From social determinants to social interdependency: Theory, reflection, and engagement


  • William Ventres University of El Salvador


attitude of health personnel, bioethics, culture, health inequities, public health, social determinants, social responsibility, vulnerable populations, social determinants of health


Introduction Scholars and practitioners in medicine and public health have devoted significant time and effort to defining the social determinants of health and identifying resulting inequities in health outcomes. By focusing predominately on social determinants as referent sources of morbidity and mortality, however, health care professionals can be led to believe that the origins of poor health-related outcomes are disconnected from the ways in which social, economic, political, and environmental factors are established and maintained. Discussion We introduce the concept of social interdependency in health ¬and illness as a way to (1) reinforce the need to consider the root causes of social determinants, and (2) accepting communal and personal responsibility for acting to ameliorate their effects. Developing a sound understanding of social interdependency in clinical practice, public health research, and health care advocacy involves an iterative process of observation, reflection, and action. Effecting positive change within these disciplines is a shared obligation. We present a case study that demonstrates these principles of social interdependency. Conclusion Developing and applying a social interdependency in health and illness means moving from imposition to inclusivity, from investigation to involvement, and from investment in medicine and public health as a product to one of process. This process—the movement from social determinants toward social interdependency—showcases how we live in a world where none of us is so separate from another that we cannot benefit by envisioning and desiring for others what we might desire for ourselves.  

Author Biography

William Ventres, University of El Salvador

Research Associate Institute for Studies in History, Anthropology and Archeology University of El Salvador


Kunitz SJ. The health of populations: general theories and particular realities. New York: Oxford University Press; 2007.

World Health Organization. Closing the gap in a generation: health equity through action on the social determinants of health. Geneva, Switzerland: World Health Organization; 2008.

Marmot M, Wilkinson R. The social determinants of health. 2nd ed. Oxford, UK: Oxford University Press; 2005.

World Health Organization. What are the social determinants of health? Geneva, Switzerland. 2013. Available at:

Braveman P, Gottlieb L. The social determinants of health: It’s time to consider the causes of the causes. Public Health Rep. 2014;129 Suppl 2:19-31.

Krieger N. Epidemiology and the web of causation: has anyone seen the spider? Soc Sci Med. 1994;39(7):887-903.

Porter D. How did social medicine evolve, and where is it heading? PLoS Med. 2006;3:e399. doi: 10.1271/journal.pmed.0030399

Breilh J. Epidemiología crítica: ciencia emancipadora e interculturalidad. Buenos Aires, Argentina: Lugar Editorial; 2003.

Spiegel JM, Breilh J, Yassi A. Why language matters: insights and challenges in applying a social determination of health approach in a North-South collaborative research program. Global Health. 2015;11:9. doi: 10.1186/s12992-015-0091-2.

Johnson DW, Johnson RT, Smith K. The state of cooperative learning in postsecondary and professional settings. Educ Psychol Rev. 2007:19:15-29.

Ventres WB. Cultural encounters and family medicine: six lessons from South America. J Am Board Fam Pract. 1997;10(3):232-6.

Dharamsi S, Woollard B, Okullo I, Kendal P, Macnab A. Health promoting schools as learning sites for physicians in-training. Health Educ. 2013;114(3):186-96. doi: 10.1108/HE-09-2013-0048

Ferrer RL. A piece of my mind: within the system of no-system. JAMA. 2001;286(20):2513-4.

Farmer P, Nizeye B, Stulac S, Keshavjee S. Structural violence and clinical medicine. PLoS Med. 2006;3:e449. doi: 10.1371/journal.pmed.0030449.

Metzl JM, Hansen H. Structural competency: Theorizing a new medical engagement with stigma and inequality. Soc Sci Med. 2014;103:126-33. doi: 10.1016/j.socscimed.2013.06.032

Silver M. If you shouldn’t call it the third world, what should you call it? NPR. January 4, 2015. Accessed July 30, 2015.

Sen A. Development as freedom. 2nd ed. New York, NY: Oxford University Press; 2001.

Ventres W, Gusoff G. Poverty blindness: exploring the diagnosis and treatment of an epidemic condition. J Health Care Poor Underserved. 2014;25(1):52-62. doi: 10.1353/hpu.2014.0025

Phillips SP. Defining and measuring gender: a social determinant of health whose time has come. Int J Equity Health. 2005;4:11. doi: 10.1186/1475-9276-4-11

Kawachi I, Kennedy BP, Lochner K, Prothrow-Smith D. Social capital, income inequality and mortality. Am J Public Health. 1997;87(9):1491-8.

Navarro V, Muntaner C, Borrell C, Benach J, Quiroga A, Rodriguez-Sanz M, Vergés N, Pasarin MI. Politics and health outcomes. Lancet. 2006;368(9540):1033-7.

