Social determinants of health

The tragic, far-too-early death of a friend this past week reminded me of the need to dedicate an entire post to this topic. When talking about well-being and longevity, the social determinants of health are simply more impactful than any other factor. I chose to go into medicine to make a difference in the healthspan of individuals and populations, but the work I do as a doctor cannot compare to the influence that one’s circumstances will have on their health. Estimates attribute 10-20% of health outcomes to medical care, while the remaining 80-90% are a result of “health-related behaviors, socioeconomic factors, and environmental factors.”

Social determinants are simply the conditions one faces as they live and work. This includes everything from income to transportation access to social support. Your address alone can sway your life expectancy by as much as two decades. How is this possible? Because things like diet, exercise, sleep, and stress vary significantly between groups, and these factors play a far greater role in your long-term health than people recognize.

Take the example of two individuals living in different neighborhoods. Person 1 has a grocery store with fresh produce just down the street. Person 2 is in a “food desert” — only liquor stores are within walking distance. Even if Person 2 had a car to drive to the nearest grocery store, they couldn’t afford to buy quality vegetables and protein. Person 1 has a gym membership, and they also have the option of jogging through the trails in their neighborhood or riding the exercise bike they have at home. Person 2, on the other hand, can’t afford a gym membership and doesn’t feel safe walking or running on their block, especially at night. Person 1 makes an above-average salary working 32 hours a week, so they can easily manage 8 hours of sleep each night. Their parents helped them get this stable job, they live with the spouse they met in graduate school, and they don’t experience much stress. Person 2 never had stable schooling from a young age, and is now forced to work two jobs to feed their kids. As a result, they struggle to sleep 5 hours a night. This only adds to the stress they already experience trying to pay the bills every month.

Any physician can tell you which of these people is more likely to show up at the hospital first. The amount of time it takes for advanced disease to develop is what makes the difference for longevity. While there are certainly equity issues with healthcare access, both Person 1 and Person 2 should receive a comparable level of care once they inevitably develop symptoms resulting from chronic disease. The expertise of their particular doctor and the technology available at their local hospital may be relevant, but only slightly (this is the 10-20% component of health discussed earlier). The real differentiating factor is how long they were able to avoid heart disease, diabetes, cancer, and the like. We know that this is almost entirely a result of the social determinants of health.

It’s worth noting that social determinants of health are not just a problem of low-income urban populations, as represented by Person 2 above. Most people will have at least one social determinant that is working against them, whether that’s living in a rural setting, experiencing stress due to work or relationships, or having poor water/air quality at home or at work. Unfortunately, racial injustice and discrimination of any kind can certainly factor into this calculation as well. Generational wealth and social capital contribute significantly to health outcomes, but are clearly not distributed equitably.

The immense impacts of the social determinants of health are why many have become proponents for a health in all policies approach to governing. The idea here is that everything we do influences health, and thus every decision we make must take health into consideration. It has become evident that we must invest in improving the social determinants of health from a systemic perspective, but individuals and communities can begin to attack these issues themselves. Education and access to information are two major determinants of health that we try to address through Zone 7, and our readers’ support enables us to make a difference — thank you!

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