House (2010) L1: Social Determinants - Key Readings Flashcards
Bunker et al (1994)
only about five years of the almost thirty-year increase in U.S. life expectancy over the twentieth century were due to preventive or therapeutic medicine. This is consistent with more recent estimates that medical care likely accounts for 10 to 20 percent of the variation in population health in the United States and other developed countries (McGinnis et al 2002).
House et al (2010)
The exact nonmedical factors responsible for the great historical rise in life expectancy are impossible to identify retrospectively, but general socioeconomic development— most notably improvements in nutrition, sanitation, housing and clothing, and general conditions of life, certainly played a central role.
Selye (1956)
The rise of modern “epidemics”— particularly heart disease and cancer— began to cloud this picture in the mid- twentieth century. As a result, several strands of research which recognized the role of socioeconomic and psychosocial determinants of health were revived. In particular, a strand of research by Hans Selye (1956) and others showed that perturbations in the relation between organisms and their psychosocial, as well as their physical, chemical, and biological environments led to physiological symptoms in the form of, for example, heightened heart rate or blood pressure. These symptoms in turn could lead to physical disease and even death.
Hans Selye (1956), and others showing that perturbations in the relation between organisms and their psychosocial as well as their physical-chemical-biological environments (created by physical, social, or psychological challenges or stressors) led to adaptive arousal of biological and physiological systems in the form of heightened heart rate, blood pressure, hormonal secretions, and depressed immune response. These are perhaps best known collectively under Selye’s rubric of stress. These physiological changes could, if prolonged, lead to long-term disregulation of homeostatic and adaptive systems, physical diseases (including hypertension, infection, and autoimmune disorders), and even death. This work led to burgeoning new fields of psychoneuroendocrinology and psychoneuroimmunology (Ader, Felten, and Cohen 1991) and showed how a broad range of socioeconomic and psychosocial factors could “get under the skin” and produce physical illness (Taylor, Repetti, and Seeman 1997).
House et al (2010)
The rise of chronic diseases ultimately produced
a change in the epidemiologic conception of, and search for, their causes—a shift from identifying a single causative agent to identifying multiple contingent causal forces, or risk factors. Though biological risk factors (i.e. blood pressure, cholesterol) were the central focus of attention initially, increasingly behaviors (such as tobacco use or a sedentary life-style), have also been identified as high risk factors for various chronic diseases.
House et al (2010) - downstream approach to health
Current research on the psychosocial, biomedical, and environmental determinants of health has moved in two directions. The more common approach might be referred to as “downstream,” that is, seeking to understand the mechanisms through which psychosocial risk factors affect health. This approach tends to lead to a biomedical approach to mitigating the health impact of social or economic risk factors—for example, finding a pharmacological treatment for stress.
House et al (2010) - upstream approach to health
An “upstream” approach, on the other hand, seeks to understand the broader aspects of social life that shape exposure to such psychosocial or environmental
risk factors. Many public policies strongly impact health because they strongly impact the socioeconomic, psychosocial, and/or environmental determinants of health. Very few policy makers have considered health in either formulating or justifying public policies. The authors hope to change this state of affairs by encouraging a proactive identification—and perhaps also mitigation or enhancement—of the health impacts of social and economic policies
House et al (2010) - rationale for exploring social determinants of health
A greater and more specific focus on the actual and potential health effects of social and economic policy could strengthen scientific understanding of the determinants of health as well as their amenability to change via public policy. It could also help extricate American health policy from unparalleled levels of spending growth with little to show for it (The United States spends more on health insurance and medical care as a percent of GDP than any other nation. Yet despite the marked growth in spending over the past fifty years, the U.S. has fallen from being amongst the top in life expectancy and infant mortality to ranking at or near the bottom among developed nations.
Of the thirty nations in the OECD, only Mexico, Turkey, and three former Soviet bloc countries consistently rank below the U.S. on such indicators). Social and economic policy may well be a more cost-effective way of improving population health.
Challenge 1: House et al (2010) Causality
Realizing this promise requires confronting a number of challenges. Determining causality is the first. The inherent difficulty in proving that a particular social or economic policy or program impacts health is complicated by competing approaches to determining causality. One view holds that the only way to establish a causal relationship is through randomized experimentation, or a close approximation. A different tradition derives its power from an accumulated body of evidence showing consistency of statistical association across a wide number of studies. Both approaches have value, and increased engagement
and interchange between the two is crucial.
