INTRODUCTION:

SOCIAL AND STRUCTURAL DETERMINANTS OF HEALTH AND HEALTH EQUITY

JAMES MARKS, MD, MPH, HELENE GAYLE, MD, MPH, AND DWAYNE PROCTOR, PHD

The National Academy of Medicine’s (NAM’s) leadership is of central importance to progress on recognition, understanding, and engagement of the health impact of social factors, signals, and biases in shaping health inequities, including racism and embedded poverty—the structural determinants of health inequity. The committee members and staff who prepared the recently released report on community-based solutions to promote health equity, Communities in Action: Pathways to Health Equity, underscored the reality and the power of these factors.¹ That is a fundamental statement and it is important for the nation to be aware that it is a conclusion supported by the NAM, and it is a conclusion derived from the committee’s careful review of the profile and science of inequity.

The committee has also contributed a hopeful element, one stemming from examples selected from around the country on what nine communities are doing to engage key factors in health and health equity. At the January 2017 meeting convened by the NAM, “Engaging Allies in the Culture of Health Movement,” stakeholders from across several sectors, including community organizations, research, philanthropy, and government, came together to consider the findings of the report and to explore the ways collaborative action could reverse the debilitating and lethal consequences of inequity. The discussion was rich and offered many insights important to our work together.

Health disparities and inequities have been experienced between and among people and communities since the earliest times that people began to organize themselves into groups and communities. In fact, some of the major factors motivating people to form communities related to the need to buffer threats to

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¹ National Academies of Sciences, Engineering, and Medicine. 2017. Communities in action: Pathways to health equity. Washington, DC: The National Academies Press. doi: 10.17226/24624.

health and safety. The recognition of the existence of disparities has prompted the development of scientific disciplines to study them.

In public health, the iconic John Snow investigation in London in the mid-1800s is an important example. He mapped the deaths from cholera during an epidemic and he found that the people who lived near and got their water from the Broad Street pump were more likely to become ill and die than people who lived elsewhere. His map and investigation was, at its core, about noticing a disparity, a difference between neighborhoods in deaths from cholera, and then taking action by removing the pump handle from the Broad Street well pump. He did it with the permission of the St. James Parish Board. In effect, he had to go to the official agency and get a policy decision. So, the very core of public health is observing a disparity—in this case, not between racial and ethnic groups probably and likely not even between education levels, but a disparity nonetheless—and then taking action.

William Foege, former Director of the Centers for Disease Control and Prevention, former President of the American Public Health Association (APHA), and member of the NAM, said in his APHA Presidential Address, “The philosophy of public health is social justice, and the primary goal of public health is to reduce or eliminate differences in mortality and morbidity between populations” (Foege, 1987). In so many words, he stated that disparity reduction, regardless of its source, in striving for equity in health is not part of what our field is about. It is our field’s central purpose and fundamental goal. We often focus on race and income and education because health and well-being differences are linked to them in large, persistent, pervasive, and systemic ways, affecting almost every disease and injury.

The importance of health equity—of fairness—to health is of such centrality that it motivated the Robert Wood Johnson Foundation, where two of us work, to place the challenge of culture of health at the top of our agenda. Our focus in this respect is essentially about fairness, especially fairness in the opportunities for good health—the affordability, the safety, and the convenience of healthy choices in all aspects of our lives. It is about equity in health itself insofar as possible, not between individuals but between groups of people where basic biological differences cannot be blamed for that disparity. This is true within our borders, and on the global scene as well, where one of us (Helene Gayle) served as the head of CARE for nearly decade, leading work to combat fundamental inequities.

As leaders in health, we have to speak to the responsibility our nation has to everyone, with a special responsibility for those at great risk or in great need. Martin Luther King Jr. said, “Injustice anywhere is a threat to justice everywhere.” Translated to health, this means that when injustice is unchallenged, including the injustice of health disparities anywhere, society exposes its shared sense

of community and nationhood to imminent risk of corrosion. These realities underscore the importance of the Academies’ report and the subsequent meeting.

The Communities in Action report clearly outlines that health inequities are in large part a result of poverty, structural racism, and discrimination, and that disparities based on race and ethnicity are the most persistent and difficult to address. In fact, the committee’s Recommendation 3-1 calls for funders to support additional research on the multiple effects of structural racism and implicit and explicit bias on health and health care delivery. The report also recognizes that discrimination extends beyond race, and that many groups—women, the LGBTQ community, people who are poor, the undereducated, and those with mental and physical delays and disabilities—face discriminatory treatment and are subject to discriminatory policies. Solutions to improving health equity require additional research to understand how discrimination affects health.

Both the report and the conversation at the meeting recognize the relationship among health, equity, and hope. People with hope can and do make different decisions for themselves and their families than those that are without. And, hope can be studied, even like a vaccine. Mothers in Oklahoma, some of them with a new baby, were given a $1,000 college fund, a 529 plan, and others were not. Even though the cost of college is orders of magnitude beyond $1,000, it was found in this study that, by age 5, the children of mothers who had received the $1,000 529 plan were working better with others, were more kindergarten-ready, and the mothers themselves thought differently about their children’s future (Beverly et al., 2016).

Even as we think of health equity as the outcome, we know that health and well-being are nurtured, they are protected and preserved, where people live, learn, work, and play. These are circumstances that our academic colleagues term the “social determinants of health,” and it is in our communities that they play out. Throughout the discussions at the NAM meeting, time and time again, we heard reference made to the centrality and potential of community initiatives, whether the issue is getting children off on equal footing in life, better training and deploying human capital for progress, enlisting business to lead change, reinforcing communication strategies, and even drawing on design as a tool to improve health equity. A core assumption throughout each of the conversations was the need to recenter focus on communities, including the measures to guide and register progress.

recently reported results from birthing centers and early education centers, parental training, and support (https://medicine.yale.edu/childstudy/comer).

investment has been raised as an obstacle to their taking leadership in the social improvement domain, the interesting experiences of ReadyNation’s pay-for-success models of investing in good policies was encouraging.

We are at a watershed time in our nation’s history. We have to be honest with ourselves. Technologic advancement, where our nation’s leadership is unquestioned, has not managed to rein in the growth in medical care costs, nor has it even enabled us to have better health relative to other countries of similar wealth and development according to standard, big-picture measures like life expectancy and infant mortality.

The major health problems of our time, especially as related to fairness and equity in health and well-being, cannot be solved by health care alone. They cannot be solved by public health alone. All of our nation’s institutions—public, private, and nonprofit—have important roles to play even if they do not think of their purpose as being fundamentally about health and well-being. Every organization or sector of our society—business, health care, academia, schools, urban planning, parks and recreation, banking and finance, agriculture, childcare—has, as its core purpose, the value it brings to making a community a good place to live and to raise a family, so people can have warm relationships with neighbors and friends, enabling them to they can thrive and succeed.

As a nation, we have had an enormous imbalance regarding where we have looked for sources of health and illness and solutions to disparity. Some might have thought of the NAM as an unusual institution to ask to take a look at health and well-being for society as a whole, but the Academy can also speak to the heart about the values that are inherent in medicine and the protection of health.

Medicine has always been about the application of science to those who are in need, who are suffering, or who are at risk. There is an urgency to act even if the science is incomplete or immature. Each of us, from our own perspective, is grateful to the NAM for its commitment to showing what we, all of us, as leaders in and of our nation can do to make working together for a culture of health and well-being the duty and privilege it is.

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