Dedicated to my fourth child and only son, Race – a lost boy amongst the girls!

Dedicated to my parents Gail and Clifford Dunn – I am so proud of you both.
Love always.

In Global Health Studies: A Social Determinants Perspective we have adopted a specific approach to exploring the health issues that affect us all living in our world today. Rather than taking an epidemiological or pathological approach, as other books in this area often do (and do well), we use a social scientific lens to critically consider global health. This enables us to forefront the importance of the social determinants of health (SDH). That is not to say that the physical and biological aspects of global health are not important; in fact, we do make mention of these at times. However, like many others, we believe that a social scientific perspective brings a new, valuable dimension and that it offers alternative understandings and potential solutions to current global health issues. We believe that our approach is unique within the global health literature and that this offers a new way of examining contemporary global health issues.

Traditional approaches to global health tend to draw on biomedical and epidemiological understandings and explanations, whereas we focus our attention on a range of issues and problems that are explored through a social scientific lens. This necessitates looking first at the historical context underpinning today’s global health approaches. Global health today is seen in a very different light from how it was understood in the past: previous events, such as technological medical developments, advances in drug treatments as well as less positive influences, for example colonialism, all serve to shape the contemporary landscape. European colonization had an impact on the health of many indigenous populations with the spread of diseases such as smallpox, destructive environmental impacts and widespread oppression. Concerns remain today in relation to the dominance of the global north, the advantaging of the agendas of more powerful countries and the many remaining challenges associated with the health of the most vulnerable. Many remain critical of the reach both of global health policy and of interventions, particularly when asking why the poorest and most vulnerable still have the worst health. So, despite progress in many areas, including the eradication of smallpox, much work remains to be done. We argue throughout this book that contemporary global issues and health challenges are related to power, policies and the social context underpinning them. Social determinants are part of the causal pathway of many global health challenges, and remain linked to communicable and non-communicable disease patterns.

While health has improved in many global contexts, numerous challenges remain. The world has experienced an epidemiological transition in which populations grew as a result of medical advances and improved standards of living, but this has not resolved all health problems. Many of the world’s inhabitants are still exposed to vulnerabilities associated with poverty and inequality and infectious diseases are therefore still an issue in many contexts. Furthermore, the increasing rate of NCDs can be linked to rapid urbanization that runs alongside contemporary lifestyle patterns. Inequalities remain prevalent and are increasing in several places; we pay attention to them in this book using a social scientific lens.

A social scientific lens necessitates a social determinants approach. The importance of social determinants in shaping health and health experience has been highlighted by the work led by Sir Michael Marmot and his team in the Commission on Social Determinants of Health (CSDH). This work emphasizes the ‘causes of the causes’: namely, how the conditions in which we live our lives directly and indirectly affect our health. Closer examination of these conditions tends to show that those who live in relative disadvantage suffer more than those who are better off (whether financially or socially). This leads to inequality and inequity and, ultimately, comes down to issues of social justice. As will be seen, equity, equality and issues of power are key themes within this book.

A social determinants perspective differs considerably from biomedical or epidemiological perspectives. It is concerned with identifying and addressing avoidable differences in health at a global level – that is, differences that exist because of social factors rather than biological ones, for example socioeconomic status, education and housing. Using a social determinants perspective means examining such factors and the impact that they have on health outcomes and health experience. Throughout this book, we draw on a range of different issues to illustrate how global health can be viewed using a social determinants lens. The World Health Organization (WHO, 2017) defines the social determinants of health as ‘the conditions in which people are born, grow, work, live, and age, and the wider set of forces and systems shaping the conditions of everyday life’. Further, the WHO purports that this ‘includes economic policies and systems, development agendas, social norms, social policies and political systems’.

Central to a social determinants perspective are issues of equity and equality and, as such, these recur as key themes within this book. As you will appreciate when you engage with this text (or as you may already know), health inequalities and health inequities persist on a global scale within and between countries and regions. By health inequities and health inequalities, we are referring to the systematic, avoidable, unfair and unjust differences in health that exist across the globe and which are influenced by social circumstances (Satcher, 2010). Differences may be due to several factors, including social, cultural and geographical. These result in some groups of people experiencing poorer health outcomes than others. In this book, we outline what we see as some of the key issues and, with the reader, explore several potential responses to these.

Alongside issues of inequity and inequality, we also consider power as a key theme. You will note that we refer to issues of power in relation to many different things. We present a critical take on power, looking at who has power and who does not, and at how this impacts on health outcomes and health experience. Power is inextricably linked to social determinants. Generally, the wealthier someone is, the more power they have to affect change in their own lives and to influence others. Power also exists at a state or governmental level and is therefore tied up with political agendas and governance. Throughout the text, we come back again and again to such debates, illustrating how important power is to a social scientific examination of global health.

