Include a Social Determinants of Health Approach to Reduce Health Inequities

Reducing health disparities, primarily those based on race/ethnicity and gender, has long been a public health priority in the United States, but the first official goal to eliminate health disparities came with Healthy People 2010.1 Recent developments led by the World Health Organization (WHO), however, have accelerated the thinking about the causes of health inequities—i.e., disparities that are systematic, avoidable, and unjust2—and how best to address their reduction.3,4 The WHO Commission on Social Determinants of Health concluded in 2008 that the social conditions in which people are born, live, and work are the single most important determinant of one's health status.3 Certainly, individual choices are important, but factors in the social environment are what determine access to health services and influence lifestyle choices in the first place. In addition to the WHO's work, state and local health departments, national government agencies (such as the Centers for Disease Control and Prevention and other divisions of the Department of Health and Human Services in the U.S.), and other national organizations have recognized the need to address health inequities in a systematic way by addressing more than individual behavioral factors.5–12 This global movement recognizes that to reduce health inequities, it will be necessary to incorporate a social determinants of health approach with existing approaches. Social determinants are defined as follows: “… the circumstances in which people are born, grow up, live, work and age, and the systems put in place to deal with illness. These circumstances are in turn shaped by a wider set of forces: economics, social policies, and politics.”13 Broadening our collective approaches to reducing health inequities by addressing the social and structural conditions needed for good health for all is urgently needed now. These social and structural conditions include education; housing; employment; living wages; access to health care; access to healthy foods and green spaces; justice; occupational safety; hopefulness; and freedom from racism, classism, sexism, and other forms of exclusion, marginalization, and discrimination based on social status. The inequitable distribution of these social conditions across groups contributes to persistent health inequities. While a social-determinants approach is important for people of all ages, it is critically valuable for children, whose positive early development can improve their health throughout the life span.14 As a former U.S. Surgeon General, I am committed to eliminating health disparities in the United States and providing care to vulnerable populations such as the indigent, foreign-born, and homeless. I urge a more broad-based and systematic approach to adequately address the health inequities that have been abundantly documented in the U.S. and which I have seen on a daily basis across the country. I call on people from all disciplines and sectors to come together and work toward achieving the Healthy People 2020 objectives, especially as they relate to social determinants of health. We need a new way of thinking, one where, as public health professionals, we lead by taking an interdisciplinary approach and collaborating across a wide range of disciplines, developing our own workforce to effectively address social determinants of health, and insisting health and non-health policies incorporate a social-determinants approach. We all have a role to play. The federal government should raise the profile of social determinants and communicate to the public what is meant by this somewhat unfamiliar approach. Public health and the work we do can be framed around health equity. Communities and local governments and organizations will have to be educated about the growing movement. Clear, concise language and concrete examples of how people can affect change will be needed. We should have “health in all policies” because nearly all social determinants are outside the direct control of the health sector. Although the goal of many social and economic policies may not be to affect health outcomes, the fact is they will.14 From funding opportunity announcements to accountability mechanisms, all facets of public health should include addressing social determinants. Our partnerships will have to be stronger if we are to have an impact. We must reach out to nontraditional partners in the private sector, industry, and other parts of government in the transportation, education, and justice sectors, for example. Analyses of equity effectiveness should be conducted alongside those of cost-effectiveness to ensure that the impact of various policies on health outcomes is given equal consideration.14,15 Finally, we must expand resources to address these underlying determinants. Public resources could be better leveraged and collaborations with the private sector and foundations should also be sought. In short, we must be proactive, collaborative, inclusive, and deliberate as we advance the use of a social-determinants approach to reducing health inequities among and between populations.