Journal Issue: Children with Disabilities Volume 22 Number 1 Spring 2012
The Impact of Technical Innovation on the Social Determinants of Health
A full understanding of the relationship between technical innovation and social patterns of health and disease has long been hampered by antagonisms in disciplinary approaches and political ideology. Social disparities in health are rooted in social forces and societal stratification virtually by definition. A World Health Organization Commission on Social Determinants of Health and a televised documentary series on this issue have recently emphasized this point.47 However, recent decades have also witnessed unprecedented technological advances in health care driven by a strong belief in the capacity of medical, largely technical, interventions to improve health outcomes. The task of understanding the role of technology in improving the health and well-being of children with disabilities will, therefore, require some reconciliation, if not integration, between these two perspectives and domains of empirical analysis.
A History of Antagonism
Tensions between the social and technical perspectives can be traced to the earliest use of health statistics to support improvements in public health. Victorian reformers, making good use of newly available vital statistics data, drafted a series of public reports calling attention to the distressingly high levels of mortality among children living in poor areas of industrializing Europe.48 This documentation, particularly the classic Report on the Sanitary Condition of the Labouring Population of Great Britain in 1842, brought long overdue public attention to the plight of the urban poor by laying out in cold statistics the unmistakable message that poverty meant more than hardship: it also meant death.49 While progressives of all types saw these reports as strong justification for reforms, there quickly emerged some very real tensions in the precise role that social and technical approaches should play in any public response. An influential group of reformers, led by Florence Nightingale and Edwin Chadwick, framed the disparities in mortality as the product of poor sanitary conditions, including overcrowded housing, inadequate sewage, and contaminated water. For this group, the focus was on improvements in public engineering, largely technical sanitary reforms, with little direct concern for the social or political claims of the poor.50 This perspective tended to elevate the technical above the social, hygiene above injustice. Although clearly a call for remedial public action, this call was advocating the eradication of unsanitary exposures rather than of the social forces that shaped them.
Other reformers, however, saw the alarming disparities in health and disease as evidence of inequities in economic relations and political power. For example, Friedrich Engels used tabulations of disparate child mortality to support calls for systematic changes in basic economic structures and political control.51 Similarly, Rudolf Virchow, a father of modern pathology, recast epidemics and inequalities in health outcomes as the product of social forces and local political conditions.52
In many ways, these tensions between technical and social perspectives have continued to characterize analytical approaches to disparate child health outcomes both in the United States and globally.53 In the early 1900s, the Children's Bureau, the major federal agency concerned with improving maternal and young child health at that time, attempted to link the establishment of technical programs with more basic arguments regarding the social plight of young families in poor urban and rural settings.54 Later in the century, growing technical capacity and a strengthened medical profession led to a refocusing of federal attention on technical approaches to improving child health.55 This trend was greatly accelerated by the creation and rapid expansion of the Medicaid program, which dramatically shifted federal funding to frankly medical interventions.
The Interaction between Technical Innovation and the Social Determinants of Health
In some measure, the recent elevation of the social determinants of health in public discourse is a regulating response to the dominance of the technical world during the past several decades. In addition, strong disciplinary impulses help generate tensions between these two different approaches. For those who elevate social causation as a focus for public response, the utility of a health indicator like the child mortality rate lies in its capacity to reflect the human impact of larger societal forces. In this sense, child mortality acts as a kind of social mirror, serving as a stark, ultimate expression of deep, often complex social influences. For those who embrace clinical or technical strategies, on the other hand, the very purpose of technical intervention in a setting of material deprivation is to uncouple poverty from its implications for health. Here, the intent is to use technical capacity not to alleviate poverty but to reduce or eliminate its power to alter health outcomes. In this manner, the goal of technical intervention is to eradicate child mortality's linkage to social causation; the ultimate goal is to create equity in child mortality regardless of the scale of persistent social stratification. For the clinician, success is defined as eliminating child mortality as a social indicator, thereby challenging the very premise of the disciplines that use child mortality as a reflection of the social determinants of health.
The reality is that technical innovation does not truly undermine the power of social causation; but it can radically transform the mechanisms by which social forces exert their profound influence. At a basic level, adverse social influences on a health outcome elevate risk in a population or reduce access to effective interventions, or both.56 This "dual currency" approach to the etiology of social differences in health outcomes, while simplistic, can nevertheless help disentangle complex disciplinary discourse and offer an analytical footing that can begin to bridge the perspectives that have traditionally separated the social causation and technical realms. This general approach has also been constructively used to reframe socioeconomic status less as a modifier of a disease pathway than "as a fundamental cause of disease."57 This formulation has stressed the multiple and often complex means by which social forces can exert their influence on health and the variation by which these influences can act over time.
Of central importance, and what ultimately determines the relative role of risk and access in shaping patterns of outcomes, is the efficacy of the intervention in question. Here, efficacy is defined as the power of an intervention to alter outcomes. Interventions wholly without efficacy are not likely to generate differences in outcomes regardless of whether differences in access exist. When interventions are ineffective, differences in underlying risk status will be the dominant cause of disparities in outcomes. When the efficacy of intervention is high, however, then differences in access to these interventions may be the dominant source of disparities in outcomes. The nature of the intervention, be it preventive or therapeutic, low-tech or high-tech, makes little difference; the crucial issue is its proven efficacy. This pivot on efficacy helps underscore the role that technical innovation can play in shaping disparate patterns of health outcomes.
In a period of unprecedented technical innovation, efficacy must be viewed as being exceedingly dynamic, reshaped and expanded with each new discovery or invention that is shown to alter outcomes or improve function. If technological innovation enhances efficacy, then access to technology will become more important. Hence, as efficacy grows, so too does the burden on society to provide access to technology equitably to all those in need. In this sense, when equity in health outcomes is an agreed-upon social goal, technical innovation places a burden on delivery systems, making outcomes increasingly sensitive to even small differences in access.
A consequence of this role of efficacy is that in a socially stratified delivery system, technical innovation has the ability to widen disparities in outcomes as well as to reduce them. A growing body of evidence is showing that social disparities in mortality are greater for diseases that are considered preventable, in essence, those that have known, efficacious, technical interventions.58 Virginia Chang and Diane Lauderdale documented a reversal in social disparities in cholesterol levels after the introduction of statin medications: before statins were introduced, higher social status conveyed an elevated risk for high cholesterol, but after they were introduced, high socioeconomic status was associated with lower risk of high cholesterol.59 Disparities have also widened after the introduction of some highly efficacious interventions, such as immunizations, cardiac surgery, and antiretroviral therapy. Similarly, if new technologies worsen outcomes or have adverse side effects, then enhanced access to these technologies among socially advantaged groups could reduce observed disparities in outcomes. For example, while assisted fertility therapy has proven highly efficacious in enhancing fertility among women and couples desirous of childbearing, it is also associated with multiple gestations and premature birth. It was not surprising to observe, therefore, that as wealthier populations were able to make greater use of these new fertility therapies and techniques, white prematurity rates rose, reducing the disparity in premature birth rates between white and African American women. Technical innovation, therefore, is inherently neutral in its effect on health disparities; its ultimate impact is determined by its efficacy (including adverse effects) as well as by social patterns of diffusion. Therefore, new or improved technologies for children with disabilities may or may not reduce disparities in disabilities or their impact on the daily lives of affected children. Rather, close examination of the interactions between the technologies, the distribution of need, and access will always be required.