In addition to power and health inequalities, there are two other key themes within this book that we believe are of paramount importance in discussions of global health from a social science perspective. The first is a critique of neoliberalism and the second is ethics. For the purposes of our discussion, we conceive of neoliberalism as an ideology that privileges the power of the individual and assumes that individuals are in control of their lives, free to do as they wish. As a result, the role of the state in people’s lives is minimized. Responsibility for health therefore becomes private rather than public. Individualist explanations for health and health inequalities are tied up with neoliberal ideology. Individualist perspectives promote individual responsibility for health and a belief that health is located and created at an individual level. Efforts to promote health therefore centre on getting people to change their behaviour. In contrast, materialist or structuralist approaches to health and health inequalities purport that government and state have a responsibility for people’s health through providing structures that support good health – such as a quality education and access to health care services. In keeping with a social determinants perspective, we view materialist/structuralist explanations as more important for understanding global health experiences. Ethics is another important theme within the book, and we discuss this in more detail in various places in relation to different issues.

As part of the continuing work of the CSDH, a specific conceptual framework, developed by Solar and Irwin (2010) for the WHO, has been created to further an understanding of SDH. In brief, the framework aims to make sense of the hugely complex factors that impact on and determine health. ‘A key aim of the framework is to highlight the difference between levels of causation, distinguishing between the mechanisms by which social hierarchies are created, and the conditions of daily life which then result’ (Solar & Irwin, 2010).

The diagram of Solar and Irwin’s framework (see Figure i.1) brings together several theoretical concepts, including psychosocial, political, ecological and economic factors. Importantly, the framework distinguishes between structural determinants (social position/stratification and proxy indicators of this such as income, education, occupation, social class, gender, race/ethnicity) and intermediary determinants of health (material circumstances, psychosocial circumstances, behavioural/biological factors and, importantly, the health system). The socioeconomic and political context is incorporated, including issues of governance through macroeconomic, social and public policies. Culture and societal values also feature, as do social cohesion and social capital. In short, this results in a comprehensive framework, which lends itself well to considering global health from a social scientific perspective. For this reason, we have used it to underpin our discussion and we draw on the concepts within the framework to explicate our social determinants approach to understanding global health.

Each chapter discusses different aspects of Solar and Irwin’s framework in detail, with specific reference to certain issues in global health. Chapter 1 discusses the global distribution of health and wellbeing regarding global patterns of disease. Chapter 2 explores inequalities in global health specifically in relation to social position and material circumstances. Chapter 3 considers the wider determinants of health, specifically focusing on globalization and the uneven impact that this has on the distribution of health and wellbeing across the world. Chapter 4 focuses on global health systems and discusses the importance of health care systems in relation to global health. Chapter 5 centres on governance and policy exploring global health governance in detail. Chapter 6 takes the discussion about governance and policy further, looking at policies for health in a global context. Chapter 7 explores cultural and societal norms and values through mechanisms of global health protests. Lastly, Chapter 8 brings all the aspects of Solar and Irwin’s framework together in consideration of contemporary challenges for global health.

This book has several pedagogical features to enable the reader to explore issues in more depth and to critically reflect on the implications of some of the social scientific debates within it. Each chapter begins with a ‘key learning outcomes’ section to enable the reader to understand the purpose of it. Key points are summarized at the end of each chapter, in addition to ‘questions for reflection’, which will facilitate deeper appreciation. Four learning tasks are presented in each chapter that give the reader an opportunity to engage more actively with the content. Finally, each chapter ends with a detailed global case study that aims to bring the chapter content to life. Throughout the book, different international examples are drawn upon to illustrate the discussion. While we have not taken a topic-based approach to presenting material, as other books on global health do, we have drawn on a wide range of diverse issues to illustrate key points – these vary enormously, from climate change to reproductive health. Where topics are discussed, they are used to illustrate key points or ideas. For further depth on individual topics, readers are encouraged to look elsewhere.

In summary, we hope you enjoy reading this book as much as we have enjoyed writing it. We have both learned a great deal in doing so. We would like to acknowledge those who have supported us in the process: our families, friends and colleagues. In addition, we recognize the important role that our editor has played and the valuable input of those who have reviewed some of the content. Most importantly, we recognize the significant contribution that the students we work with from around the world have made to the development of our ideas and the motivation that they give us to write.