Established 1992

1. Established 1992 Translating the Determinants of Health into a US Policy Framework Barbara Kivimae Krimgold, Center for the Advancement of Health Text

2. Introduction • In Healthy People 2010, the Department of Health and Human Services establishes the goal of eliminating preventable health disparities by race, ethnicity, gender and socioeconomic status.

3. Introduction Improvements in the nation’s health depend in part on more effectively using what we know about the many determinants of health and disease to develop public and private policies that shape the social, economic, physical, educational, and occupational environments in which people live.

4. Introduction The United States annually invests billions of dollars in health research on the assumption that if weknow more about what determines health and disease, we will be able to reduce pain and suffering and contribute to the vitality, productivity, and long lives of American citizens. However, this investment is only effective if we translate this research into policy and practice.

5. What Do We Know? What do we know about the determinants of health? How can community action enhance health and reduce health disparities based on race, ethnicity, gender or socioeconomic disadvantage?

6. Health is a precious commodity Good health is an important prerequisite for equal opportunity and the pursuit of happiness. There are many determinants of health, including health care, our psychological, educational and material resources, and the social and physical environment in which we live. Many social, economic and environmental factors influence our behavioral choices and our physical and psychological well-being and get “under our skin” to determine our health.

7. Health is Importantto Society too Poor health affects child development, adult well-being and family stability and it has both social and economic costs. It leads to an increased burden of sickness care and the even greater cost of lost opportunities. It undermines workforce effectiveness and productivity, as well as the ability of U.S. firms to compete. (Auerbach et al. 2000)

8. Yet the Factors that Determine Health are Poorly Understood Health care is important, but not the primary determinant of health status for a population. Individuals need health care, and disadvantaged populations, who generally suffer earlier and more chronic disease and disability, need more health care, not less, than the average. But, as essential as medical care is, it is not the most significant determinant of a healthy society. The United States spends roughly $4,000 per person on medical care annually – more than any other nation – but three fourths of developed countries outrank the United States on common health status measures such as life expectancy and infant mortality (Anderson 1999).

9. Health Behaviors and Lifestyles Affect Healthand Cause Premature Mortality,Illness and Disability These behaviors are strongly linked to fundamental socioeconomic characteristics that persist over time despite changes in disease prevalence and risk factors (House and Williams 2000; Lantz et al. 1998; Link and Phelan, 1995). Individual choices and individual health performance are thus influenced strongly by our families, our neighborhoods and communities and our work and social environments.

10. There is a relationship between an individual’s job, educational, or income level and his/her health • For each step up the socioeconomic ladder, there is a corresponding improvement in health. Factors like control over work, when and how to complete tasks, and psychologically supportive supervision contribute to differences in health and well-being. Flexible hours and adequate family leave benefits are also important in helping workers maintain family well-being (Heymann 2000).

11. The Gradient:Mortality By Income Among White U.S. Men Age adjusted mortality rate per 10,000 person years 7.5 10 12.5 15 17.5 20 22.5 25 27.5 30 32.5 $000 Income Source: MFRIT data, adapted from Davey-Smith et al.

12. Material deprivation is harmful to health Poverty is the greatest risk factor for poor health and child poverty levels, in particular, are extremely high in the United States relative to other rich countries (UNICEF 2000). One in five of our children and more than two in five of our minority children are growing up in poverty (Williams, 2001). Recent work indicates that the 30-60 percent difference in mortality between U.S. states and Canadian provinces may be related to modest social investments, such as reducing child poverty, and that it would take only 0.66 percent of GDP to eliminate child poverty in the United States (Ross et al. 2000;UNICEF, 2000).

13. Mortality By Income Distribution Among U.S. States and Canadian Provinces 800 675 550 Working Age male mortality per 100,000 425 300 18 20 22 24 Median percentage of income received by the least well-off 50% Source: adapted from Ross et al.

14. Impact of Transfer Programs On Household Poverty Rates in the U.S., Canada and Sweden Percent of households under poverty level Sourse: Luxembourgh income Study data, from Hertzman

15. Unequal distribution of income has beenshown to have a negative impact on health status Inequality is also associated with higher levels of mistrust and crime and lower levels of civic participation and economic opportunity of women (Kawachi et al. 1997; Kennedy et al. 1998).

16. Poor Health may Result From the Negative Impact that the Physical Environment can have on Health and Behavior Neighborhoods that lack physical resources are more likely to expose residents to crime and violence, inadequate housing and parks, lack of good sanitation, unsafe home and work places, and pollution. Low income neighborhoods also have fewer grocery stores, less access to fresh fruit and vegetables, fewer safe recreation areas and more liquor stores (Macintyre 2000).

17. Health may be affected by perceptions of discriminatory treatment at the individual and structural levels Even after controlling for health care and income, blacks have worse health at every socioeconomic level than their white counterparts (House and Williams, 2000). Perception of inferior treatment at every income and educational level may take a psychological and physiological toll on individuals directly and indirectly. For example, documented discrimination in housing has contributed to the current high rates of residential segregation by race and income.

