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Your health is about more than just your health

Why we need to pay more attention to social determinants of health

A bit of a mind twister, no? We all know this intuitively, but we never really internalise it the way policymakers are forced to commit this mantra to memory.

Your health is about more than just your health.

In the everyday parlance of health policy wonks and epidemiology geeks, we call this phenomenon ‘the social determinants of health’. Things like educational attainment, income, residential and racial segregation, and gender. As much as your genetics and your lifestyle factors, these social determinants of health can be directly attributable to hundreds of thousands of deaths. In fact, Galea et al actually calculated the deaths attributable to each of the social factors in the US in a single year (2000) and compared them to deaths from three of the leading disease killers in the US. It really is staggering to think about and eye-opening when you look at some of the deeper statistics on each one of these dimensions.

As an example, the Robert Wood Johnson Foundation conducted a series of analyses on these social determinants of health and found that residential segregation (ie where you live) has a major impact on overall health outcomes. Take a look at Figure 1 (pictured below). Within a radius of nine to 17 metro stops (10-30 miles) in Washington, DC, the lifespan of individuals can change by as much as nine years. And the graphical portrayal of health disparities based on income and education are just as stark. Think about it for a moment. Your lifespan can be almost ten years shorter simply based on where you live. And this is not a comparison between lifespans in sub-Saharan Africa and North America. This is a comparison between lifespans in the same city.

Figure 1

And these social determinants of health should not be viewed in isolation of each other. A lower education in and of itself has the potential to cause enough damage to an individual’s health simply by virtue of our knowledge about the association between educational attainment and health literacy. The lower the number of years of total schooling, the lower the overall health literacy score. And the lower the score, the worse the outcomes. For example, we have known for many years that differences in health literacy levels have been consistently associated with increased hospitalisations, greater emergency care use, lower use of mammography, lower receipt of influenza vaccine, poorer ability to demonstrate taking medications appropriately, poorer ability to interpret labels and health messages, and, among seniors, poorer overall health status and higher mortality.

But there is also that interplay between determinants that I referred to. A lower education also has an impact on where you live. Why? Because your level of education has an impact on how much you earn. And how much you earn determines how much you can afford to pay for rent. And if you can’t afford to pay a higher rent in a better neighbourhood, chances are that your neighbourhood may have sub-optimal transportation and unreliable childcare – both of which may potentially impact your access to health care (not to mention your access to higher-paying jobs and better schools).

We can hope that one out of every thousand children is able to break out of this cycle of despair. But those numbers don’t move the needle. We need drastic measures over a generation that impact more than the lucky few. And we need to track the outcomes longitudinally to show that they work. We need free housing for socioeconomically disadvantaged persons for a fixed but meaningful period of time. We need free schooling through university. We need income equality policies that allow the disadvantaged a mechanism to close the gap between their income and the median income. We need free childcare and free public transportation for those who are most in need.

But what we need the most is to revisit the axiom that should be our guiding principle: ‘There is nothing more unequal than the equal treatment of unequal people.’

Thanks to Dr David Williams from Harvard TH Chan School of Public Health for the inspiration and idea for this column

Rohit Khanna is Managing Director of Catalytic Health,  a healthcare communications, advertising and strategy agency. He can be reached at:

13th August 2018

From: Healthcare



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