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The Social Determinants of Health

Looking Upstream

Kathryn Strother Ratcliff



Improving the health of our world requires knowledge of the principal determinants of our health and the ways to address them effectively. Fortunately many scholars, activists, community residents, and organizations like the World Health Organization, as well as various professional organizations, people, and groups have worked hard to understand and change what has become known as the social determinants of health (SDoH).

The task of understanding the SDoH is not easy, as our social world is a complicated and ever-changing place. Our understanding of the significance and long-term impact of human activity on our health and on the environment evolves with research and experience. Furthermore, the upstream triggers that affect our health downstream through conditions of daily life such as work, water, air, food, and transportation are subject to the vagaries of politicians, policy makers, industry advocates, lobbyists, and activists. These players necessarily change as public sentiment and the political climate shifts.

I am writing this during a particularly dramatic shift in health-related influences in the United States. With new industry-friendly occupants in the White House and a Republican Party that has vowed to replace the Affordable Care Act in control of both houses of Congress, what had been a growing commitment to addressing the SDoH was dramatically turned on its head. The promise of a “cleaner, greener” future seems at odds with the new administration’s aim to grow our economy by deregulating industry and by pursuing policies that threaten negative impacts on the SDoH. For example, in his first month in office, President Trump signed an order that would roll back a whole host of Environmental Protection Agency (EPA) regulations needed to protect the environment, including a regulation that restricted coal companies from dumping mining waste into waterways. The man he appointed director of the EPA, Scott Pruitt, has had close working ties with fossil fuel industries, worked to block President Obama’s climate change agenda, and, as Attorney General of Oklahoma, sued the EPA 14 times.

While business and industry leaders applaud the new president’s assault on protective regulation, science-based agencies throughout the government, from the National Science Foundation (NSF) to the Department of Energy (DOE), have been rattled by White House requests for information on scientists engaged in climate and other environmental research; many are concerned that this is a first step to eliminating from the government anyone with these views. The National Forest Service made headlines defying orders to suspend the distribution of public information about climate change during the transition of the new administration, and scientists scheduled an unprecedented march on Washington. How will these activities factor into society’s ability and desire to reduce poverty, clean up our environment, reduce emissions that contribute to climate change, provide safe and healthy jobs, and eliminate health disparities?

While the examples highlighted in this book predate the current changes, they illustrate precisely the mechanisms that have connected and continue to connect our political, economic, and social institutions to our health. Indeed, the issues remain the same, regardless of politics. As members of a society, we are all responsible for identifying the drivers of systemic public health problems and for working to correct them. Looking “upstream” is the first step in our collective progress. That is where this book begins. It ends optimistically, with examples of both government action and corporate social responsibility that illustrate a fundamental common ground: the importance of an environment in which we should be able not only to survive, but to thrive as a healthy, productive society.

This book is an attempt to reach out to college audiences in public health, sociology, political science, and environmental science as well as to the general public that has not yet joined the conversation but needs to, if we are to make substantial progress. By providing an accessible overview of the SDoH and some of the possible solutions, this book hopes to ignite interest and informed activism. Our communities, nations, and the world are not healthy. We cannot continue down our current path. Doing so is not sustainable.

Kathryn Strother Ratcliff
March 2017

Storrs, Connecticut


America is a rich nation with an abundance of highly sophisticated and to-be-envied healthcare technology. It has well-trained, sophisticated healthcare providers and spends much more per person on healthcare than other nations do: it spends about $8,700 a year, while most peer countries spend less than $5,000, the average being $3,453 (OECD Health Statistics 2015). Its health expenditures aren’t just a little bit more; they are a lot more.

With all of this going for them, it would seem that Americans are healthier than the citizens of other countries; but they are not. Two typical health outcomes used to measure the health status of a population are telling: infant mortality and life expectancy. On these two measures, the United States does not rank highly; it is about thirtieth on both. This means that in almost thirty other countries babies are more likely to survive and people are more likely to live longer than in the United States.

