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In our January/February 2013 commentary “Getting to the Root of the Problem: Health Promotion Strategies to Address the Social Determinants of Health”,1 we argued that approaches that are upstream in nature (e.g., structural interventions) have greater potential to improve long-term health and health equity than more downstream approaches (e.g., environmental interventions) because of their broad reach and ability to address the “determinants of determinants”. In his letter to the Editor, Mr. Bruce makes an excellent point that not all interventions can be classified so neatly, as he illustrates using the BC Farm to School initiatives. We agree that structural and environmental interventions are not mutually exclusive, and our intention was not to advocate for structural interventions to the exclusion of environmental ones. In our commentary, we argued that structural interventions should be employed in addition to environmental interventions to create sustainable and equitable change. Part of this argument was based on the recognition that structural and environmental interventions can influence and interact with each other, as Mr. Bruce notes with his example of social norms interacting with policy change in tobacco control. McGibbon2 in fact presents a useful intersectionality framework that pulls together social determinants of health, identity (similar to our structural category) and geography to further emphasize unwanted synergies leading to systemic inequities. In our published commentary, we advocated for structural interventions in order to draw more attention to this area that has received little focus in policy-making and program building, in contrast to environmental interventions that have received considerable attention and resources. Our analysis revealed there are very few programs with an explicit, concurrent focus on changing environmental mechanisms and addressing systemic power relations/structural determinants of health. We envision policy and program interventions that tackle oppressive practices, access and distribution of resources side by side, just like the BC Farm to School initiatives that impact these areas more indirectly. We invite further dialogue and critical analysis about how we approach the social determinants of health in public health interventions. This is public health’s niche expertise within the broader health sector – let us embrace our leadership position.

Authors’ Response: The Dual Importance of Environmental and Structural Strategies