Contemporary Public Health: Principles, Practice, and Policy

1. The Social and Ecological Determinants of Health

1 The Social and Ecological Determinants of Health Steven H. Woolf and Paula Braveman In 2003 the landmark report Unequal Treatment drew the nation’s attention to disparities in the way health care is delivered to racial or ethnic minority groups.1 Studies had documented that patients with similar clinical presentations but different races or ethnicities received different clinical recommendations and different levels of clinical care. The report also documented disparities in access to care and health insurance coverage. The health care system responded by launching a variety of initiatives to study the issue, standardize care delivery, heighten providers’ cultural competency, and increase minority representation among health care professionals. The effort to expand access to medical care and health insurance coverage has been a central theme of health care reform. Although these efforts have yielded some progress in reducing disparities in health care,2 disparities in health itself persist. African American infants are twice as likely as white infants to die before their first birthday, a ratio that has been nearly the same for more than forty years.3, 4 Between 1960 and 2000 the standardized mortality ratio for blacks relative to whites changed little, from 1.472 in 1960 to 1.412 in 2000, and by 2002 there were an estimated 83,750 excess deaths in the United States among blacks.4 The maternal mortality rate is also higher among some racial and ethnic minority groups.5 For example, black women were around 3.4 times as likely as white women to die of pregnancy -related causes in 2006—a difference of 32.7 versus 9.5 maternal deaths for every 100,000 live births.6 In the “Eight Americas” study, Murray and colleagues divided the U.S. population into eight groups: Asians (America 1), below-median-income whites living in the Northland (America 2), Middle Americans (America 3), 26   Woolf and Braveman poor whites living in Appalachia and the Mississippi Valley (America 4), Native Americans living on reservations in the West (America 5), black Middle Americans (America 6), poor blacks living in the rural South (America 7), and blacks living in high-risk urban environments (America 8).7 For males, the difference in life expectancy between America 1 and America 8 was 16.1 years (table 1.1), as large as the gap between Iceland, which had the highest male life expectancy in the world, and Bangladesh.7 Health disparities are just as large in some cities of the United States. For example, in Orleans Parish (New Orleans), life expectancy varies by 25.5 years between zip codes. In zip code 70112—the neighborhoods of Tulane, Gravier, Iberville, Treme, and the central business district of New Orleans—life expectancy is 54.5 years,8 comparable to the 2009 life expectancy reported by Congo (55 years), Nigeria (54 years), and Uganda (52 years).9 Health disparities related to race and ethnicity persist even among patients in health care systems that offer similar levels of access to care and coverage benefits, such as the Veterans Health Administration and Kaiser Permanente integrated health care systems.10, 11 This evidence tells us that the causes of and solutions to such disparities lie beyond health care. Determinants of Health and Health Disparities Understanding the causes of health disparities requires an understanding of the determinants of health itself. Morbidity and mortality are influenced by intrinsic biological factors such as age, sex, and genetic characteristics. Some Table 1.1. Life Expectancy of Eight Demographic Subgroups in the United States America General Description Male Life Expectancy at Birth (yrs) Female Life Expectancy at Birth (yrs) Female–Male Difference in Life Expectancy (yrs) 1 Asian 82.8 87.7 4.9 2 White low-income rural Northland 76.2 81.8 5.6 3 Middle America 75.2 80.2 5.0 4 White poor Appalachia/ Mississippi Valley 71.8 77.8 6.0 5 Western Native American 69.4 75.9 6.5 6 Black Middle America 69.6 75.9 6.3 7 Black poor rural South 67.7 74.6 6.9 8 Black high-risk urban 66.7 74.9 8.2 Source: Murray CJ, Kulkarni S, Ezzati M. Eight Americas: New perspectives on U.S. health disparities. Am J Prev Med. 2005;29(5 Suppl 1):4–10. The Social and Ecological Determinants of Health   27 other risk factors that affect health are referred to as “downstream” determinants because they...