With thanks to my colleagues Michael Compton and Ruth Shim
Social Determinants of Health
Those factors that impact upon health and wellbeing: the circumstances into which we are born,
grow up, live, work, and age, including the
health system.*
“Do we not always find the diseases of the populace
traceable to defects in society?”
Rudolf Virchow (1821–1902)
*World
Health Organization: Closing the Gap in a Generation: Health Equity through Action on the
Social Determinants of Health: Commission on the Social Determinants of Health, 2008.
Causative Factors
These circumstances are shaped by the
distribution of money, power, and
resources at global, national, and local
levels, which are themselves influenced
by policy choices.
The Causes of the Causes
The Fundamental Causes of Disease:
If risk factors are the precursors of
disease, then the environmental and
contextual factors that precede or shape
these risk factors are the causes of the
causes.
Biopsychosocial Perspective
“To provide a basis for understanding the
determinants of disease and arriving at rational
treatments and patterns of health care, a medical
model must also take into account the patient, the
social context in which he (or she) lives and the
complementary system devised by society to deal
with the disruptive effects of illness, that is, the
physician role and the health care system. This
requires a biopsychosocial model.”
George Engel
Prominent Causes of Health
Disparities And Inequities
Social Determinants are major contributors to:
Health disparities: differences in health status
among distinct segments of the population
including differences that occur by gender, race or
ethnicity, education or income, disability, or living
in various geographic localities
Health inequities: disparities in health that are a
result of systemic, avoidable, and unjust social and
economic policies and practices that create
barriers to opportunity
What Accounts for
Preventable Deaths?
The Social Dimensions of Health
Health begins and is dependent upon where
we live, learn, work, and play.
Zip code may be more predictive of one’s
overall health than one’s genetic code.
Social Justice
What is Social Justice?
The distribution of good (advantages) and bad
(disadvantages) in society, and how these things
should be distributed in society. It is concerned
with the ways that resources are allocated to
people by social institutions. David Miller
Assuring the protection of equal access to
liberties, rights, and opportunities, as well as
taking care of the least advantaged members of
society. John Rawls
How Does Social Justice
Relate to Health?
 Considered the moral and ethical foundation of
public health, i.e., distributive justice, e.g., the OHP.
 Concerned with human well-being.
 Ensures that individuals in society have equal
opportunities to lead healthy, meaningful, and
productive lives.
Powers M, Faden R: Social Justice: The Moral Foundations of Public Health and Health Policy.
New York: Oxford University Press; 2008.
The Social
Determinants of
Mental Health
Social Determinants of
Mental Health
 Inseparable from the social determinants of health
 Deserve special emphasis, because:
• Mental and substance use disorders are highly prevalent and
highly disabling.
• The interdependence and mutual potentiation of these
conditions with other general medical conditions is well
established.
• These conditions have largely been neglected, underresourced, and stigmatized.
• Behavioral health conditions are often expensive to treat, but
much more expensive if ignored.
Suicide and Social Determinants
Durkheim, 1897:
• Demonstrated the
relationship between social
exclusion and suicide.
• Described suicide as a social
phenomenon, e.g.:
• “Wisconsin Death Trip”
• Farmers in India ingesting
pesticide due to
overwhelming debt.
Psychosis and Social Determinants
Faris and Dunham suggested
an inverse relationship
between social organization
and schizophrenia.
Mental disorders in urban areas: an ecological study of
schizophrenia and other psychoses (1939)
SDMH: Major Factors
 Discrimination and Social Exclusion
No one is born hating another person because of the color
of his skin, or his background, or his religion. People must
learn to hate, and if they can learn to hate, they can be
taught to love, for love comes more naturally to the
human heart than its opposite. Nelson Mandela
 Adverse Early Life Experiences
The Child is father of the Man. William Wordsworth
 Poor Education
The school is the last expenditure upon which America
should be willing to economize. Franklin D. Roosevelt
SDMH: Major Factors
 Unemployment, Underemployment, and Job
Insecurity
If a man doesn’t have a job or an income, he has neither life nor
liberty nor the possibility for the pursuit of happiness. He
merely exists. Martin Luther King, Jr.
 Poverty, Income Inequality, and Neighborhood
Deprivation
What a devil art thou, Poverty! How many desires—how many
aspirations after goodness and truth—how many noble
thoughts, loving wishes toward our fellows, beautiful
imaginings thou hast crushed under thy heel, without remorse
or pause! Walt Whitman
 Food Insecurity
There will never cease to be ferment in the world unless people
are sure of their food. Pearl Buck
SDMH: Major Factors
 Poor Housing Quality and Housing Instability
The connection between health and the dwelling of the population is
one of the most important that exists. Florence Nightingale
 Adverse Features of the Built Environment
Where you stand depends on where you sit. Nelson Mandela
 Poor Access to Health Care
Of all the forms of inequality, injustice in health care is the most
shocking and inhumane. Martin Luther King, Jr.
Architecture of Risk
The Social
Determinants of
Health and
Mental Health:
Case Examples
The Causal Chain
Why is Melanie in the hospital?
Because she has a bad infection in her leg.
But why does she have an infection?
She has uncontrolled diabetes.
But why is her diabetes not under better control?
She hasn’t been taking her prescribed medication.
But why isn’t she taking her meds regularly?
She can’t get to her appointments regularly and can’t
afford the meds.
The Causal Chain Continues
But why can’t she get to the clinic that has free
meds?
Her neighborhood is unsafe and there isn’t access
to affordable transportation or reliable childcare.
But why did she get diabetes in the first place?
She eats cheap, unhealthy foods.
But why doesn’t she eat healthier?
Because she lives in a food desert and has
poor understanding of health and
nutrition.
Why and why and why?
The Causal Chain
Why is Jason in the hospital?
Because he tried to commit suicide.
But why did he try to kill himself?
He had been drinking and using drugs for the past 2 weeks.
But why was he strung out on drugs and alcohol?
He was trying to escape the desperation of being homeless.
But why was he homeless?
He had lost his apartment in the rough part of town and
was robbed when sleeping in the park.
The Causal Chain Continues
But why did he lose his apartment?
His job at the local fast food restaurant didn’t pay enough.
But why was he working there?
He never graduated from high school.
Why didn’t he complete his education?
Because he had been abused as a child and bullied in
school because of his obesity and tattered clothes.
Why and why and why?
Addressing
the Social
Determinants
of Mental Health
Why Address SDMH?
 There is no health without mental health.
 Mental illnesses are major causes of
morbidity and mortality.
 Prevention works.
 Addressing the social determinants can
reduce health disparities and inequities.
 It is a moral and ethical imperative.
Clinical Interventions
 Screening and secondary preventive interventions.
 Addressing policies in clinical settings.
 Developing resource guides for patients, families, and
staff.
 Referring patients to available supports (supported
employment, supported education, supportive
housing, poverty assistance, etc).
Policy Interventions
Public Policies
 Shift the concept of mental illnesses from an individual
patient approach to a public health, population-based
approach.
 Advocate for policies/laws that improve education,
increase employment opportunities (or extend
employment benefits), decrease food insecurity, end
discrimination, improve housing standards, etc.
 Offer your expertise to your elected officials
(individually, or through professional organizations).
 Cross-sector collaborations are key.
Community Interventions
Cultural Norms
 Educate your communities
 About the importance of culture
 About the negative impact of stigma
 Use laws to change norms
 Create a culture of tolerance and acceptance
 Speak up when this culture is not respected
“Reducing health
inequities is…an
ethical imperative.
Social injustice is
killing people on a
grand scale.”