Stoddart MCJ. Ideology, hegemony, discourse: a critical review of theories of knowledge and power. Soc Thought Res. 2007;28:191-226.

Galtung J. A structural theory of imperialism. J Peace Res. 1971;8(2):81-117.

Verkerk MA, Lindemann H. Theoretical resources for a globalised bioethics. J Med Ethics. 2011;37(2):92-6. doi: 10.1136/jme.2010.036830

Waitzkin H, Iriart C, Estrada A, Lamadrid S. Social medicine then and now: lessons from Latin America. Am J Pubic Health. 2001;91(10):1592-601.

Green M, Hulme D. From correlates and characteristics to causes: thinking about poverty from a chronic poverty perspective. World Dev. 2005;33(6):867-79. Doi: 10.1016&/j.worlddev.2004.09.013

Dharamsi S, Ho A, Spadafora SM, Wollard R. The physician as health advocate: translating the quest for social responsibility into medical education and practice. Acad Med. 2011;86(9):1108-13. doi: 10.1097/ACM.0b013e318226b43b

Nichter M. Global health: why cultural perceptions, social representations, and biopolitics matter. Tucson, AZ: University of Arizona Press; 2008.

Garrafa V, Porto D. Intervention bioethics: a proposal for peripheral countries in a context of power and injustice. Bioethics. 2003;17(5-6):399-416.

Ventres W, Haq C. Toward a cultural consciousness of self-in-relationship: from “us and them” to “we”. Fam Med. 2014;46(9):691-5.

Hesserl S. Time for Outrage! London, UK: Charles Glass Books; 2011.

Breilh J. La determinación social de la salud como herramienta de transformación hacia una nueva salud pública (salud colectiva). Rev Fac Nac Salud Pública. 2013;31 Supl 1:13-27. Available at:

Ventres WB, Fort MP. Eyes wide open: an essay on developing an engaged awareness in global medicine and public health. BMC Int Health Hum Rights. 2014;14:29. doi: 10.1186/s12914-014-0029-4.

Greenhalgh T, Russell J. Evidence-based policymaking: a critique. Perspect Biol Med. 2009;52(2):302-14. doi: 10.1353/pbm.0.0085

Hart JT. The inverse care law. Lancet. 1971;i(7696):405-12.

Labonte R. Global action on social determinants of health. J Public Health Policy. 2012;33(2):139-47. doi: 10.1057/jphp.2011.61

Bainbridge L, Grossman S, Dharamsi S, Porter J, Wood V. Engagement studios: students and communities working to address the determinants of health. Educ Health (Abingdon). 2014;27(1):78-82. doi: 10.4103/1357-6283.134330.

Dawson A, Jennings B. The place of solidarity in public health ethics. Public Health Rev. 2012;34(5):65-79. doi: 10.1002/hast.490

Ferrer RL, Carrasco AV. Capability and clinical success. Ann Fam Med. 2010;8(5):454-60. doi: 10.1370/afm.1163

Ferrer RL, Gonzalez Schlenker C, Lozano Romero R, et al. Advanced primary care in San Antonio: linking practice and community strategies to improve health. J Am Board Fam Med. 2013;26(3):288-98. doi: 10.3122/jabfm.2013.03.120238

Sen A. Human rights and capabilities. J Hum Dev Capab. 2005;6(2):151-66. doi: 10.1080/14649880500120491

Ferrer RL, Cruz I, Burge S, Bayles B, Castilla MI. Measuring capability for a healthy diet and physical activity. Ann Fam Med. 2014;12(1):46-56. doi: 10.1370/afm.1580

Westerhaus M, Finnegan A, Haidar M, Kleinman A, Mukherjee J, Farmer P. The necessity of social medicine in medical education. Acad Med. 2015;90(5):565-8. doi: 10.1097/ACM.0000000000000571

Ventres W, Dharamsi S. Social responsible medical education: the REVOLUTIONS framework. Acad Med. 2015 Aug 25. [Epub ahead of print.] Accessed at:

Starfield B, Shi L, Macinko J. Contribution of primary care to health systems and health. Milbank Q. 2005; 83(3):457–502.

UN System Task Team on the Post-2015 UN Development Agenda. Social protection: A development priority in the post-2015 UN development agenda. 2012. Accessed at:

Lopéz Arellano O, Escudero JC, Carmona LD. Social determinants of health: perspective of the ALAMES working group on social determinants. Soc Med. 2008;3(4):253-64. Accessed at:

Ventres WB, Wilson CL. Beyond ethical and curricular guidelines in global health: attitudinal development on international service-learning trips. BMC Med Educ. 2015;15:68. doi: 10.1186/s12909-015-0357-7.

Ventres WB. The Q-list manifesto: getting things right in generalist medical practice. Fam Syst Health. 2015;33(1):5–13. doi: 10.1037/fsh0000100






Social Medicine in Practice