Healthy Cities: Old and New Solutions - Theme Cities: Solutions for Urban Problems - page 492

13﻽5 Addressing the Determinants of Health

The so-called 'health field' concept promoted by a former Canadian Minister of Na-
tional Health and Welfare (Lalonde 1974 ) is often regarded as an important marker
of a renewed emphasis upon public health after its dominance faded from the 1880s
once urban environmental conditions improved. The health field approach moved
away from an emphasis upon medical care alone, by stressing the need to inves-
tigate all four key categories of the factors that affect health: human biology (all
factors related to the body, including genetics); environment (all features outside
the body that affect health, but over which individuals have little control); life-style
(personal decisions made by individuals that affect health, such as drug-taking etc.);
and provision of heath care facilities (their quality, availability and accessibility of
health care). Other studies have provided alternative versions of the main categories
of what are now known as health determinants, sometimes in diagrammatic form
(Dahlgren and Whitehead 2006 ). These summary features have been extended by
more recent research that has shown the need to look more closely at a subset of
these determinants that are often overlooked, namely how various characteristics
of the social realm—such as the effect of the socio-economic inequalities, or from
stress or social exclusion—influence health outcomes. These factors are part of
what are being described as the social determinants of health (Wilkinson and Mar-
mot 1999 , 2003 ), although the term has sometimes been used to categorize most
determinants under the 'social' title (LCC 2012 , p. 6).
These summaries of the various health determinants provide useful initial de-
scriptions of many of the relevant groups of factors that influence ill-health. But it
does seem worthwhile to extend and re-arrange the ideas to provide a more compre-
hensive view. In Fig. 13.1 eight broad domains of factors that influence health are
identified together with the surroundings contexts. Within these health determinant
categories, examples of the more specific factors can be identified which have del-
eterious effects on health. Many of these were not routinely dealt with by current
health care systems, but are now being more closely investigated by epidemiolo-
gists and other researchers. These domains may be initially considered as separate
categories of related factors for the sake of clarification; in reality many often com-
bine with one another to create ill-health, especially in our complex, multi-faceted
urban places. Also, many of the factors have two-way relationships with one anoth-
er, including modifications on human biology through epigenetic processes linked
to life-styles or environments that affect the operation of genes. Moreover, some of
the features are directly linked to disease; others take more time to cause ill-health.
But the influence of all these factors cannot be discounted when evaluating health
in an area, since they provide the background conditions that lead the body to be
weakened and prone to specific diseases. Although these factors can be looked at
individually, in practice they combine in a spatial context to create differential place
characteristics, not simply in physical or built-environment terms but also through
the economic and social environmental characteristics and life-style choices. This
ensures that each location will have very different risks and protections for health