Put simply, there has been a longstanding argument within the health professions and related interests from governmental agencies to private corporations and, increasingly, among patients and their advocates. It concerns the main determinants of disease and the most efficacious responses of the health care system. We are generally no longer troubled by the conflicting claims of those who imagined ailments to be the result of spells and black magic versus those who were convinced that there were natural causes for physical disorders from minor irritations to life-threatening illnesses. Nonetheless, the passion about the causes of health problems that is felt by contemporary researchers and clinicians, policy makers and analysts, and suppliers of medical technology and pharmaceuticals sometimes seems as strong as any dispute between those convinced of supernatural cures versus those persuaded that science held the key to treatment and recovery from sickness and infirmity. Current discussions, however, are chiefly between those who subscribe to the biomedical model and those more attuned to the psychosocial roots of ill health.
All health care professionals, from the most technologically advanced physicians and surgeons to the most modest contributors in massive urban hospital complexes and remote health care clinics, need to be aware of the controversy—keeping in mind that both sides not only merit respect, but are also participants in a common cause. No matter how strong the advocacy of one of the competing models and its variations, the acknowledgement of a need for the contributions of both approaches is crucial for continuing excellence in the health care system.
Elizabeth A. McGibbon is clearly an advocate for the importance of social circumstances as prime determinants of health. No matter what methods and techniques are deemed superior once a serious disease is detected, she represents the view that diseases need not develop as frequently or as virulently as they do, if proper steps are taken before the affliction has had a chance to develop. Health promotion and disease prevention are critical elements of any system that hopes to reduce illness before the need for more expensive and sometimes less effective critical intervention and chronic care. Despite the wisdom of the pre-metric adage that “an ounce of prevention is worth a pound of cure,” the message does not seem to have gotten through to political and economic interests which manage disproportionately to fund “cure” at anywhere up to fifty times the budgetary resources dedicated to “prevention”.
In Oppression, McGibbon has assembled a collection of contributions that carefully identify the intricate relationships among each of the well-defined social determinants of health (SDH). More significantly, she provides a superb basis for understanding the mechanisms by which oppression is a common factor linking inequities in age, social class, race and ethnicity and gender and, ultimately, determining population health.
The “Introduction” broadly describes these interconnections from a Canadian perspective while, at the same time, specifically articulating the general intent of the book—namely, forwarding the notion that oppression has been well entrenched within society, that it is ideologically sustained by neoliberalism and enabled by globalization, and that the power differentials and relationships among people of different backgrounds and circumstances lead to the inequitable relationships with respect to the SDH.
McGibbon states that her experiences of direct exposure to and professional engagement in frontline work involving mental health issues and homelessness have been important influences in choosing the material and, most importantly, developing the theoretical foundation and purpose of the book. With this background made open and transparent, McGibbon goes on to implore readers to take a critical perspective when examining the SDH. She does this with the aim of underscoring the origin of countless associations involving inequity and thereby exposes the moral imperative that accompanies such a critical approach.
Crucial to understanding her work is a clear definition of the title: “oppression.” Oppression, she says, “is discrimination backed up by systemic or structural power, sometimes referred to as institutional power, including government, education, legal and health system policies and practices.” It is, therefore, not merely the fact of poverty, misogyny or racism, but the way in which these prejudices are expressed in concrete social relations. It is more than unfairness in ideas; it is injustice in personal and political action. At the same time, McGibbon and her colleagues do not fall into the trap of subscribing to a narrow, political ideology. Their consistent focus is on concrete experiential engagement with conditions as they are, unconstrained by the demands of abstract social theory and empirically detached strategies for social change. McGibbon writes: “My compass for this book rests in my years of clinical work on the pointy edges of material and social deprivation … In order to make meaning of what I witnessed, early on I discovered that the sheer enormity of unfairness and relentless everyday injustices must surely have a source, a catalyst, an engine.”
In order to develop her analysis and share the type of understanding that she learned “on the street,” McGibbon has organized the book into three parts. The first, entitled “Politicizing Health”, explicitly examines the asymmetrical power relationships of oppression and their relation to health. The second, “How Oppression Operates to Produce Health Inequities”, delves into specific health outcomes and how the relationships and structures previously discussed perpetuate instances and patterns of ill health. Finally, “Toward Structural Change”, offers several perspectives and approaches to alter the systemic prejudice that frequently accompanies and propagates the social inequities that are at the root of many SDH.