Many people would find the juxtaposition of the high health expenditures and poor health outcomes puzzling. But there is a good reason for this seemingly illogical pairing: healthcare is only one contributor to health, and it is a small one. The quality of the US healthcare system, the amount that Americans spend on it, and the ever more impressive medical advances are not the main contributors to population or individual health. Lester Breslow, a US public health leader, said it succinctly: “In the long run, housing may be more important to health than hospitals” (quoted in Richmond 2012). Or, stated differently, “in creating its way of life, each society creates its way of death,” disease and injury (quoted in Freund and McGuire 1999: 2). A classic article (McKinlay and McKinlay 1977) provides a focused piece of evidence for this idea by analyzing the contributions of medical interventions to the declining death rate for nine common infectious diseases: measles, scarlet fever, tuberculosis, typhoid, pneumonia, influenza, whooping cough, poliomyelitis, and diphtheria. All are diseases associated with effective vaccines or other medical measures (e.g., the administration of penicillin). Many people believe that the decline of those diseases was due to such medical interventions, but the analysis showed that most of the decline in the death rate for each disease actually came before the medical measure had been introduced, and was often the result of improved sanitation. Clearly these observations suggest that medical measures are important, but not the most important cause of improved health. When Centers for Disease Control (CDC) looks at the contributors to health, it reports that only about 20 percent of the nation’s health is the result of medical care, while 5 percent is the result of biology and genetics, 20 percent is the result of individual actions, and over 50 percent is caused by the “social determinants of health” (CDC 2011). To improve America’s health statistics, Americans need to better understand these other determinants of poor health and to design and fund initiatives that tackle them. These social determinants are the focus of this book.

But what are “social determinants”? The Robert Wood Johnson Foundation (2010) found that these words did not resonate easily with most people. In chapter 2 we will explore important social determinants in greater depth, but here let me define them simply as (1) conditions of life people are exposed to because of the way their society is built—how we live, how we work, how we move from place to place, and what we eat and drink; and (2) the causes or triggers of those conditions of life—such as government policies, social structure, and the actions of powerful actors and organizations.

A growing consensus in many academic fields, in the World Health Organization (WHO), and among human rights spokespeople is that we need to take the social determinants of health more seriously. We have long focused on the biological causes of poor health (genes, germs, viruses) and on the contribution of the healthcare system to better health. But the focus is now changing. Examining social determinants is often referred to as an “upstream” approach, so named from the oft-used image of people drowning in a river. This image is typically credited to John McKinlay, author of a classic article in which he quotes his friend Irving Zola:

There I am standing by the shore of a swiftly flowing river and I hear the cry of a drowning man. So I jump into the river, put my arms around him, pull him to shore and apply artificial respiration. Just when he begins to breathe, there is another cry for help. So I jump into the river, reach him, pull him to shore, apply artificial respiration, and then just as he begins to breathe, another cry for help. So back in the river again, reaching, pulling, applying, breathing and then another yell. Again and again, without end, goes the sequence. You know, I am so busy jumping in, pulling them to shore, applying artificial respiration, that I have no time to see who the hell is upstream pushing them all in. (McKinlay 1979: 9)

Although both efforts—saving people in immediate danger and discovering why they are in danger—are important, this book is focused on the latter and examines the society’s infrastructure (our conditions of life), why it is built as it is (the causes or triggers of these conditions) and the resulting consequences for health.

An important aspect of the upstream perspective is that it makes sure that the analysis of these upstream root causes takes the race, ethnic, and class structure of society and the power of institutional racism into account. Continuing with the river imagery, there are disparities among people that determine who is pushed into the river, and hence who has the worst health consequences. Or, moving from the image to real examples, corporate decisions on the advertising and availability of tobacco, alcohol, and healthy food in rich white neighborhoods versus poor minority neighborhoods have disparate health impacts. The enduring racism in our society, combined with government policies such as discriminatory housing or with practices like redlining (see chapter 3), have encouraged the development of segregated neighborhoods, African American ones being at a considerable disadvantage in terms of air pollution, dampness, dust, and pests (all of which contribute to asthma), and the residents being exposed to stress from the living conditions and discrimination. The combination of these upstream determinants leads to major disparities in asthma, black children being more likely to suffer than white ones (Williams et al. 2009). Such differences are well documented in a substantial literature on health disparities. Some researchers cast this health disparity information in a social injustice or human rights framework, so that the lenses they use go beyond recounting disparities in health to offering an evaluative statement: these differences shouldn’t exist—they are unjust.

