Response to Buse et al.’s letter to the editor

Dear Editor:

We would like to thank Buse and colleagues for their letter (Buse et al., 2022), sharing insights on our April 2022 commentary “Social, political, commercial, and corporate determinants of rural health equity in Canada: an integrated framework” (Leimbigler et al., 2022). Our commentary is intended to invite audiences to move beyond the social determinants of health and rethink other determinants of health from a rural equity perspective. In our proposed framework, we specifically highlight four determinants of health—social, political, corporate, and commercial—and how conversations around them have been largely separate; thus, we connect these as a starting point for showcasing the importance of an integrative and systematic approach to health.

Buse et al. (2022) make an excellent point that environmental and ecological determinants are foundational to all human health, rural or not. We agree, and it is interesting to ponder how environmental and ecological determinants could be incorporated into a rural health equity framework. Health inequity refers to disparities in health that are plausibly avoidable differences in health that adversely affect socially disadvantaged groups—distinguishing these from other health differences more generally (Braveman et al., 2011). In some ways, rural living Canadians may in fact be more advantaged environmentally compared to their urban counterparts—with greater access to natural as opposed to built environments, lower noise and air pollution, etc. Indeed, a recent review stressed the importance of considering environmental determinants of population health in urban settings (Salgado et al., 2020), but whether ecological determinants of health are a key rural health equity consideration deserves further investigation. It’s certainly possible to speculate potential inequities. For example, we mentioned industry withdrawal creating economic “ghost towns”, which could also encompass significant impacts on the environmental landscape (e.g., soil and water contamination) for years to come (Meissner, 2019).

Extractive industries (corporate determinants) are interconnected with rural health equity, and these environmental impacts are integrated in our framework and our figures. These determinants are also connected to the environment and ecological conditions of the regions, and further exploration of the power asymmetries between extractive industries and communities in rural areas is important for future research.

We approach the issue from an institutional perspective, aware that agency and power dynamics play a crucial role in shaping and configuring our conceptualization of determinants of health. Buse et al. (2022) point out the ongoing separation of health and environmental scientists’ approach to determinants of health. In our view, this may reflect an institutional bias in framing the determinants of health that primarily focus on individual and community health.

The real question the letter raises is how environmental or ecological determinants of health can continue to be better integrated into mainstream population and public health considerations. We invite further dialogue, critical analysis, and cross-disciplinary collaboration in considering possibilities for incorporating the ecological determinants of health in an integrated rural health equity framework.