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Topic overview

In our society, wealth makes health. People who have socioeconomic challenges or live in poverty have shorter lifespans than the rich, with a difference of 15 years between men in the top 1 percent of income and men in the poorest 1 percent. The situation is not expected to improve with the continued spread of the income gap.

Economics is, however, just one of many interacting factors that can make or break health. Ethnicity, education level and sex are certainly relevant, as the breathtakingly tragic outcome disparities for black women giving birth in the United States demonstrate. Other important factors that create health disparities that transcend income measures include disability status, geographic location and occupation. Almost every social construct that stratifies or categorizes people will play a role in health inequalities.

These social determinants of health status are crucial factors for all health journalists to consider because they affect every aspect of the beat, from who participates in clinical trials to who benefits from their findings to political and social policy decisions that ignore or elide the gaps that these factors create. Giving consideration to these influences can deepen and strengthen reporting and certainly presents abundant opportunities for coverage in their own right.

Here’s why it will pay off for journalists to dig into this subject:

The health gap appears to be getting worse. Socioeconomic, race and ethnic disparities in infant death rates and premature mortality shrank between 1966 and 1980 across the U.S. But since then, the relative health inequities have grown wider, according to numerous studies. Virtually all gains in life expectancy since 1980 occurred among the highly educated. Steep reductions in infant mortality have benefitted white Americans more than African Americans, among whom infant death rates are now more than double the rate among whites. 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. Researchers at the Harvard School of Public Health estimate that 14 percent of premature deaths among whites and 30 percent of premature deaths among blacks between 1960 and 2002 would not have occurred if everyone had experienced the mortality rates of whites with incomes in the top one-fifth. Among industrialized countries, the U.S. ranking for life expectancy has dropped from 14th in 1980 to 27th in 2010. That’s stirred debate about the reasons why the U.S. is falling behind. Some blame trends in individual behavior or failures of the health care system. But others suspect that the root cause is worsening social inequality.

Scientists are making fascinating discoveries about the biological ways that social determinants shape health. Prolonged exposure to stress can trigger the release of hormones, such as cortisol and epinephrine, that undermine immunity, boost inflammation, and increase vulnerability to conditions such as diabetes and heart disease. Stress during fetal development, from a mother’s poor diet or exposure to pollutants, for example, may set the stage for diseases decades later in life by altering metabolism or triggering lasting changes in the activity of genes.

Some studies suggest that these “epigenetic” changes in gene expression can be passed on to children and influence the occurrence of disease in more than one generation.

Health reform is under threat. Expanding health insurance coverage, as part of the continuously threatened Affordable Care Act or more recent calls for “Medicare for all,” can help, but it does not address the social factors that lead people to medical care in the first place. Even in nations with universal health coverage, socioeconomic status still influences health and longevity outcomes. The implication is that social factors in effect before a person needs healthcare need closer attention. Disparities in access to education, economic opportunity, safe neighborhoods, disability accommodations, and other factors affect health and survival. The implication is that health reform needs to focus on more than health insurance reform. Each of the facets of live that make or break a person’s health need reform, as well.

Political battles loom. How best to educate children, extend economic opportunity to the disadvantaged, and regulate urban development are controversial questions, to say the least. When it comes to the social determinants of health, political leaders on the conservative end of the spectrum tend to emphasize the role of individual behaviors such as unhealthy eating, lack of physical exercise, smoking, and abusing drugs. And, in fact, a lot of questions remain unanswered. There is not enough evidence yet to say, for instance, whether school funding, tax credits, or income support could do more to improve health than policies more narrowly focused on changing behavior.