18. The presence or absence of social support has a powerful influence on health • Individuals are more resilient to infection and illness when their mental health is good and their social networks are strong (Berkman and Syme 1979).

19. Stress is dangerous to health The effects of stress include depression, susceptibility to infection, diabetes, a harmful pattern of cholesterol and fat in the blood, high blood pressure, and higher risk of heart attack and stroke (McEwen and Seeman 1999). Because stress can lead to depression and anxiety, individuals under stress may also self-medicate with unhealthy substances such as cigarettes, drugs and alcohol. Substance abuse occurs in a social context; behavior is influenced by peer norms and available options.

20. A Concern is the Failure to Invest Adequately in Good Early Childhood Development for Children Research shows that some of the foundations for healthy emotional and moral development are laid at an early age, that missed opportunity here correlates with poor educational attainment, drug use, anxiety and depression, and teenage pregnancy, contributing to underemployment, chronic disease, and early aging (Hertzman, 2001). The lifestyle health and achievement trajectories by class show a widening gap in the new global economy, as high quality education increases in value and low skill jobs show declining earnings. (Graham, 2000).

21. Philosophers and ethicists argue that health and its social determinants have a special moral significance This is because they contribute so heavily to the opportunities open to individuals (Daniels 2000; Sen 2000). Some ethicists suggest that a society that permits high levels of health inequality is a society that doesn’t care about its people. (Halpern 2001).

22. What Can Be Done? Although there is no “silver bullet” for improving health, there are many actions that can be taken to improve our health and well being and to reduce preventable health disparities. “We don’t need a revolution to achieve better health,” argues Richard Wilkinson, “Small differences in socioeconomic status matter.” In the case of health, there is no “zero-sum game” (Krimgold and Lefkowitz 2001). What are some of those interventions?

23. Investments in thehealthy development of young children are sound investments Lifting children out of poverty is a desirable goal; it would improve their health and life chances and those of the next generation. Lower income and racially segregated neighborhoods in particular would benefit from additional services and opportunities to improve education and skills for parenting, for quality child care and living-wage work.

24. Health care, insurance and support for healthy behaviors need to be continuous, not intermittent or discriminatory • Health care is of special importance to groups at greater risk of premature diseases and disabilities; low-income and minority populations need more extensive health care and insurance than other American, not less.

25. Improving the quality of child care and family leave policies will enhance parents’ capacity to maintain individual and family health and well being Activities to foster a civil society and develop human and social capital will have a payoff in improved health and well-being. Changes in the work environment to increase worker control over work, provide appropriate compensation and benefits, and improve family leave policies have been shown to increase productivity and reduce sick leave and disability.

26. A fairer economic environmentand a social contract with all generations of Americans can pay off in improved health status • Economic and social policies are also health policies (Kaplan 2001). A more equal economic environment could be achieved through tax, transfer, and employment policies, such as increases in the Earned Income Tax Credit, minimum wage and unemployment compensation.

27. To close the gap between knowledge and action, it is critical to assess the impact of economic and social policies on health and health behavior • This can be done through ongoing research and public impact statements as well as through national and community indices of social health and health disparities, all of which will provide us with tools for evaluating our success.

28. Expanding our View of Health Our health behavior and our health policies must reflect an expanded, more complex and realistic view of how we actually achieve our highest potential for health and well being. This seems to include what Nobel prize winning economist Amartya Sen described as development of our “human capability,” To achieve a full measure of health and to act in ways that promote individual health, people need, he advised, not only freedom from material deprivation but “the freedom to live lives that they have reason to value.” (Sen 2001)

29. We have the opportunity to develop and promote a more realistic view of the determinants of health and policies to promote population health • To make equal opportunity ring true for all Americans, we need to create more ladders to good education, good jobs, good lives and good health.

30. People react to the findings on inequalities in health in a variety of ways • First is disbelief: • it cannot be true.

31. People react to the findings on inequalities in health in a variety of ways • Second, if true, it is the result of differences in medical care.

32. People react to the findings on inequalities in health in a variety of ways • Third, if it is the result of inequalities in society, nothing can be done

33. People react to the findings on inequalities in health in a variety of ways • But, it is true; it is not primarily the result of differences in access to high quality medical care; and there is much that can be done about it, if society has the will. (Marmot 2001)

34. What Can be Done? • Its time to engage communities and the nation in a dialogue and action to eliminate health disparities.

35. conclusion • Social Determinants of Health research provides a rich array of policy options for further exploration. Serious health consequences of continued poverty and growing inequality raise basic questions about society. Can the US continue to ignore opportunities to reduce inequality and improve heath and well-being, workplace competitiveness and family life? Or will we develop a policy agenda for a new social contract for the 21st Century?