Beyond Medical Care: The Beyond Medical Care: The Social Determinants Social Determinants

of Health of Health

Human Capital Research CollaborativeHuman Capital Research CollaborativeU. Minnesota-Minneapolis Federal Reserve U. Minnesota-Minneapolis Federal Reserve

October 14, 2010October 14, 2010Paula Braveman, MD, MPHPaula Braveman, MD, MPH

Professor of Family & Community MedicineProfessor of Family & Community MedicineDirector, Center on Social Disparities in HealthDirector, Center on Social Disparities in Health

More health care spending-- but less healthMore health care spending-- but less healthInfant Mortality -

20051 Iceland 2 Sweden3 Luxembourg4 Japan5 Finland6 Norway7 Czech Republic8 Portugal9 Belgium10 France11 Greece12 Italy13 Spain14 Germany15 Ireland16 Austria17 Switzerland18 Denmark19 Korea20 Netherlands21 Australia22 New Zealand23 United Kingdom24 Canada25 Hungary26 Poland27 United States28 Slovak Republic29 Mexico30 Turkey

Source: OECD Health Data 2009

Large racial/ethnic Large racial/ethnic disparities in healthdisparities in health

A baby born to an African-American (black) A baby born to an African-American (black) woman is twice as likely to die before reaching her woman is twice as likely to die before reaching her or his first birthday as a baby born to a European-or his first birthday as a baby born to a European-American (white) womanAmerican (white) woman

A black woman is 3 to 4 times more likely to die of A black woman is 3 to 4 times more likely to die of pregnancy complications than a white woman – pregnancy complications than a white woman – even after considering age, number of previous even after considering age, number of previous births, and educationbirths, and education

Latinos in the U.S. have higher rates of diabetes Latinos in the U.S. have higher rates of diabetes and its complicationsand its complications

Disparities in life expectancy at age 25 Disparities in life expectancy at age 25 by income (& education) by income (& education)

Poor/fair child health variesPoor/fair child health variesby income (& education)by income (& education)

Adults’ self-reported poor or fair health Adults’ self-reported poor or fair health varies by (a) income & (b) race/ethnicityvaries by (a) income & (b) race/ethnicity

Poor/fair health among adults varies Poor/fair health among adults varies by income in each racial/ethnic group by income in each racial/ethnic group

Poor/fair adult health varies by race or ethnic group, within income groups

Scarlet fever deaths per 1 million Scarlet fever deaths per 1 million children under 15: England and Waleschildren under 15: England and Wales

0

500

1000

1500

2000

2500

1865 1885 1905 1918 1928 1938 1948 1958 1968

Sulpha drugsPenicillin

Thomas McKeown, 1974

Measles– mean annual deaths per 1 million Measles– mean annual deaths per 1 million children under 15 in England & Waleschildren under 15 in England & Wales

0

200

400

600

800

1000

1200

1400

1855 1875 1895 1913 1922 1932 1942 1952 1962

Immunization began

Infant deaths per 1,000 live births Infant deaths per 1,000 live births in England & Walesin England & Wales

0

20

40

60

80

100

120

140

160

1842 1860 1873 1888 1903 1915 1932 1946 1962

What influences health?What influences health?

Medical careMedical care Genetic makeupGenetic makeup Climate & natural physical environmentClimate & natural physical environment Behaviors, nutritionBehaviors, nutrition What else?What else? And what influences the influences?And what influences the influences?

How could income affect health? How could income affect health?

Income directly shapes: Income directly shapes: Medical careMedical care Housing qualityHousing quality Nutrition & physical Nutrition & physical

activity optionsactivity options Neighborhood Neighborhood

conditionsconditions Social networks & Social networks &

supportsupport StressStress

Parents’ income shapes Parents’ income shapes the next generation’s:the next generation’s:

EducationEducation Working conditions Working conditions

(physical & (physical & psychosocial)psychosocial)

IncomeIncome

Center on Social Disparities in Health, University of CA, San Francisco

What influences health? What influences the influences?

