Reflections from the CDC 2010 health equity symposium.

Twenty-six years ago, Secretary of the U.S. Department of Health and Human Services Margaret M. Heckler called for an end to health disparities among minority populations across the nation.1 Since then, the U.S. government has introduced various initiatives to reduce health disparities among our nation's most marginalized populations. Despite these efforts, health disparities persist. As attempts to reduce health disparities continue, there have been major advances in the theory and research surrounding these challenges. One key development has been the renewed acknowledgment of the larger social context in contributing to the enduring gaps in health seen across vulnerable and disadvantaged groups. This notion is not brand new; in the 19th century, it was understood that the social and physical environment affected health. In 1848, Virchow concluded that poor sanitation, ignorance of basic hygiene, lack of education, and near starvation were the root problems of a typhus epidemic, and in 1855, Snow described the effects of contaminated water on spreading cholera.2,3 As this knowledge has evolved, one approach has emerged: reducing health disparities by addressing the social determinants of health (SDH). The term “social determinants of health” refers to the complex, integrated, and overlapping social structures and economic systems that include social and physical environments and health services. Adequately addressing the social and economic conditions in which people live, work, and play offers renewed hope to reduce health disparities and promote health equity.4 In 2010, the Centers for Disease Control and Prevention (CDC) hosted a symposium entitled “Establishing a Holistic Framework to Reduce Inequities in Human Immunodeficiency Virus (HIV), Viral Hepatitis, Sexually Transmitted Diseases (STDs), and Tuberculosis (TB) in the United States.” The purpose of the symposium was twofold: first, we celebrated the release of a white paper of the same name,5 and second, we offered exciting and engaging discussions with national experts on topics related to addressing SDH in public health practice, policy, and research. The day also included a frank discussion with senior staff members of the National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention (NCHHSTP) and three invited speakers: Paula Braveman, MD, MPH, of the University of California, San Francisco; Scott Burris, JD, of Temple University in Philadelphia, Pennsylvania; and Johnnie “Chip” Allen, MPH, of the Ohio Department of Health in Columbus, Ohio. The discussion focused on how NCHHSTP can further incorporate an SDH approach into its work. At the start of the discussion, a number of questions and challenges were posed: How does NCHHSTP convince others that achieving health equity in the U.S. should be a public health priority? In light of the fact that resources have been declining, how do we adequately address SDH? How do we address SDH in an era with increased negativity toward groups disproportionately impacted by infectious diseases (e.g., men who have sex with men, Hispanic/Latino people, and immigrants)? As NCHHSTP is a leader in infectious disease prevention, what activities should we initiate to address both SDH and their role in HIV, hepatitis, STD, and TB prevention? What changes to our surveillance and data-collection systems should we make to measure, monitor, and collect information on SDH? How do we incorporate laws into public health surveillance research? How does synergy in programs impact the individual? How do laws fit into this? Where do we begin our focus? What is the starting point? What SDH-related variables should be a priority for annual monitoring? These questions were an important starting point to better identify CDC's role in achieving health equity. This session also reiterated the need for CDC to take the lead in reducing health disparities and promoting health equity in the U.S. and abroad.