The social determinants of health: what are the three key roles for health promotion?

Renewed interest in the social determinants of health represents yet another cycle of recognition of their importance that began in earnest in the 1850s with the writings of Frederich Engels1 and Rudolph Virchow.2 For more contemporary health promoters, the focus on early life, education, employment and working conditions, food security, health care services, housing, income and its distribution, social safety net, social exclusion, and unemployment and employment security3 produces a déjà vu experience recalling the Ottawa Charter’s health prerequisites of peace, shelter, education, food, income, stable ecosystem, sustainable resources, social justice, and equity.4 There was excitement then about addressing these structural determinants of health. There is excitement now about addressing the structural determinants of health. Restraining this enthusiasm and its policy outcomes in 1986 was the reality that the world’s English-speaking nations were on the cusp of a neo-liberal resurgence in public policy that served to effectively squash attempts to restructure society in favour of health.5 Now, 20 years later in the midst of neo-liberal inspired economic globalisation, we are again being urged to identify and modify the structural determinants of health that have since decayed in the interim.6 How likely are we to succeed in these efforts?