It’s hard to think clearly about health reform if you ignore the social determinants of health, that is, how each person’s place in the hierarchy of self-determination and power, educational opportunity, neighborhood quality, working conditions, job security, income and wealth shape their vulnerability to illness and premature death. Check your knowledge by taking this true-or-false quiz:
1. Rates of illness and premature death are higher among the poor, but there is a threshold at which increases in social status no longer affect health.
FALSE: Until the 1980s, experts generally assumed such a threshold, and that higher rates of illness and death among the poor arose from material deprivation (lack of medical care, inadequate food and greater exposure to pollution). That changed with the Whitehall Study of British civil servants, which found gains in health and longevity at each step up in job status all the way to the top of the ladder. There was no threshold at which the link between higher social status and better average health stopped, a finding which has held true in studies elsewhere.
2. Progress in recent decades has narrowed the entrenched inequalities in infant mortality and premature death that divide the U.S. population by socioeconomic class and race.
FALSE: Disparities in infant death rates and premature mortality in adults shrank between 1966 and 1980 across the U.S., but since then health inequities have grown wider. Since 1980, virtually all gains in life expectancy occurred among highly educated groups, one study found. Infant mortality for African Americans was 1.7 higher than for whites 1940, and despite steep reductions in infant deaths, the gap between blacks and whites has widened such that the rate among blacks was 2.4 times higher than among whites as of 2006. In the 1950s, black and white Americans had comparable death rates for heart disease and cancer, but now death rates for both diseases are significantly higher among blacks.
3. Expanding health insurance coverage and access to medical care (the focus of the federal Affordable Care Act) is unlikely to reverse the health disparities caused by the social determinants of health.
TRUE: In countries that established universal health coverage decades ago, lower social status still correlates with worse health and shorter lives. The research on social determinants suggests that progress is likely to require broader social changes, such as improving access to education, boosting economic opportunity and making disadvantaged neighborhoods safer and and more vital.
4. Food deserts – neighborhoods with few or no grocery stores selling fresh, affordable produce – are a well-defined root cause of obesity and other health problems in disadvantaged communities.
FALSE: There is evidence showing that low-income and minority Americans are more likely to live in food deserts. But it’s not at all clear to what extent the lack of supermarkets and grocery stores contributes to obesity or other health outcomes.
5. Price is not a significant driver of the unwholesome food choices that are prevalent among people on the lower rungs of the socioeconomic ladder.
FALSE: A recent meta-analysis by researchers at Brown University and the Harvard School of Public Health calculated that healthy eating costs about $1.50 more per day per adult than eating a low-quality diet ($550 more annually per person). That extra cost represents a 25 percent increase for a household that spends $6 per person on food each day, which is more than many low-income families budget. Another study found that the cost of substituting healthier foods can cost 35 to 40 percent of an American low-income family’s food budget. Energy-dense foods (made of processed grains, sugar, and fat) are typically the most affordable choices. Such fare also has a longer shelf-life, which is extra meaningful for people short on money and needing to minimize waste. Processed foods also cost less in terms of the time it takes to plan and prepare meals for those struggling to work long hours outside the home while handling child care and housekeeping. Studies including disadvantaged households (e.g.here and here) suggest that such families can often barely afford food, purchase most of their groceries at the lowest available prices and would probably have to pay more to adopt healthier choices.
6. Studies consistently find that when cities provide stable, subsidized housing to people with chronic mental health and substance abuse problems who live on the streets it saves taxpayer dollars by reducing the burden on law enforcement and hospitals.
FALSE: In a study of supportive housing in Chicago, the savings were statistically insignificant. In a five-city study, clients in supportive housing wound up costing more than a comparison group of people not given housing. A study of homeless people given supportive housing in Seattle found that medical and law enforcement costs costs dropped to about half the level seen among comparable homeless people on a waiting list. But this savings estimate did not include the capital costs of building and refurbishing apartments. Raising capital is likely to be a tall hurdle for many communities and this issue often gets ignored in news reports about the promise of supportive housing. Of course, saving money is an unusual thing to require of a policy that cost-effectively relieves suffering. The cost-effectiveness of medical interventions is customarily measured in terms of quality-adjusted life-years gained, not dollars saved.
7. African-Americans have levels of overall poverty that are two to three times higher than those of white Americans, and this explains the strikingly worse health outcomes among African-Americans.
TRUE AND FALSE: Poverty levels among African-Americans remain two to three times higher than among whites, but even after taking socioeconomic status into account, many disparities in health remain. A study comparing white physicians from Johns Hopkins University with black physicians from Meharry Medical College found large racial differences in health. Diabetes and hypertension were twice as high among the black doctors, who also had higher rates of heart disease than the white doctors. African-Americans at all income levels appear to face greater exposure to adverse social conditions and physical environments than whites. A revealing study compared African-Americans and whites on measure called “allostatic load,” which is supposed to reflect how well or poorly the cardiovascular, metabolic, nervous, hormonal and immune systems are functioning. Scores are based on readings of blood pressure, body mass index, kidney function, blood sugar, cholesterol, C-reactive protein and other tests. The study found that African-Americans scored worse than white Americans at all ages, and the racial differences persisted after adjustment for poverty. In fact, non-poor blacks scored worse than poor whites.
8. Social disadvantage appears to accelerate aging at the cellular level.
TRUE: Studies have found links between adversity and the length of telomeres, the protective sections of DNA at the tips of chromosomes that shorten with age. Children who experience chronic stress from a disadvantaged life have shorter telomeres than their advantaged peers, according to a recent study of 9-year-old African-American boys. Adults who completed less than a high school education had significantly shorter telomeres than those who graduated from college, in another study. The evidence is not conclusive, however. Some investigators have found inconsistent correlations between telomere length and socioeconomic status.
9. Stress during fetal development – from a mother’s poor diet, for example, or exposure to pollutants – may set the stage for diseases decades later in life as an adult.
TRUE: Numerous studies have shown that low birth weight babies have higher rates of cardiovascular and metabolic illness and premature death in adulthood. Poor nutrition and environmental factors can alter metabolism, hormone production and gene expression, causing lifelong changes in the body’s organs and tissues and provide a physiological and metabolic basis for adult-onset disease. Recent evidence suggests that the long-term consequences of adverse conditions during early development may be transmitted across generations by epigenetic modification of genes.
10. Intensive day care for infants and toddlers in disadvantaged homes may produce health benefits that persist into adulthood.
TRUE: In the Carolina Abecedarian Project, babies born in the 1970s were randomized into two groups. Both received nutritional supplements, basic social services and access to health care, but one group also received cognitive and social stimulation interspersed with caregiving and supervised play throughout an 8-hour day for the first five years. As adults in their mid-30s, disadvantaged children randomly assigned to treatment had a significantly lower prevalence of risk factors for cardiovascular and metabolic diseases.
To learn more about the social determinants of health, visit AHCJ’s core topic pages on the subject. You’ll find definitions and explanations for key terms, tip sheets, stories about how other reporters have covered disparities in health and lots of resources and sources to tap in your reporting.