Introduction
While the notion that health depends on social conditions may seem obvious to many, this idea has a long and complex history filled with conceptual disputes. The term “social determinants of health,” which we use today, is not the product of a recent discovery but rather the outcome of a process where different traditions within public health attempted to answer an insistent question: why do certain populations fall ill and die more than others?
Historical Context
In the 19th century, British sanitarians faced the health hazards of industrialization. Edwin Chadwick documented how working conditions and urban overcrowding produced distinct disease patterns across social classes. William Farr’s statistical work revealed that mortality was not random but systematic and deeply unequal. The sanitarians pioneered linking disease to social conditions, but their approach had clear limitations. They identified disparities from a Victorian moral standpoint, viewing poverty as a social problem threatening the health of others. Their focus was on intervening in environments rather than questioning the social order generating them, yet they laid the groundwork for public health to shift from individual-centric views to considering collective life.
The Evolution of Public Health Thought
A century later, international public health embraced this sanitarian insight, now known as “social determinants of health.” Government reports, commissions on inequalities, and concentric models with biological, behavioral, and structural factors transformed old concerns about living conditions into globally accepted technical language. This narrative significantly expanded the explanatory landscape without altering the underlying thinking that conceives health as a result of quantifiable external forces.
The Rise of Social Determination
In parallel, a distinct tradition emerged in Latin America: social determination of disease. Unlike determinants, which listed conditions, social determination sought to comprehend historical processes shaping bodies and populations. A conceptual rupture occurred here.
Key Differences Between Social Determination and Social Determinants
- Ontological: No sharp separation between the biological and social; the body is a terrain where history is inscribed.
- Causal: Shifted from linear causes to complex, interconnected processes.
- Political: Disease ceased to be a simple “impact” and became an expression of social order.
Social determination did not merely broaden the map; it changed the paradigm. It introduced a distinct way of imagining public health, integrating structure, territory, history, and body dialectically. The question then becomes: why did such a significant rupture fail to become the dominant framework?
Barriers to Social Determination
Two primary reasons explain why social determination did not become the dominant framework. First, a technical reason: contemporary public health organizes around an evidence regime dependent on standardized measurements. What cannot be quantified is difficult to turn into policy or international recommendations. Determinants of health thrived because they could be translated into time series, gradients, and models—tools adaptable to graphs and tables. Social determination, however, articulated historical processes without producing stable quantitative tools for integration into the global statistical apparatus. It lacked cross-cutting indicators and comparable algorithms, limiting its potential as a governance tool for health.
Second, a political reason: social determination emerged in dialogue with historical materialism and explicit critiques of the dominant model. This association made it ideologically marked for multilateral organizations seeking neutral technicality, at least in appearance. Determinants of health, conversely, offered a language that allowed discussing inequality without pinpointing responsible parties and proposing administrative interventions without challenging the structure producing that inequality. The governable became hegemonic; the critical, marginal.
Towards a Complex Public Health
The genealogy reveals that the issue wasn’t the validity of social determination but its incompatibility with the institutional regime organizing global public health. Its critical potential couldn’t find a place in a system prioritizing manageable categories over structural interpretations.
Moreover, despite its conceptual audacity, social determination didn’t resolve an underlying epistemological void. Both approaches—determinants and social determination—treated health primarily as an effect, whether negatively in the former or dialectically in the latter, rarely acknowledging health as something actively constructed and sustained over time.
Here, the genealogy opens a fertile space. The challenge today isn’t choosing between determinants and social determination but recovering the ability to think of health as a dynamic process rather than an outcome. It’s not about inventing a new label but shifting perspectives—from static factors and structures to relationships shaping health; from damage indicators to sustaining capacities; and moving beyond linear cause-and-effect thinking to understanding complex relationship networks producing life organization forms.
In this horizon, measurement remains crucial, but the question changes: what relationships are we measuring? Which life webs do we make visible and which remain obscured? Thinking about public health through complexity means abandoning the simplistic notion of health as mere absence of disease and embracing it as an emergent property of interacting living systems.
As Carlos Maldonado posits, the goal is to think health—not just disease—within the framework of current scientific revolutions, where life and health can be understood as moving information (Maldonado, 2018).
Recommended References
- Breilh, J. (2013). La determinación social de la salud y la epidemiología crítica. Buenos Aires: Lugar Editorial.
- Maldonado, C. E. (2018). Complejidad y salud pública. Marcos, problemas, referencias. Revista Salud Bosque, 8(2), 83–96. https://doi.org/10.18270/rsb.v8i1.2497
*The author is a Professor at the Department of Public Health, Faculty of Medicine, UNAM and Emeritus Professor at the Department of Health Measurement, University of Washington.
The opinions expressed in this article do not represent the position of the institutions where the author works. [email protected]; [email protected]; @DrRafaelLozano
