Eco-social determinants of health
Carlos Lema Añón
The WHO defines the social determinants of health as “The social determinants of health are the circumstances in which people are born, grow up, live, work and age, and the systems put in place to deal with illness. These circumstances are in turn shaped by a wider set of forces: economics, social policies, and politics” (WHO, 2013).
The idea that socioeconomic conditions are key to health dates back to 19th-century health reformism and social medicine and highlights the essential figure of Rudolf Virchow (1821–1902). Virchow argued that people’s health is a social issue, that society must protect health, and that economic conditions significantly affect health and disease. All of this must be studied scientifically, so the approach to promoting health must be both social and medical (Rosen, 1993, p. 231). While social medicine, therefore, has European roots, the Latin American school of social medicine would be particularly prominent for much of the 20th century. Its approach, highlighting the link between the living conditions of the working classes, underdevelopment, and dependency as factors that generate disease, prioritized the adoption of measures and proposals for improvement characterized by a social rather than a medical approach—an orientation that, in part, influenced the Pan American Health Organization itself (Waitzkin et al., 2010).
However, the current relevance of the social determinants of health framework stems from the development of a series of multidisciplinary empirical studies since the 1980s. A key factor in this was the publication in Great Britain of the so-called “Black Report” in 1980 (based on data from England and Wales from the 1950s to the 1970s). Among its most notable findings, it showed that life expectancy was strongly linked to economic and social status—that is, to differences in social class and membership within those classes. This result was particularly striking in the British context, as it demonstrated that three decades of a universal health care system had failed to break the link between health and socioeconomic status.
The effectiveness of the social determinants of health framework led to the proposal of additional concepts to highlight and account for factors that determine the health of individuals and populations. This draws attention to the need, on the one hand, to take these non-medical factors into account in the design of public health policies, and to the fact that an unequal distribution of these determinants or unequal access to them would also lead to unfair health outcomes. Among these related concepts are the notion of commercial determinants of health, as well as certain concepts or frameworks for including the eco-social determinants of health.
The proposal of these explanatory frameworks may have the merit of drawing attention to the responsibilities of certain actors in the deterioration of health, or to the justification of certain public policies or regulations. Thus, the idea of commercial determinants of health can, for example, apply to certain companies in the food sector or to tobacco companies (Kickbusch et al., 2016). However, in this sense, commercial determinants of health are still social determinants of health, understood broadly.
In the case of the eco-social determinants of health, however, both international organizations and academic literature employ a variety of concepts, such as environmental health, environmental health risks, environmental determinants of health, ecological health, One Health, etc. (Armengual et al., 2025). Each of these terms expresses, with different nuances, the influence of environmental and/or ecological factors on human health. Thus, for example, environmental health refers to the public health approach that studies aspects of health determined by environmental factors. For its part, the concept of environmental health risks, as defined by the WHO in its strategy on health, environment, and climate change, refers to “all physical, chemical, biological, and occupational factors in the environment external to individuals, as well as all related behaviors” (WHO, 2020). The One Health approach, to mention one final example, highlights the interdependence among human, animal, and environmental health, although it appears largely oriented toward the prevention of zoonoses.
The existence of this plurality of concepts and conceptions suggests that there is no common framework for discussing the relationships between health and nature in the context of the eco-social crisis. And the truth is that each of them involves a series of starting points, basic assumptions, and, in general, approaches that are not always compatible with one another. In any case, it is worth highlighting, in general terms, some virtues and risks present in these approaches.
It is noteworthy, first of all, that, in contrast to traditional biomedical perspectives, all these proposals emphasize collective, preventive, and, logically, environmentally connected aspects. With regard to the collective aspect, rather than focusing on the health of each individual, all these perspectives propose considering the collective and social aspects that affect and determine health at the population level. This is evident both in the concept of health being used and, especially, in the proposals for preserving, improving, or restoring health, which also target the collective and interventions that are not limited to the individual. In this regard, significant emphasis is placed on preventive interventions: once the determinants of health have been identified, the aim is to reduce associated morbidity and mortality through interventions targeting those determinants. This is a feature shared by approaches based on the social determinants of health, but what the perspective of socio-environmental determinants contributes, in any of its forms, is precisely the incorporation and prioritization of environmental aspects and those related to the eco-social crisis that affect health (see Eco-social justice).
That said, the specific way eco-social aspects are incorporated affects the main risks posed by certain proposed formulations and frameworks. To systematize, we could call them anthropocentric risk and technocratic risk. Regarding the former, although it is possible to adopt more ecocentric approaches to health, a moderate degree of anthropocentrism is not necessarily a problem, insofar as it is simply a matter of perspective or starting point regarding human health. Anthropocentrism becomes a limitation to the extent that it implies a dualistic view that separates humans from an external nature to be dominated. Thus, for example, some perspectives based on the idea of environmental health risks would represent this view. Technocratic risk is to some extent related, insofar as it treats environmental determinants as a sort of external risk, disconnected from human action and its place within nature. A technocratic approach would treat environmental determinants as and manage them in a depoliticized manner. Precisely to avoid this risk, it is preferable to adopt the terminology of eco-social determinants of health.
The importance of non-medical determinants of health for population health and health disparities is enormous. Historically, the greatest advances in health have been due to social reforms regarding working conditions (abolition of child labor, reduction of the workday, social protection of labor), poverty reduction, improvements in living conditions, food security, etc., to a greater extent than those resulting from medical advances (Hofrichter, 2000; Porter, 1999, p. 79 ff.). Therefore, it cannot be assumed that the sole, privileged, or most efficient way to protect health is one based on individual medical intervention regarding disease. Conversely, the negative impact of social and eco-social determinants of health is also significant. Considering, for example, the health effects of climate change, we have already witnessed a 63% increase in deaths caused by extreme heat compared to 1990 (Romanello et al., 2025); but the impact on health from its effects can also stem from other extreme weather events (storms and floods), the spread of infectious diseases, food and water insecurity, loss of livelihoods, conflicts over resources, etc. (see Socio-environmental conflicts)
Let us also bear in mind that the earliest conceptualizations of environmental justice emerged in response to conflicts surrounding the health of human populations, which had been devastated by the launch of extractive economic operations that were extremely harmful not only to ecosystems but also to the people dependent on those ecosystems (see Extractivism). Rachel Carson wrote her famous Silent Spring as a manifesto against the indiscriminate use of pesticides (especially DDT) because of their deleterious effects on the natural environment, but especially because of the harm they were causing to human health through water and food contamination (Carson, 1962). The same could be said of the Warren case, which is also often considered a pioneering example in the discussion of environmental justice: in that instance, it involved the establishment of a toxic chemical waste dump in a rural area predominantly populated by African American communities. This is a paradigmatic case of environmental racism (see Slow violence) that sparked massive protests and has, over time, become a landmark in the history of the struggle against eco-social injustice. As it relates to this entry’s topic, it clearly illustrates how reflection on the social determinants of health naturally intersects with the ecological determinants of health.
A key aspect of the eco-social determinants of health is how they affect people unequally, particularly vulnerable populations, through the mechanisms that produce and perpetuate social inequality. In this way, social differences translate into different health outcomes; social (and eco-social) injustices end up being internalized by individuals in the form of diseases or, as Farmer puts it, social, political, and economic forces are embodied in individual experiences and shape the risk of developing diseases (Farmer, 2003, p. 30). Thus, if the purely biomedical perspective based on individual action against disease is insufficient to protect health, it is certainly insufficient to prevent or reduce health inequalities. This evidence strongly links research on the eco-social determinants of health to the issue of ecological justice.
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