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A long path in a dark forest, representing the journey towards decolonisation.

The injustices of social health determinants: how these are shaped and can be addressed

28 Oct 2025 | Paula Terris-Pennycott and Dustin Hosseini

For our penultimate Black History Month blog of the series, we welcome guest bloggers Paula Terris-Pennycott and Dustin Hosseini. Paula works as a Clinical Lecturer in Paramedic Science at University of Cumbria, on secondment from East of England Ambulance Service and Dustin is a Lecturer in Health Science at the University of Cumbria, is studying towards a doctorate in education at the University of Strathclyde, and is an Associate Tutor at the School of Education at Glasgow University where he co-leads the Decolonising the Curriculum Community of Practice.  

In this post, Paula and Dustin discuss how colonialism shapes our current healthcare system, and how decolonial thinking can help us to unpick the role and implications of health determinants so we can begin to take action for addressing injustices in health.  

How colonialism shapes our contemporary health system 

While contemporary empires such as Spain, Portugal, Great Britain, France, Germany, Belgium and others no longer control the vast swaths of people and land they once did, the lasting effects of colonisation on formerly enslaved and colonised peoples still persist. These effects continue through what is called coloniality, which encompasses how some ways of knowing, being and doing are seen as ‘normal’ while others are hidden, suppressed or oppressed.

Old map of the British empire.

 Understanding the concepts of the coloniality of power, knowledge and being can offer readers a framing to understand how colonialism shapes our contemporary health system. One way that colonialism shaped medical knowledge is through the invention and codification of race, and the subsequent hierarchisation of races that persists in all former centres of empire and their former settler-colonies. In brief, coloniality persists in shaping our contemporary health systems that see ‘the norm’ as those who are White, male, able-bodied, neurotypical, and heterosexual while anyone else is considered lesser or outside the norm; those who are Brown or Black, female, transgender, neurodivergent and/or disabled are rendered as ‘lesser’ within the current system due to coloniality’s lasting effects. In everyday medical practice, this can be experienced directly and indirectly by patients and medical professionals through ‘medical silencing’, underpinned by a mixture of racism, gender-discrimination and others. Accordingly, those who are White and able-bodied will benefit from the healthcare system more as the science that initially created it was based upon Eurocentric ways of understanding the world, underpinned by ideas such as racism and eugenism, thus leading to lasting racial and ethnic health disparities.   

Understanding health determinants or social determinants of health  

Health determinants are the factors that act on us throughout our lives, affecting physical and mental health, and ultimately our potential life expectancy. The World Health Organisation includes gender, location, genetics, social support networks, and individual characteristics in its definition of health determinants. Some of these are expected, such as social/economic status; although, how well known is it that individuals living in poverty are more likely to be obese, with all the associated health issues? Others may be more surprising. The higher your level of education, the longer you could live. Loneliness is said to be as damaging to health as smoking 15 cigarettes a day, and some say it is an underappreciated determinant of health.  

An urban landscape on the left and a rural one on the right.

Health determinants can have positive and negative effects. Whilst living in a rural setting provides better air quality, often more living space, and less crowding, urban life offers better access to a variety of health supporting factors such as being close to a range of healthcare providers and a larger choice of resources such as gyms, social groups, entertainments. Whilst rural life appears to give more opportunity for physical activity, many rely on cars. The reliance on a good public transport system also tends to come with a good step count.  

Health determinants rarely work alone. You are more likely to be able to attain a degree and the attached health benefits if you come from an affluent background. Women in areas of deprivation are expected to have less years in good health than their male counterparts, despite living for longer.  

The interplay of ethnicity and health determinants 

At first look, ethnicity as a health determinant seems to favour those of Black African heritage (longest life expectancy) with White British and Mixed Heritage individuals coming off worse (lowest life expectancy). However, healthcare in Britain is Eurocentric, with education and subsequent training, CPD and treatment focused on white bodies. Examples of this includes equipment that struggles to take readings on darker skin, such as pulse oximeters, to ECG machines that are set up for heart tracings on white 50-year-old males. Even the often-used term “cyanosis” indicating low levels of oxygen is based on the name for a shade of blue. This is not appropriate when increased melanin pigmentation in many People of Colour cause lips to go to more of a grey shade. There are also concerns that health issues which affect more People of Colour such as Diabetes, Lupus, and Sickle Cell are not given as much focus as predominantly white conditions. Despite NICE Guidelines stating that patients in pain with a Sickle Cell crisis should be given opiate-based pain relief within 30 mins of triage, this does not always happen.

BHM Black person in healthcare setting

In a striking contrast, despite not having any more risk of mental health issues compared to their white peers, Black adults are 3.5 times more likely to be held against their will for treatment under the Mental Health Act. In addition, the experiences of Women of Colour are compounded by the intersections of gender and race: they have the combined and cumulative effect of their ethnicity and gender. As an example, the shadow of historical figures such as J. Marion Sims, and his non-consensual experiments on enslaved women named Lucy, Anarcha and Betsy, still hangs over the medical treatment of Women of Colour today. He perfected techniques without anaesthesia, then moved onto white women with the added use of pain relief. This was based on his belief that Black women feel reduced or no pain. A belief that still subconsciously exists in some healthcare providers today. 

How can decolonisation help us to re-imagine healthcare systems?  

Following on from the above examples, we can see the impact that colonialism and the lasting effects of coloniality continue to have on marginalised communities today. Decolonisation of medicine and public health offers one way to identify and address injustices present within the current healthcare systems. Yet what does this mean for patients and medical practice?  

According to this article, decolonisation in global health ‘involves critically examining and reforming the power imbalances and systemic inequities that have roots in colonial histories.’ A significant part of this involves addressing the intersecting issues of race and medicine. This would involve undertaking ‘radical institutional change[s] … to meaningfully restore power and agency to marginalised interests and groups, not merely to acknowledge these issues, apologise, or rename old buildings.’ In brief, identification and the naming of the issues (e.g. racism, gender-based discrimination, classism, etc.) is important, yet taking action to rectify injustices must follow to allow for the reimagining and development of a more equitable healthcare system for everyone.  

Echoing this piece on decolonial imaginations, one way to do this is to reimagine public health as a concept that values and integrates many forms of knowledge while centring on communities, peoples, and solidarities. This would see public health as recognising that ‘all knowledges that are locally and contextually bound can be used to understand the global, the world’. This might entail directly consulting and including the lived experiences and perspectives of marginalised groups to improve healthcare, such that it becomes more equitable for everyone while not privileging any one group. By working with marginalised groups, citizens and healthcare professionals could reimagine health training curricula and practices that break down the traditional patient-medical professional hierarchies that come to value patient insight and voice, which illustrated through the examples above, is especially important for marginalised communities whose concerns often go unheard. This would involve re-imagining the patient-medical professional relationship that values all parties as knowledge holders thus echoing the earlier piece on decolonial imaginations. This would entail legitimising the knowledge, concerns and experiences of patients to complement the knowledge and expertise that medical professionals bring, enabling a healthcare system that is more equitable for all.  

Further reading & resources 

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When giving birth becomes a risk: a Black woman’s story

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Black History Month 2025: CRER's manifesto for an anti-racist Scotland

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