Two Paths to Health in All Policies: The Traditional Public Health Path and the Path of Social Determinants

In recent decades, public health has increasingly looked upstream to social determinants of health and their distribution in society for potential remedies to dominant causes of poor health and health inequity. This is clear in the visionary project of the World Health Organization Commission on Social Determinants of Health report.¹ It is also central in Healthy People 2020, the public health objectives of the US Department of Health and Human Services.² A prominent approach to incorporating social determinants within the purview of public health is referred to as Health in All Policies, the principle that because public health is rooted in many other, nonhealth sectors of society, public health practice should recognize and engage these other sectors. Rudolph et al.^3(p5) define Health in All Policies as “a collaborative approach to improving the health of all people by incorporating health considerations into decision-making across sectors and policy areas.” In conceptualization and in practice, however, two quite distinct paths have been taken toward the supposedly common end—Health in All Policies. I describe these alternative paths as the traditional public health path and the path of social determinants of health. In this editorial, I describe the conceptualization of these divergent paths, provide examples of both, acknowledge the contributions of the traditional public health path, and propose that the path of social determinants of health is a new frontier in public health that offers broad opportunities for research, collaboration, and public health benefit.

On the traditional public health path, standard public health practices (e.g., immunization programs, antismoking policies, and exercise programs) are disseminated and incorporated into the policies and practices of other agencies (Figure A, available as a supplement to the online version of this article at http://www.ajph.org). These host agencies adapt and incorporate the specified public health practices into their own routines. Rudolph et al. gives the following examples:

Health in All Policies builds on a long public health tradition of successful intersectoral collaboration, such as efforts to implement water fluoridation, reduce lead exposure, restrict tobacco use in workplaces and public spaces, improve sanitation and drinking water quality, reduce domestic violence and drunk driving, and require the use of seatbelts and child car seats.^3(p6)

The movement of knowledge and practice is from the public health sector to the other sector. The traditional public health path has yielded enormous public health benefit.

On the path of social determinants of health, the public health consequences of these other nonhealth sectors (e.g., the education system, the transportation system, and the justice system) are explored and cultivated for public health benefit within their programs and policies. Because the focus within these nonhealth sectors is on the subject of their own sector, health consequences may not be commonly recognized by practitioners, but health consequences are nevertheless at least plausible and worthy of exploration. On the path of social determinants of health, the movement of knowledge and practice is in the direction opposite to that of the traditional public health path (i.e., from the other sector to the public health sector); the recipient public health sector then adapts and incorporates the nonhealth sector’s knowledge and practice for public health objectives.

Not all of the policies and programs of other agencies need produce public health benefits. Some may have no health effects. Others may be harmful. For example, transportation policy that encourages automobile transportation rather than mass transportation may have extensive public health harms,⁴ as may policies that raise speed limits, eliminate helmet laws, raise allowable blood alcohol levels for drivers, increase limits of exhaust pollutants allowed, and so on. Public policies and programs have multiple stakeholders, motivations, interests, and consequences; policy decisions must be made among these.

TRADITIONAL PUBLIC HEALTH PATH: AN EXAMPLE

The National Prevention Council, established by the Affordable Care Act of 2010, brought together the heads of 17 Executive Branch cabinet agencies, including the Surgeon General (the council chair), the US Departments of Health and Human Services, Agriculture, Education, Transportation, Labor, Interior, Homeland Security, Housing and Urban Development, Defense, Justice, and Veterans Affairs. In 2011, the council formulated a National Prevention Strategy,⁵ including several of the principles suggesting an intention to follow the path of social determinants of health:

Many of the strongest predictors of health and well-being fall outside of the health care setting. Social, economic, and environmental factors all influence health. People with a quality education, stable employment, safe homes and neighborhoods, and access to high quality preventive services tend to be healthier throughout their lives and live longer.^5(p6)

If “many of the strongest predictors of health and well-being fall outside of the health care setting,” then these nonhealth care predictors should be included among the intervention armaments for health and well-being. However, all of the concrete recommendations in the National Prevention Strategy are traditional public health path options; none take the path of social determinants of health. The recommendations focus on seven priorities, including tobacco-free living, drug and alcohol abuse, healthy eating, and injury and violence prevention. The explicit note: “The Strategy prioritizes prevention by integrating recommendations and actions across multiple settings to improve health and save lives” again indicates the traditional public health path approach. The most recent Annual Status Report (2014)⁶ celebrates the following recent accomplishments of the National Prevention Strategy: increase in tobacco-free college campuses, school fitness testing, assistance to students for mental illness, and decrease in homelessness. These are successes, but with the possible exception of a decrease in homelessness, they are successes on the traditional public health path.

PATH OF SOCIAL DETERMINANTS OF HEALTH: AN EXAMPLE

A powerful example of the path of social determinants of health to Health in All Policies is the “One King County” program of King County, Washington, established in 2008. Framed as providing equitable opportunities for all citizens—“Equity and Social Justice”—health was just one of the outcomes of interest.

The King County program has focused on underlying social determinants for the promotion of well-being of all in the community. The project has provided half-price public transportation for residents with incomes below 200% of the poverty level, launched a program to build 700 units of affordable housing with access to public transportation, and enrolled 200 000 uninsured residents under the Affordable Care Act—reducing the proportion of uninsured from 16% to 10%—a combination of traditional public health path and path of social determinants of health.⁷ King County has had a major focus on the path of social determinants of health to Health in All Policies.

DIRECTIONS

Work on the path of social determinants of health to Health in All Policies may be divided temporally into retrospective and forward-looking enterprises, the latter probably the simpler of the two. In forward-looking Health in All Policies (i.e., health impact analysis), health consequences of diverse sectors are evaluated in the planning of policies and programs. In retrospective Health in All Policies, the policies and programs already in place in diverse nonhealth sectors are audited to assess possible health consequences. Beneficial nonhealth sector policies and programs then may be adapted and adopted into public health practice. Efforts may be made to mitigate those nonhealth-sector policies and programs with harmful public health side effects.

Separation of government functions into sectors may be a necessary evil of organizational efficacy in general and of government in particular; one cannot do everything at once, and narrowed focus has benefits. However, the construction of sectors, “silos,” also fosters inattention to cross-sector connections and obscures a need for their exploration and exploitation. The path of social determinants of health to Health in All Policies is a new frontier in public health, still relatively unexplored, but with great potential to advance public health research, collaboration, and benefit.