A Canadian frame of reference is retained throughout the book. All of the contributing authors are Canadian, and many of the concepts and ideas utilized have been developed in a Canadian context. This is partly due to the fact that the concepts of inequity and oppression are used far less often in other countries (the United States in particular); instead, inequality—a merely statistical, ahistorical and apolitical measure—is generally the focus of examination, study and policy recommendation. Inequality is easily accepted within liberal, pluralist analysis that recognizes problems, but does not go beyond the framework of sociological stratification studies toward a workable political solution. Accordingly, the moral imperative that McGibbon brings is apt to be much reduced, if not abandoned, when inequity is not treated as the focal point.
A Canadian book focusing on SDH would, of course, not be complete without the inclusion of its principal Canadian champion, Dennis Raphael (2010, 2011, 2012) of York University. Raphael has contributed the concluding chapter to the opening section, entitled “Critical Perspectives on the Social Determinants of Health”. He provides an overview of various popular discourses on SDH and their relation to both public policy and political perspectives. The Canada Health Act is also prominently mentioned at various points throughout the work, mostly to draw attention to the legislated core values that exist within Canada and, thus, to remind readers that health is not just a matter of isolated individual diagnosis, prognosis and treatment, but also an essential element in the maintenance of the community as both a practical and an ethical set of human relationships.
The notion of prejudice is unpacked near the start of the book by McGibbon herself. Instead of “pre-judging”, the narrative throughout the work urges a consideration of health as a human right, a material manifestation of justice, and a proper legal approach to the topics at hand. Many of the concrete, structural recommendations that are made near the close of the book make reference to human rights and justice as a response to prejudice. The common theme is reiterated throughout.
A book of this nature would also be incomplete without reference to the “causes of the causes” of ill health, a phrase initially coined by Link and Phelan (1995). Not only does McGibbon make reference to this in the preface, but she also does an excellent job of ensuring that it remains a strong theme throughout the book. The collection is complete and thorough, including discussions regarding (im)migrant health, a topic of increasing concern in some sectors of Canadian society. Adding to the depth of the compilation, Foucault’s influence is apparent in several articles—an essential reference point in any contemporary discourse regarding relationships of power.
On a personal note, I believe the book develops an important idea that would enlighten many individuals working within the social realm of health and wellness. Although many of my colleagues are quite aware of the SDH and the various health outcomes resulting from current social and economic conditions, it is as if the extensive literature reiterating relationships and “causes of causes” circles the core issue without locating its root. McGibbon’s emphasis on oppression incorporates the diverse themes concerning class, race, gender that have been explored as specific dimensions of a problem (Grabb, 1997), but not brought together in a theoretically coherent way. McGibbon presents the central idea of oppression and frames it in an innovative and intriguing way as the cynosure or central guide to understanding a host of related variables in the explanation of health issues.
The only minor drawback lies in the third part where recommendations are made regarding substantial structural change. Most of the book maintains a consistently Canadian focus, but some of the concluding essays lack a Canadian focus and seem to stray into global discussions, for which a sound evidentiary base has not been established. Nevertheless, the final chapter does indeed bring both the national and the global perspectives together in a satisfying ending.
Overall, McGibbon has produced an excellent work that offers an accurate depiction of power relations as they relate to health from a paradigm consistent with many in the field of the SDH, especially health promoters. It would be beneficial if more health professionals, students and members of the public alike became aware of the critical thinking present in this book.
Grabb, E. G. (1997). Theories of Social Inequality: Classical and Contemporary Perspectives, 3rd edition. Toronto: Harcourt, Brace & Company.
Link, B. G. & Phelan, J. (1995). “Social conditions as fundamental causes of disease,” Journal of Health and Social Behavior Spec. No:80-94.
Mikkonen, J. & Raphael, D. (2010). Social Determinants of Health: The Canadian Facts. Toronto: York University School of Health Policy and Management.
Raphael, D. (2012). Tackling Health Issues: Lessons from International Experiences. Toronto: Canadian Scholars’ Press.
Raphael D. (2011). Poverty in Canada: Implications for Health and Quality of Life, 2nd edition. Toronto: Canadian Scholars’ Press.
Raphael, D. (2010). About Canada: Health and Illness. Halifax: Fernwood Press.
Lexy Smith-Doughty's academic background is in Health Science (University of Western Ontario) and Public Health (University of Toronto). She is currently a Research Assistant with the Centre for Addiction and Mental Health in Toronto and will begin studies for her J.D. degree in the Faculty of Law at the University of New Brunswick in 2013. She can be reached at firstname.lastname@example.org.