The Social Determinants Of Health

The Lalonde report of 1974 (issued by then Canadian ministerof national health and welfare Marc Lalonde) popularized theidea that direct medical care might be but a bit player in producinghealth and reducing mortality. That report highlighted the factthat other factors—biology, environment, lifestyle—figuremore prominently than medical care in producing health. Thereport also noted a striking disparity between this findingand the shares of income devoted to various determinants ofhealth. Indeed, although estimates of the effect of improvedmedical care on reductions in mortality hover around 10–15percent, public policy and investment in this country focusoverwhelmingly on better access to and improved quality of care,not health promotion and disease prevention.

Although the report’s findings have not translated intoradical shifts in investment priorities, health researchersfrom many disciplines have nevertheless produced a wealth ofdata and analysis exploring nonmedical, social factors and theoften complicated pathways by which they influence health andillness.

In this section, Dolores Acevedo-Garcia and colleagues observethat health opportunities are inextricably bound to where onelives, and that in addition to traditional public health outreach,new policies need to be developed to increase access to "opportunityneighborhoods," by improving housing mobility and promotingopportunities for healthy living in disadvantaged neighborhoods.In a Perspective, Nicole Lurie and colleagues focus on issuessurrounding a business case for disparities reduction in healthcare organizations.

Next, Sarah Gehlert and colleagues focus on the role of socialenvironments in producing disease disparities. The authors describea model that establishes a multilevel causal chain startingfrom social environment and ending at cellular health, incorporatingboth psychological and behavioral responses. Since the modellinks social factors through a chain of "downstream" conditionsall the way to end-state diseases, it provides a tool for policymakersto assess the effectiveness of policy interventions on groupdifferences in health.

In the final two papers, Ellen Meara and colleagues and RachelKimbro and colleagues focus on interactions between educationand health/mortality. Meara and colleagues find that in spiteof increased attention during the 1980s and 1990s to reducingmortality among those who are educationally disadvantaged, suchpeople have continued to lose ground compared to those who havemore education. Kimbro and colleagues provide additional insightby drilling down on the education issue, exploring the variableeffects of education on health behaviors and outcomes amongvarious racial and ethnic groups and arguing that policy toreduce disparities must take these differences into account.

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The Social Determinants Of Health