Question

How does this issue depict the role of the social determinants of health in the spread of disease?

Answer 1

Ans) Despite challenges, controversies, and unanswered questions, the tremendous advances in knowledge that have occurred in the past 25 years leave little room for doubt that social factors are powerful determinants of health.

- The consistency and reproducibility of strong associations between social (including socioeconomic) factors and a multitude of health outcomes in diverse settings and populations have been well documented, and the biological plausibility of the influence of social factors on health has been established. It is not surprising that exceptional examples of health indicators, settings, and subgroups in which health does not necessarily improve with greater social advantage can be found. There may be thresholds above which a higher degree of a given social factor (e.g., income) no longer yields better health.

- Exceptions would also be expected as the effects of any given factor are contingent upon the presence of myriad other factors—social, economic, psychological, environmental, genetic, and epigenetic. Considering the long, complex causal pathways leading from social factors—particularly upstream ones such as income and education—to health, with opportunities for countless interactions at each step, it is indeed remarkable that there are so few exceptions to the general rule.

- The relative importance of social vs. genetic factors is often debated. The emerging awareness of gene-environment interactions, however, has drastically altered nature-vs.-nurture debates. Social and genetic causes of disease can no longer be seen as mutually exclusive. We now know that adverse genetic endowment is not necessarily unalterable, that a “bad” (or “good”) gene may be expressed only in the presence of triggers in the social or physical environment, and that these environments potentially can be modified by social policies.

- Despite gaps in current knowledge, the case for needing to address upstream socioeconomic factors is strong, and enough is known to inform interventions, which must be rigorously evaluated. Given that SDH—including socioeconomic conditions such as income, wealth, and education—are by definition outside the realm of standard medical care.

- Many public health practitioners have little experience in sectors outside public health-care delivery. Medical care providers, including nurses, physicians, and others, undergo intensive training in medicine, not in social work, and we believe in the power of medical care to heal, alleviate suffering, and save lives. Nevertheless, the knowledge indicating a crucial role for socioeconomic and related social factors in shaping health has become so compelling that it cannot be ignored insofar as public health and health-care personnel are committed to health.

- Current knowledge suggests ways to collaborate with others to improve health outcomes for socially disadvantaged populations.

- At a minimum, appreciation of some of the social factors that influence health-related behaviors and health status itself can help clinical providers develop more effective treatment plans.

- Clinical and public health practitioners can strengthen routine procedures to assess and respond to social needs through referrals and/or on-site social and legal services.

- Public health workers and clinicians also can develop health-promotion strategies that reach beyond individual clinical and social services to communities, to influence living and working conditions that are generally the strongest determinants of whether people are healthy or become sick in the first place.

- They can participate in or promote research adding to the understanding of the mechanisms by which social factors influence health, and test which strategies appear most effective and efficient.

- Finally, clinicians and public health practitioners can be key resources for local, state, and national policy makers on the crucial issue of health equity for all Americans, including those facing the greatest social obstacles.