Introduction
In recent decades, public health discourse has embraced terms like social, commercial, environmental, and political determinants of health. At first glance, this vocabulary expands the traditional scope by acknowledging that health depends not only on hospitals and doctors but also on employment, housing, education, food, markets, and power. The language seems to bring the real world into health conversations. However, beneath this surface lies a stronger continuity than the proclaimed novelty.
The Semantic Trap
The notion of “determinants” appears critical and modern but preserves the causal logic that has organized public health since the 19th century: “something acts upon something.” Previously, it was bacteria causing disease; now it’s poverty, unemployment, cheap alcohol, or fiscal policies. The conceptual structure remains the same: external factors produce internal effects. While the vocabulary is renewed, the mental syntax does not change. Health continues to be viewed as a result of manageable impacts, an independent variable in an equation seeking to identify, classify, and control threats.
Defining Health by Absence
The first semantic trap lies in calling these factors “determinants of health,” which strictly are determinants of disease. The name has changed, but the essence remains. Health is defined by subtraction—the absence of risk. Capabilities for vital living are reduced to an epidemiological residue: what remains after intervention has, with varying success, reduced countable damages. A country “gains health” when it loses deaths or hospital admissions. We measure what disappears, rarely what emerges. The determinants’ language reinforces a view where life matters less than loss.
The Political Implications
This text participates in a conversation that includes critical Latin American epidemiology and recent reviews of the social determinants framework. However, it proposes shifting focus to the linguistic and epistemological trap that nearly makes it impossible to think of health as a vital process rather than merely the absence of disease.
Semantic Displacement
The semantic shift towards the positive—”determinants of health” instead of “causes of disease”—softens conflict. It’s more comfortable to talk about health than illness, and more neutral to say “social determinants” than “structures that sicken.” The term choice depoliticizes the phenomenon. Positive language turns harm into a technical variable, inequality into a gradient, and injustice into a statistical coefficient. Labor exploitation, racism, or patriarchy appear as “associated factors,” never as power relations organizing bodies and territories.
Maintaining the Status Quo
Large models that introduced this way of seeing—from the Lalonde Report to Dahlgren and Whitehead’s diagram—expanded the map but not the episteme (Dahlgren & Whitehead, 1991). They showed layers of influence, concentric circles, and social gradients. However, they maintained the logic of factors acting on individuals. Global public health adopted these frameworks because they allowed incorporating social themes without touching the technical foundations of health governance: indicators, goals, international comparisons. Latin American authors noted that the emphasis on “determinants” left the “social determination of health” in the shadows: not only influencing factors but historical processes producing ways of living, getting sick, and dying.
The Laboratory Episteme
The laboratory’s episteme—which prioritizes controlled observation, variable separation, and certainty pursuit—was almost intact in health social studies. Even when discussing inequality, the dominant ambition is to measure, classify, and predict. Complexity is reduced to managing multiple factors; what appears as a holistic approach is, in reality, a multifactorial one: more pieces but the same machine. Social life is treated as an aggregate of variables rather than a web where relationships matter more than elements. This operation loses precisely what critical epidemiology and authors like Nancy Krieger have tried to recover: the link between bodies, history, and power (Krieger, 2011).
Commercial Determinants of Health
The notion of “commercial determinants of health” illustrates another facet of this trap. The expression aimed to expose the role of tobacco, alcohol, ultra-processed food, or artificially sweetened beverage industries in disease production. However, the term itself is contradictory: the market doesn’t determine health; it causes harm. Presenting it as a “determinant of health” softens the conflict and adapts it to technical language. Structural critique becomes a manageable category. The industry moves from being a responsible actor to a measurable factor. Instead of asking about the economic organization making these products and strategies possible, we focus on quantifying exposures and relative risks. The issue becomes statistical rather than political.
The Success of Determinants
This operation isn’t innocent. The determinants’ discourse allows harm to be visible without naming the actors who produce it. It enables denunciation without causing too much discomfort. This language is compatible with a world that celebrates evidence while avoiding structural conflict. Social determinants flourished because they were neutral, not demanding an examination of the structures that produce them, and could be incorporated without reconfiguring the existing order.
Measuring What Matters
The asymmetry between what’s named and what’s silenced also appears in how we measure. Our information systems meticulously record deaths, hospital admissions, new cases, risk factors, and years of life lost. Conversely, we lack consistent metrics on community links, autonomy, life purpose, or mutual care capacity. The statistical apparatus supporting public health was designed to pursue disease, not understand health. Thus, the determinants’ trap isn’t in what they say but in what they prevent us from thinking: the more we refine damaging measurement, the fewer words we have to name the life we aim to sustain.
Overcoming the Barrier
Overcoming this barrier requires returning language unique to health, recognizing it as a vital process, a capacity for relationship, and a possibility of meaning. Adding new determinants or multiplying analysis levels isn’t enough; a deeper transformation is needed: shifting from the impact logic to interaction logic, fragmented causality to relational understanding, and from a control science to a life science.
This doesn’t mean abandoning measurement but measuring differently: relational factors instead of objects, observing without context amputation, and translating complexity without betraying it.
Conclusion
The determinants’ trap, ultimately, isn’t due to technical insufficiency but conceptual success. They allow discussing justice without naming injustices, health without naming life, and prevention without mentioning care. They name health while reinforcing the episteme that makes it invisible. Perhaps originality no longer lies in inventing new determinants or adding adjectives to the “health” word, but in something simpler and more demanding: daring to name the life we want to defend and the kind of world that makes it possible.
References
- Dahlgren, G., & Whitehead, M. (1991). Policies and strategies to promote social equity in health. Stockholm: Institute for Futures Studies.
- Krieger, N. (2011). Epidemiology and the people’s health: Theory and context. New York: Oxford University Press.
*The author is a Tenured Professor in the Department of Public Health, Faculty of Medicine, UNAM and an Emeritus Professor in the Department of Health Measurement, University of Washington.
[email protected]; [email protected]; @DrRafaelLozano
