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“When we talk about the opportunities people have and how those opportunities affect their health, we’re talking about who we are as a country.”
DR. JONATHAN FIELDING’S ORIGINAL PLAN was to become a practicing pediatrician, but during his medical school and pediatric residency training he was struck by the limitations of health care. Societal-level issues such as food insecurity, substandard housing, substance abuse, violence and environmental concerns could not be adequately addressed by a visit to the doctor, but were fundamentally affecting the health of his patients.
That epiphany resulted in Fielding’s decision to pursue a career in public health, and ever since — including in his 16 years of service as Los Angeles County’s chief public health official — he has been a leading national voice in advocating for public health strategies that address the social determinants of health. Fielding served as chair of the Secretary’s Advisory Committee on National Health Promotion and Disease Prevention Objectives for 2020, which provided the recommendations to the U.S. Department of Health and Human Services for the development and implementation of Healthy People 2020, the 10-year plan laying out U.S. public health objectives. Under Fielding’s leadership, Healthy People 2020 included social determinants (“create social and physical environments that promote good health for all”) as one of the four overarching goals for this decade. Fielding was recently appointed chair emeritus of the national advisory group for Healthy People 2030.
Fielding, a faculty member since 1979, spoke with FSPH’s Public Health Magazine about the social determinants that play a powerful role in determining health, and how public health can work across disciplines to make a difference.
Q: What do you mean when you refer to social determinants of health?
A: These are the underlying determinants of health — factors such as income and education, as well as social and environmental policy, that affect the conditions under which people live, work, play and pray. In very fundamental ways, social determinants influence the health choices people make — as well as the choices they have or don’t have — and underlie many of the health inequalities that are so pronounced. If you just look at life expectancy by income, for example, it is very striking. In the United States, the life expectancy of a 40-yearold man in the poorest 1 percent of income distribution is 14.6 years shorter than for a 40-year-old man in the richest 1 percent. For women, the difference is more than 10 years.
Q: Beyond income and education, what are some examples of social determinants and their impact in the United States?
A: Some are obvious and others are much less so. We know that a healthy diet tends to be more expensive than an unhealthy diet, and that people in low-income communities often have limited access to fresh fruits and vegetables. What’s less obvious, but of inordinate importance, is the impact of stress in these communities — the concerns people have about whether they are going to have enough money to pay the rent or to eat, and whether they can safely leave their home after dark.
When I say social determinants, I’m including economic and political. How do we get everyone who is eligible for the federal earned income tax credit to use it? How do we change our educational system so that we increase the high school graduation rate? Does our culture celebrate diversity, or do people feel uncomfortable with others who are not like themselves? The physical environment is also a determinant — both the natural environment and the built environment. On one level, climate change is the result of market forces and population growth that determine greenhouse gas emissions. Yes, it is a physical issue, but what we do to mitigate these emissions and adapt to changes is determined by politically driven environmental and social policies at multiple levels.
There are many things we can do that can make a difference, both in the short and the long term. Take education as an example. We need universal preschool, after-school remedial programs for math and English that increase graduation rates, vocational training options that are linked with well-paying jobs. And to start children on the right path, we need to strongly support breastfeeding and the federal Women, Infants, and Children program for low-income pregnant and postpartum women. This program, through a focus on prevention and access to healthy foods, has helped reduce obesity among infants.
Q: How important are social policies in addressing these determinants?
A: Very important. The health gap between African-Americans and whites narrowed in the decades after the civil rights legislation of the 1960s. Affordable housing, job training programs, and increased access to health insurance have all helped, but not all approaches that improve health at the population level reduce the disparities. Tobacco is an obvious example — we know policies have been effective in reducing tobacco use, but there are still higher rates among the lower income and less well educated, which disproportionately are represented among minority groups.
But we don’t always win the argument. We have seen the fight that’s gone on with policies around sugar. We know that we could reduce obesity if people reduced their intake of sugar and starches — particularly, but not limited to, sugar-sweetened beverages — and yet we’ve been slow in the uptake. The reality is that private interests greatly outspend those that are interested in the public’s health, and they are often at odds. So the issue of who has a voice in our politics, and how big of a bank account they have to spend to support their position, is a social determinant of health and a public health concern.
Q: Since so many of these issues are affected by non-health fields, does public health have an obligation to work more closely across traditional boundaries?
A: Absolutely. We need to work with transportation, with education, with those that determine eligibility for housing. We need to be concerned with labor policies and the criminal justice system. For example, the pendulum is now swinging back to not incarcerating people for being drug users, but to try to get them help. Those programs need to be expanded, and that involves a knowledgeable judiciary, rapid access to medical care, social support, affordable housing, and efforts to reduce the discrimination these individuals face when their incarceration ends and they seek employment. The bottom line is we cannot be effective if we work alone.
Q: Are these social determinants getting more attention now, or are they still underappreciated?
A: The focus hasn’t always been as strong as it is now. The social determinants have always been a public health issue, going back to the treatises of the mid-19th century that talked about the public health importance of things like housing conditions and access to clean water. However, over time, public health issues enjoyed less attention. Unfortunately, in the United States we are now over-invested in health care and under-invested in social programming and economic support for communities and populations where we know we could reduce the health gradient. Many people still believe health care is the most important determinant of health in populations. It is an important determinant, but not the most important one.
The problem is how do you get people to listen to and embrace public health approaches to remedy the adverse effects of social determinants. We need the thought leaders and our elected politicians to understand the levers for improved health and reduced health inequities — better K-12 educational systems, affordable housing, improving income for those in poverty, and building the right incentives for both the public and private sectors. Unless we in public health are considered experts in how these key factors affect health, our voice will not have resonance with key decision makers.
I do think more people are listening, but there’s still a long way to go. To help strengthen our argument, we need to address these issues in ways that can be demonstrated to be cost-effective and produce a strong health and economic return on investment. We have to try different strategies and carefully evaluate them. We need evidence-based solutions. And we need to be clear that this is not just about health per se, it’s about economic vitality. When we talk about the opportunities people have and how those opportunities affect their health, we’re talking about who we are as a country.