Low Educational Attainment

Poor Adult & Child Health

Low income

Unhealthy housingPoor nutrition

Unhealthy neighborhoodLack of exercise

Stress

Poor working conditionsPhysical hazards

Lack of health insuranceLack of sick leave

Lack of control

Poor Job

Educational attainment

Educational attainment

HEALTHHEALTH

Exposure to hazards Control / demand imbalance Stress

Work-related

resources

Housing Neighborhood environment Nutrition Stress

Work

Health insurance Sick leave Retirement benefits Other benefits

Working conditions

Income

HEALTHHEALTH

HEALTHHEALTH

How could education affect health? Nutrition Exercise Drugs & alcohol Health/disease management

Educational attainment

Educational attainment

Sense of control Work-related factors Health-related behaviors Stress

Social standing

Social support

Social & economic resources Stress

Social & economic resources Health-related behaviors Family stability Stress

HEALTHHEALTH

Health knowledge, literacy & behaviors

Educational attainment

Educational attainment

How could your How could your neighborhood affect neighborhood affect your children’s health?your children’s health?

Physical danger (crime)Physical danger (crime) Safe places to exerciseSafe places to exercise Lead, air pollution, moldLead, air pollution, mold Access to healthy foodAccess to healthy food Social networks & supportSocial networks & support Role models, peer pressureRole models, peer pressure Stress, fear, anxiety, despairStress, fear, anxiety, despair Quality of schoolsQuality of schools

CRH

DAMAGE TO MULTIPLE ORGANS & SYSTEMS

premature aging, chronic disease

STRESSOR

CORTISOL

Hypothalamus

Pituitary Gland

Adrenal Glands

ACTH

How could stress get into the body?How could stress get into the body?

Center on Social Disparities in Health, University of CA, San Francisco

Chronic stress in childhood. Cumulative Chronic stress in childhood. Cumulative effects of stress over the life courseeffects of stress over the life course

Poverty/low income is often stressfulPoverty/low income is often stressful Stress during critical periods and/or chronic stress Stress during critical periods and/or chronic stress

could lead to ill health in adulthood through could lead to ill health in adulthood through neuro-endocrine, immune, inflammatory pathways neuro-endocrine, immune, inflammatory pathways • E.g., adult chronic disease (heart disease, diabetes)E.g., adult chronic disease (heart disease, diabetes)

• Adverse birth outcomes (low birth weight, prematurity)Adverse birth outcomes (low birth weight, prematurity)• Could cause neuro-endocrine dysregulation with Could cause neuro-endocrine dysregulation with

lifelong effectslifelong effects Cumulative stress over lifetimeCumulative stress over lifetime

What about racial/ethnic What about racial/ethnic disparities?disparities?

Compared with blacks and Hispanics, whites:Compared with blacks and Hispanics, whites:• Have more income and schoolingHave more income and schooling• At a given educational level, have higher incomesAt a given educational level, have higher incomes• At a given income levelAt a given income level

Have more wealthHave more wealth Live in better-off neighborhoodsLive in better-off neighborhoods

• At a given income/educational level, are more At a given income/educational level, are more likely to have grown up in more advantaged likely to have grown up in more advantaged familiesfamilies

All these can influence healthAll these can influence health• via multiple, complex pathways, including stressvia multiple, complex pathways, including stress

Racial/ethnic disparitiesRacial/ethnic disparities

Race/ethnic group often captures unmeasured Race/ethnic group often captures unmeasured socioeconomic factorssocioeconomic factors• Depth of poverty, wealth, educational quality, neighborhood Depth of poverty, wealth, educational quality, neighborhood

conditions, childhood experienceconditions, childhood experience

• Health-damaging or -promoting exposuresHealth-damaging or -promoting exposures

• More stress, fewer resources More stress, fewer resources Added stress due to a legacy of discriminationAdded stress due to a legacy of discrimination

• Not just overt incidents or intentional biasNot just overt incidents or intentional bias

• Pervasive vigilance, anticipating unfair treatment or judgmentPervasive vigilance, anticipating unfair treatment or judgment

Economic & SocialOpportunities and Resources

Living & Working Conditionsin Homes and Communities

PersonalBehavior

Medical Care

HEALTH

Widening the focus: Seeking the causes of the causes

Policies to promote healthier homes,

neighborhoods, schools and workplaces

Policies to promote child and youth development

and education

Policies to promote economic development and reduce

poverty & racial segregation

Robert Wood Johnson Foundation Commission to Build a Healthier America www.commissiononhealth.org

Finding solutions:Finding solutions: Understanding how health is Understanding how health is transmitted across lifetimes and generationstransmitted across lifetimes and generations