The social determinants of health are
those factors that affect people’s health status that are the result of the
social situation in which they find themselves. Thus, in the well-known graphic
from Healthy People 2010 (dropped,
for some reason, from Healthy People 2020),
which I have reproduced several times, they complement the other determinants
such as the biological (genetics), but are represented in most of the other
areas. Physical environment and socioeconomic environment, certainly, but even
“behaviors” are affected by the circumstances into which one is born and lives.
So is biology, actually, as we learn more about genetic coding predisposing
some people to addictive behaviors. Certainly it is not all volitional or
evidence of weak character.
The social determinants of health can be partially
enumerated, and include adequate housing (including sufficient heat in the
winter), adequate food, education, and also a reasonable amount of nurturing
One
of the clearest ways to show the impact of these determinants is by a technique
called “geo-mapping” in which certain characteristics (income, educational
level, gang violence, drug use, number of grocery stores or liquor stores,
public transportation routes, whatever you can think of) are laid over maps of
a city, town, or region. We have seen these portrayed on TV or in the
newspapers as national and state maps for political events (such as what areas
voted for who), but they can also be very useful for understanding the
different challenges faces by people living in different areas. The work of
Steven Woolf and his colleagues at Virginia Commonwealth University has greatly
contributed to this work; in addition to their incredibly useful County Health Calculator, has
produced graphs that can be found on the Robert
Wood Johnson Commission for a Healthier America site that show how life
expectancy can vary dramatically in different neighborhoods, as in the map
displayed of the Washington, DC area, mapped along Metro lines for greater
effect, or the one of my area, Kansas City, Missouri (which doesn’t have a
Metro!)
A recent contribution to this field has been made by Melody
S. Goodman and Keon L. Gilbert, of Washington University in St. Louis, who
mapped the dramatic differences across Delmar Boulevard in that city, in “Divided
cities lead to differences in health”. Their graphic shows the disparities
in education, income, and housing value, and, unsurprising, racial composition,
on either side of Delmar. This work was covered in a BBC documentary. Dr.
Goodman, speaking to a symposium from her alma mater, the Harvard School of
Public Health, is quoted as saying “Your
zip code is a better predictor of your health than your genetic code.”
This is a pretty sad commentary, given not only the
incredible amount of money that has been spent on unraveling the genetic code
but the amount of faith and expectation that we have been convinced to have in
how this new genetic knowledge will facilitate our health. By knowing what we
are at risk for, genetically, the argument goes, science can work on “cures”
that target the specific genes. This is a topic for a different discussion, but
in brief one problem is that the most common diseases we suffer from are not
the result of a single gene abnormality. It is probable that, at least in the
short-to-medium term, knowledge of our genetics will be more likely to lead to
higher life insurance rates than cures of our diseases. The more profound
issue, however, is that there is evidence from the social determinants of health,
from the work of Woolf and Goodman and many others, that we do not address the
causes of ill health even when we know what they are.
Why is this so? Why
is there such great resistance to understanding, believing, that investment in
housing, education, jobs, and opportunities will have a much greater impact on
people’s health than more and more money spent on high-tech medical care (and,
of course, profit for not only the providers, but the drug and device companies
and middleman insurance companies)? It is in part because we hope (and, when we
are more privileged, expect) that we will be the beneficiaries. And it is also
because we choose to believe that those who do not have the benefits we have
(of money, education, family) somehow “deserve” it because of character flaws.
The issue of “fault” is articulately addressed by Nicholas
Kristof in a New York Times Op-Ed on
August 10, 2014, “Is
a hard life inherited?” Kristof argues that it is, not genetically but
because the circumstances to which one is born and in which one grows up, the
presence of caring parents who read to you rather than beat you, who take care
of you instead of abusing drugs, as well as adequate food and housing make a
tremendous difference in how you turn out.
Indeed, another major
study by Johns Hopkins sociologist Karl Alexander, to be published in his
“life’s work”, “The Long Shadow: Family Background, Disadvantaged Urban Youth,
and Transition to Adulthood”, and covered
on NPR, confirms this. Alexander and his colleagues tracked nearly 800
children for more than 20 years, and found that those from less privileged
backgrounds with lower incomes and less supportive families did worse. Only 33
of the children moved from the low income to the high income bracket. Problems
with drugs and alcohol were more
prevalent among white males than other groups, but they did better financially
anyway. Some people, rarely, overcome the deck being stacked against them, but
most of those who do well after being born with relative privilege would likely
not be among them had they been in the same situation. Kristof writes:
ONE delusion common
among America’s successful people is that they triumphed just because of hard
work and intelligence. In fact, their big break came when they were conceived
in middle-class American families who loved them, read them stories, and
nurtured them with Little League sports, library cards and music lessons. They
were programmed for success by the time they were zygotes. Yet many are
oblivious of their own advantages, and of other people’s disadvantages. The
result is a meanspiritedness in the political world or, at best, a lack of
empathy toward those struggling…
That lack of empathy leads to a lack of action; we are
willing to accept people living in conditions that we would never accept for
our family and neighbors, not only across the globe but across town, or even
across a street. From the point of view of health, our priorities and
investments are misplaced when we do not address the social determinants of
health as well as cures for disease. When we do not try to change the known
factors of zip code that impact our health as we investigate those of the
genetic code.
If there are to be “cures” that come from our understanding
of genetics, there is every reason to expect that they will be one more thing
that is available to the people on the south side of Delmar Boulevard in St.
Louis long before they are to those on the north side of the street.
[1] Jones
CP, Jones CY, Perry GS, “Addressing the social determinants of children’s
health: a cliff analogy”, Journal of Health Care for the Poor and Underserved,
2009Nov;20(4):supplement pp 1-12. DOI: 10.1353/hpu.0.0228
"Alexander and his colleagues tracked nearly 800 children for more than 20 years, and found that those from less privileged backgrounds with lower incomes and less supportive families did worse"
ReplyDeleteWho would have guessed it?