Exposure in Search of Disease: Applied Public Health

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Social Determinants of Health
9th Annual Joint Conference on Health Wenatchee,
Washington October 7 9, 2002 Juliet
VanEenwyk, PhD
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Acknowledgements
Angela Zechmann, MD, MPH Stephen Bezruchka, MD
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An extensive body of scientific literature notes
that people of relatively higher socioeconomic
position (SEP) are healthier than people of lower
SEP

• Individual factors
• Income
• Education
• Occupation

• Community characteristics
• Resources
• Social cohesion
• Income gap

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Gradient exists at all levels of the SEP hierarchy
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Washington Mortality and EducationWA Death
Certificate 1997 1999, SPS
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Relationship between health and SEP has been
documented in diverse cultures and in countries
with universal health insurance.
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Why?
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Usual Explanations

• Drift
• Lifestyle
• Medical Care
• Physical Environment

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Medical Care
Life Expectancy (years)
The US ranks first in per capita health care, but
ranks 25th in life expectancy and 24th in years
of healthy life expectancy.
WHO 2000 World Health Report
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The social and economic conditions that
influence whether people become ill are more
important than acute medical care
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Other Explanations
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Income Disparities

• Relative income is as important as absolute
  income as a determinant of health
• Where income is more equally distributed,
  health is better

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age-adjusted mortality rate per 100,000
Ross et. al. BMJ 2000
BETTER HEALTH
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percent of income received by bottom 50 of
households
MORE EQUALITY
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Economic Inequality

• "Inequality of income takes the broad, safe
  and fertile plain of human society and stands it
  on edge so that everyone has to cling desperately
  to her foothold and kick off as many others as
  she can."
• George Bernard Shaw 1927

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stress
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High income disparity leads to low social capital

• the resources imbedded in social relations
  that facilitate cooperation and collaboration
  in communities
• social cohesion
• social connectedness
• opposite of community disorganization

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• In communities in which most people are
  social equals (i.e., low income disparities)
  levels of friendship and social trust and
  hence, social capital will be relatively high
• Communities with high income disparity and
  low social capital do not invest in
  infrastructure housing, transportation, day
  care, schools, parks, medical facilities,
  libraries, etc.

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Post Script on Social Capital

• Cohesive communities can be aversive to
  outsiders
• Building cohesion without changing
  underlying structure can be insidious

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Racism and Other Institutional Biases

• Placement of hazardous waste sites (race more
  important than poverty)
• Job and educational opportunities
• Medical care

chronic stress
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Why?

• Usual explanations
• Drift
• Lifestyle
• Medical Care
• Physical Environment

• Other explanations
• Income inequality
• Social capital
• Racism

• Two more explanations
• Life course
• Social support

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Solutions
Guide to Community Preventive Services
Sociocultural Environment Section

• center-based preschool programs, such as Head
  Start, to prevent developmental delay
• rental vouchers to allow lower income
  individuals find housing in safe neighborhoods

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Other Ideas

• Redistribute income from rich to poor via the
  tax structure and tax policy..
• Capital gains tax
• Inheritance tax
• Who gets audited
• Income or user tax versus sales tax

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NYT Feb 11, 2001
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WHO Healthy Cities
Policy proposals for local and national
governments in 10 areas related to social
determinants of health

• work environment, e.g., decision- making,
  ergonomics, rewards
• healthy food supply, e.g., local and
  sustainable agriculture
• transportation, e.g. reduce dependence on
  cars

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2002 Health of Washington State

• 66 chapters
• Washington State health data
• Interventions
• Full report at www.doh.wa.gov/HWS
• Executive summary and full report on CD-ROM
  ..available today..or contact
• maryann.shannfetty_at_doh.wa.gov