The social determinants of health: it's time to consider the causes of the causes

Abstract

During the past two decades, the public health community's attention has been drawn increasingly to the social determinants of health (SDH)-the factors apart from medical care that can be influenced by social policies and shape health in powerful ways. We use "medical care" rather than "health care" to refer to clinical services, to avoid potential confusion between "health" and "health care." The World Health Organization's Commission on the Social Determinants of Health has defined SDH as "the conditions in which people are born, grow, live, work and age" and "the fundamental drivers of these conditions." The term "social determinants" often evokes factors such as health-related features of neighborhoods (e.g., walkability, recreational areas, and accessibility of healthful foods), which can influence health-related behaviors. Evidence has accumulated, however, pointing to socioeconomic factors such as income, wealth, and education as the fundamental causes of a wide range of health outcomes. This article broadly reviews some of the knowledge accumulated to date that highlights the importance of social-and particularly socioeconomic-factors in shaping health, and plausible pathways and biological mechanisms that may explain their effects. We also discuss challenges to advancing this knowledge and how they might be overcome.

Figure 1

Life expectancy in the U.S. at age 25, by education and gender, 2006^a

Figure 2

Infant mortality rate in the U.S., by mother's education, 2009^a

Figure 3

U.S. children aged <17 years with less than very good health, by family income, 2011–2012^a

Figure 4

Percent of U.S. adults aged ≥25 years with activity-limiting chronic disease, by family income, 1988–1998^a

Figure 5

Socioeconomic gradients in poor/fair health among adults aged 25–74 years within racial/ethnic groups in the U.S., 2008–2010^a

Figure 6

Pathways through which education can affect health^a