Beyond Medical Care: The Social Determinants of Health Human Capital Research Collaborative U. Minnesota-Minneapolis Federal Reserve October 14, 2010 Paula Braveman, MD, MPH Professor of Family & Community Medicine Director, Center on Social Disparities in Health

More health care spending-- but less health Infant Mortality Iceland 2Sweden 3Luxembourg 4Japan 5Finland 6Norway 7Czech Republic 8Portugal 9Belgium 10France 11Greece 12Italy 13Spain 14Germany 15Ireland 16Austria 17Switzerland 18Denmark 19Korea 20Netherlands 21Australia 22New Zealand 23United Kingdom 24Canada 25Hungary 26Poland 27United States 28Slovak Republic 29Mexico 30Turkey Source: OECD Health Data 2009

Large racial/ethnic disparities in health A baby born to an African-American (black) woman is twice as likely to die before reaching her or his first birthday as a baby born to a European- American (white) woman A baby born to an African-American (black) woman is twice as likely to die before reaching her or his first birthday as a baby born to a European- American (white) woman A black woman is 3 to 4 times more likely to die of pregnancy complications than a white woman – even after considering age, number of previous births, and education A black woman is 3 to 4 times more likely to die of pregnancy complications than a white woman – even after considering age, number of previous births, and education Latinos in the U.S. have higher rates of diabetes and its complications Latinos in the U.S. have higher rates of diabetes and its complications

Disparities in life expectancy at age 25 by income (& education)

Poor/fair child health varies by income (& education)

Adults’ self-reported poor or fair health varies by (a) income & (b) race/ethnicity

Poor/fair health among adults varies by income in each racial/ethnic group Poor/fair health among adults varies by income in each racial/ethnic group

Poor/fair adult health varies by race or ethnic group, within income groups

Scarlet fever deaths per 1 million children under 15: England and Wales Sulpha drugs Penicillin Thomas McKeown, 1974

Measles– mean annual deaths per 1 million children under 15 in England & Wales Immunization began

Infant deaths per 1,000 live births in England & Wales

What influences health? Medical care Medical care Genetic makeup Genetic makeup Climate & natural physical environment Climate & natural physical environment Behaviors, nutrition Behaviors, nutrition What else? What else? And what influences the influences? And what influences the influences?

How could income affect health? Income directly shapes: Medical care Medical care Housing quality Housing quality Nutrition & physical activity options Nutrition & physical activity options Neighborhood conditions Neighborhood conditions Social networks & support Social networks & support Stress Stress Parents’ income shapes the next generation’s: Education Education Working conditions (physical & psychosocial) Working conditions (physical & psychosocial) Income Income Center on Social Disparities in Health, University of CA, San Francisco

What influences health? What influences the influences? Low Educational Attainment Poor Adult & Child Health Low income Unhealthy housing Poor nutrition Unhealthy neighborhood Lack of exercise Stress Poor working conditions Physical hazards Lack of health insurance Lack of sick leave Lack of control Poor Job

Educational attainment HEALTH  Exposure to hazards  Control / demand imbalance  Stress Work- related resources  Housing  Neighborhood environment  Nutrition  Stress Work  Health insurance  Sick leave  Retirement benefits  Other benefits Working conditions Income HEALTH How could education affect health?  Nutrition  Exercise  Drugs & alcohol  Health/disease management Educational attainment Sense of control  Work-related factors  Health-related behaviors  Stress Social standing Social support  Social & economic resources  Stress  Social & economic resources  Health-related behaviors  Family stability  Stress HEALTH Health knowledge, literacy & behaviors Educational attainment

How could your neighborhood affect your children’s health? Physical danger (crime) Physical danger (crime) Safe places to exercise Safe places to exercise Lead, air pollution, mold Lead, air pollution, mold Access to healthy food Access to healthy food Social networks & support Social networks & support Role models, peer pressure Role models, peer pressure Stress, fear, anxiety, despair Stress, fear, anxiety, despair Quality of schools Quality of schools

CRH DAMAGE TO MULTIPLE ORGANS & SYSTEMS  premature aging, chronic disease STRESSOR CORTISOL Hypothalamus Pituitary Gland Adrenal Glands ACTH How could stress get into the body? Center on Social Disparities in Health, University of CA, San Francisco

Chronic stress in childhood. Cumulative effects of stress over the life course Poverty/low income is often stressful Poverty/low income is often stressful Stress during critical periods and/or chronic stress could lead to ill health in adulthood through neuro-endocrine, immune, inflammatory pathways Stress during critical periods and/or chronic stress could lead to ill health in adulthood through neuro-endocrine, immune, inflammatory pathways E.g., adult chronic disease (heart disease, diabetes)E.g., adult chronic disease (heart disease, diabetes) Adverse birth outcomes (low birth weight, prematurity)Adverse birth outcomes (low birth weight, prematurity) Could cause neuro-endocrine dysregulation with lifelong effects Could cause neuro-endocrine dysregulation with lifelong effects Cumulative stress over lifetime Cumulative stress over lifetime

What about racial/ethnic disparities? Compared with blacks and Hispanics, whites: Compared with blacks and Hispanics, whites: Have more income and schoolingHave more income and schooling At a given educational level, have higher incomesAt a given educational level, have higher incomes At a given income levelAt a given income level Have more wealth Have more wealth Live in better-off neighborhoods Live in better-off neighborhoods At a given income/educational level, are more likely to have grown up in more advantaged familiesAt a given income/educational level, are more likely to have grown up in more advantaged families All these can influence health All these can influence health via multiple, complex pathways, including stressvia multiple, complex pathways, including stress

Racial/ethnic disparities Race/ethnic group often captures unmeasured socioeconomic factors Race/ethnic group often captures unmeasured socioeconomic factors Depth of poverty, wealth, educational quality, neighborhood conditions, childhood experienceDepth of poverty, wealth, educational quality, neighborhood conditions, childhood experience Health-damaging or -promoting exposuresHealth-damaging or -promoting exposures More stress, fewer resourcesMore stress, fewer resources Added stress due to a legacy of discrimination Added stress due to a legacy of discrimination Not just overt incidents or intentional biasNot just overt incidents or intentional bias Pervasive vigilance, anticipating unfair treatment or judgmentPervasive vigilance, anticipating unfair treatment or judgment

Economic & Social Opportunities and Resources Living & Working Conditions in Homes and Communities Personal Behavior Medical Care HEALTH Widening the focus: Seeking the causes of the causes Policies to promote healthier homes, neighborhoods, schools and workplaces Policies to promote child and youth development and education Policies to promote economic development and reduce poverty & racial segregation Robert Wood Johnson Foundation Commission to Build a Healthier America

Finding solutions: Understanding how health is transmitted across lifetimes and generations