Social Determinants of Health A Call to Action for the Employer Community

A lmost 2,000 years ago, Galen (8) observed, ‘‘Both in importance and in time, health precedes disease. Therefore, we ought to consider first how health may be preserved and then how one may best cure disease. ’’ This statement leads us to ponder what the causal factors may be for disease and ill health. Oftentimes, epidemiology seeks to identify the risk factors for diseases and conditions. Elevated blood cholesterol or blood pressure is associated with an increased risk for cardiovascular disease. Based on such information, screenings are often called for to identify the individuals who may be at high risk for subsequent disease and they become appropriate candidates for outreach and interventions to reduce risk. However, it may be time to view the issue through a different lens. What if we were to consider, from a population health perspective, the underlying causal factors that cause the biological markers for subsequent disease (such as elevated cholesterol) to get closer to the sources of the problem? Here, for example, we examine the dietary behaviors of people as a more proximal cause of the disease, rather than the biological effect the diet itself has on blood lipid profiles. Unfortunately, if we consider only the proximal factors for the risks, there may be an inappropriate and unjustified urge to blame individuals for the disease end points V that is, adopt the position that ‘‘if people were to just change their behavior, we wouldn’t have the negative consequences of so much ill health including excess health care costs, lost productivity, and the like. ’’ Despite the modifiable nature ofmany behaviors, it is not always entirely an individual choice to change behavior. It probably makes sense to look even deeper. After decades of research, it has become increasingly clear that individual choices are not necessar i ly the reason why people, for example, consume diets high in saturated fats, salt, and calories. Behaviors are actually tied quite closely to the nature of the policies that shape economic incentives for farmers, the food supply itself, the culture of the group, and affordability and accessibility of healthy food options, among other reasons. These may all be considered social circumstances that influence the behavior of individuals and populations. These behaviors, in turn, predispose them to risk factors that may be viewed as ‘‘signal events’’ for impending disease, ill health, lower functional status, and premature death. Let’s consider these social circumstances that shape the behaviors that are the ‘‘causes of the causes. ’’ Previously, this column has reported on the interconnectedness of the behaviors of individual employees and the influence of the company environment on them (4). The bidirectional interaction between individuals and their (corporate) community makes health both a personal good and a public good (3). The health status of both the individual and the larger community to which they belong is directly related to the emotional, psychological, physical, and financial well-being of both the employee and the company. Searching for actionable opportunities to change the underlying causes of the causes will produce the potential to improve health and economic outcomes for both employees and the company for which they work. The intention of this column is to consider the social determinants of health and to stimulate action that will lead to change in the social context in which employees function, thereby providing specific reference to the worksite setting.