The social justice perspective used in this book is more inclusive. I argue that some structural features affect the health of everyone, and a focus limited to health disparities between specific social groups glosses over this general impact. In this view, social injustice is not just about differences but also examines conditions that affect us all—conditions no one should experience (see Hofrichter 2003a and Levy and Sidel 2013). Thus it is an injustice if we all live in a world that assaults our health by preventable means (e.g., inadequate clean water, lack of sustainable methods to grow food, or pollution that effects climate change). A focus on disparities alone could easily miss the full impact of these conditions on our health. Since some of the causes of disparities—such as discrimination, at both the individual and the institutional level—are not the same as the causes of population health (Krieger 2008a: 1100), I will not attempt to cover the full complexity of such disparities, which is reflected in the important literature. That said, this book will clearly note that health disparities exist in almost all situations, which means that the people most likely to be exposed to unhealthy conditions of living—poor air and water quality, limited food choices, dangerous work environments, and so on—are lower-class individuals and people of color. Likewise, I won’t fully cover gender disparities in health, although I will offer some important examples. Due to discrimination and cultural values, women face very different kinds of assault on their health from the ones men do. They are more likely to be victims of domestic violence and of stress from discrimination, they are disproportionately poor, and they face atypical occupational hazards as a result of genderbased division of labor (Ratcliff 2002).

While the social determinants of health as a topic refers to society in general, this book supports the viewpoint that people matter and social justice is paramount (Marmot 2005). Throughout the book you will encounter not just a social justice and human rights perspective, but also a strong critique of situations of differential power in which democracy seems to be forgotten. Our government “of the people, by the people, and for the people” has in many situations been overrun by those with enormous economic and political power. Each chapter documents instances of this trend—which is the result of weak public regulatory efforts, strong private interests, or both—and reveals the alarming health hazards that have resulted. Where possible, I also look for positive trends, social activism, reform, or legislation that might prevent, mitigate, or reverse negative health outcomes.

Chapter 2 will discuss social determinants in greater detail, then six substantive chapters will explore various aspects of how we live (chapters 3, 4, and 5), how we move from place to place and in our built environment (chapter 6), how we work (chapter 7), and how we eat (chapter 8). Topics fully deserving similar coverage but that are not covered due to space include the pharmaceutical industry and the firearms industry: the power of each has changed the conditions of life for millions. The reader is referred in particular to Freudenberg’s (2014) excellent coverage in Legal but Lethal.

In every chapter of this book I will examine the associated conditions of life, the causes of those conditions, and the resulting consequences for health. To limit my scope, I will focus on physical health more than on mental health and on the United States more than on other countries. While several health problems will constitute the clear “dependent variable” in each chapter, the discussion of disease and injury will include neither a technical description (the understanding of which would require a background in biology, biochemistry, and endocrinology), nor a technical discussion of appropriate treatments. Rather, each chapter will present descriptive information designed to educate the reader on the impact of a disease (e.g., how asbestosis reduces the quality of one’s life) and on the extent or seriousness of the health problem in question. The focus throughout will be on the social determinants of health (SDoH).

In examining many conditions, we will discover that the evidence that a particular toxic agent has caused a particular health hazard is not as robust as we might like. In those situations, when strong but less than conclusive evidence exists, I suggest that delays in reducing exposure to a potential health hazard in order to allow the collection of additional information is ill advised. The long history of unhealthy conditions of living is so alarming that immediate action to reduce exposure is often warranted. I will invoke the precautionary principle (discussed in chapter 4), which states that, when there is serious potential for harm, even if proof is not definitive, society has an obligation to act. Finally, I will argue that we can’t just focus on remedying existing unhealthy situations but must prevent the next ones from happening. The trajectory we are on is not a healthy one, and we need to change course.

The concluding chapter will suggest some of the ways in which we can look upstream and begin to reduce the root causes of ill health, often by drawing on creative ideas from entrepreneurs, community residents, and social justice networks (among others). In addition, I will refer back to examples from the chapters, especially ones that draw upon the important “popular epidemiology” work of Phil Brown and the community activism it inspired. Finally, the last chapter will examine the importance of healthcare providers’ looking upstream and thereby doing a better job of saving people from drowning in the river.