants of health and disease.
This is not a question of being subversiveit is
rather a simple matter of information and knowledge
transfer.
There is no shortage of areas in which health
researchers and workers could engage: social deter-
minants of health such as poverty, housing and food
insecurity, and social exclusion appear to be the pri-
mary antecedents of just about every affliction known
to humankind [19]. Our short list of such afflictions
includes coronary heart disease, type II diabetes, arthri-
tis, stroke, many forms of cancer, respiratory disease,
HIV/AIDS, Alzheimers, asthma, injuries, death from
injuries, mental illness, suicide, emergency room visits,
school drop-out, delinquency and crime, unemploy-
ment, alienation, distress, and depression. Examples of
such analyses and critiques of the dominant paradigms
are available [92,93].
8.2. Motivate
Health researchers and workers can shift public, pro-
fessional, and policymakers focus on the dominant
biomedical and lifestyle health paradigms to a social
Please cite this article in press as: Raphael D, et al., Barriers to addressing the social determinants of health: Insights from
the Canadian experience, Health Policy (2008), doi:10.1016/j.healthpol.2008.03.015
determinants of health perspective by collecting and
presenting stories about the impact social determinants
of health have on peoples lives. Ethnographic and qual-
itative approaches to individual and community health
produce vivid illustrations of the importance of these
issues for peoples health and well-being [94]. There is
some indication that policymakers and certainly the
media may be responsive to such forms of evidence
[13,71]. In Canada, such research clearly constitutes a
small proportion of public health and health services
research [72].
There is increasing recognition of the importance
of community-based research and action [95,96]. But
frequently, these activities are narrow and seem unwill-
ing to allow citizens to raise issues of public policy
concerned with income distribution, employment and
labour issues, and fundamental questions of citizen par-
ticipation in governmental priorities and actions. Such
activities can be a rich source of insights about the
mainsprings of health and means of influencing public
policy. Such a perspective allows community mem-
bers to provide their own critical reflections on society,
power and inequality. At a minimum these approaches
allow the voices of those most influenced by the social
determinants of health to be heard and hold out the
possibility of their concern being translated into polit-
ical activity on their part and policy action on the
part of health and government officials. Ultimately, the
end of such activities should be the creation of social
movements in support of health. The Peoples Health
Assembly is but one example of such a movement in
support of health [97].
8.3. Activate
The final role is the most important but potentially
the most difficult: supporting political action in support
of health. There is increasing evidence that the quality
of any number of social determinants of health within a
jurisdiction is shaped by the political ideology of gov-
erning parties. It is no accident that nations where the
quality of the social determinants of health is high have
had greater rule by social democratic parties of the left.
Indeed, among developed nations, left cabinet share
in national governments is the best predictor of child
poverty rates which itself is associated with extent of
government social transfers [83]. Nations with a larger
left-cabinet share from 1946 to the 1990s had the low-
HEAP-2171; No. of Pages 14 ARTICLE IN PRESS
D. Raphael et al. / Health Policy xxx (2008) xxxxxx
est child poverty rates and highest social expenditures;
nations with less left-share had the highest poverty rates
and lowest social expenditures. Canada, like the other
liberal nations of New Zealand, Ireland UK, and the
USA is among the lowest nations in left federal cabinet
share (0%) and among the highest in child poverty rates
(15%) in the 1990s (providing a poor poverty standing
of 19th of 26 OECD nations).
It has also been documented that poverty rates and
government support in favour of health the extent
of government transfers is higher when popular vote
is more directly translated into political representation
through proportional representation [53]. Canada also
does not have proportional representation the lack
of which is associated with higher poverty rates and
less government action in support of health. Propor-
tional presentation is important because it provides for
an ongoing influence of left-parties regardless of which
party forms the government.
This analysis recognizes the profound barriers that
exist in having the Canadian government address the
social determinants of health. Dominant ideologies typ-
ical of the health sciences, public attitudes towards
personal responsibility, and increasing market influ-
ence all work against having a social determinants of
health agenda implemented.
Nevertheless, developments in Europe indicate that
concerted public health and community efforts can
profoundly influence the development of policies that
determine the extent of health inequalities and the over-
all state of population health within a nation. The policy
directions being undertaken by nations such as Sweden
and Finland are two such examples [84,85]. Similarly,
the success of the WHO European Office Healthy Cities
initiative is another example of the power of cities and
communities to influence health policy [86,87]. Canada
has a rich history of concerted public pressure that can
lead to positive policy change.
The social determinants of health concept can help
make the links between government policy, the market,
and the health and well-being of citizens in Canada and
elsewhere. For those working in the health sector, it can
serve as motivation for working for change. The inter-
ests of their clients, patients or consumers are served by
speaking out against poverty, social exclusion, inequal-
ity, and inadequate services. There are potent barriers
however, to such actions and this is especially the case
in nations identified as liberal welfare states. We hope
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the Canadian experience, Health Policy (2008), doi:10.1016/j.healthpol.2008.03.015
11
this article can assist in recognizing and surmounting
these barriers.
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