Challenge 2: House et al (2010) Cost effectiveness
A second challenge has to do with cost-effectiveness. Even if we determine causality, it is possible that achieving a desired health impact may be too costly relative to its putative effects. The health effects of social and economic policy must be evaluated not only absolutely, but also relative to not being implemented, and relative to other programs and policies specifically aimed at health.
Challenge 3?
Next, even if a non-health policy or intervention is recognized as both causal and cost-effective with respect to health, an objection may be raised that it is simply politically, technically, or otherwise unfeasible.
House et al (2010) - what’s the issue with US focus on improving medical services?
The concentration in so many health policy discussions on medical services as the sine qua non for improving population health neglects historical knowledge about the causes of major changes in the health of populations. It also neglects real opportunities outside the domain of medical care to improve population health.
It may seem paradoxical and impossible that a society could achieve better population health without explicitly increasing health care expenditures, but this is only if we assume that health care is the major determinant of health. As dramatic and consequential as medical care is for individual cases and for specific conditions, much evidence suggests that such care is not, and probably never has been, the major determinant of levels or changes in population health. This evidence is consistent with data suggesting a low to near-zero correlation between health care expenditures and levels of population health across wealthier OECD nations, as well as with data that show declining rates of return to health from growing health care expenditures over time in the United States (Cutler, Rosen, and Vijan 2006). Rather, economic, social, psychological, behavioural, and environmental factors are increasingly recognized as the major determinants of population health ( McKinlay and McKinlay 1977). If health care, whether therapeutic or preventive, is not the major determinant of health, then health pol-icy must move beyond a single-minded focus on the delivery and financing of health care. We must understand through research and practice the health effects of the wide range of social and economic policies that are, arguably, major determinants of the level and distribution of health in populations.
What’s the problematic health paradigm scientists and policymakers in health share, and where did it come from? (House et al., 2010)
A brief historical perspective is necessary to understand why and how social and economic policies may be equally or more important than health policies in maintaining and improving population health. Within the United States and many developed and developing nations, the scientific success of the germ theory of disease between the mid-nineteenth and mid-twentieth centuries fostered hegemony of a solely biomedical perspective on the health of individuals and populations. The general decline, and in some cases eradication, of feared infectious diseases suggested that understanding microbiological bases of life and disease provided a golden pathway to improved population health. Bacteriology, virology, genetics, and basic molecular, cellular, and developmental biology—together with their translation into the practice of health care—allowed continual advances and improvements in health. Many scientists and most policy makers and citizens continue to share this biomedical perspective, which shone brightly in the mid-twentieth century, epitomized by the discovery of polio vaccines and their use to virtually eradicate the disease.
Smoking and obesity (House et al, 2010)
For both smoking and obesity, much effort has been focused on understanding the pathophysiological mechanisms producing adverse health effects, as well as the individual-level factors that influence initiation, maintenance, and cessation of these behaviors. Intensive research on tobacco-related health hazards and on smoking cessation has entered its sixth decade. Despite basic scientific advances in these areas, it is now widely recognized that trends in smoking and other health risk behaviors are driven primarily by economic and social developments, and by policies that once fostered and now limit individuals’ opportunity and motivation to buy and smoke tobacco products
Using epidemiological methods similar to those that identified blood pressure, cholesterol, cardiovascular and respiratory function, smoking, diet and nutrition, alcohol consumption, and physical inactivity as major risk factors for the newly epidemic chronic diseases, social epidemiology has over the last several decades identified a growing range of economic, social, environmental, and psychological variables that are comparably potent risk factors for health. These include social relationships and supports, chronic and acute stress, psychological and personal- ity dispositions, engagement with productive social roles and organizations, and the social as well as physical-chemical-biological environments in which people live and work
House (2010) Why move beyond looking at health care spending to tackle health?
Existing research suggests that a wide range of social and economic policy should significantly and substantially affect health. To the extent that such policy- based research confirms this pattern, we can consider a broad range of public and private policies beyond the realm of health care as mechanisms for promoting health and preventing or alleviating disease. These social and economic policies may have additional beneficial consequences for health that are equally or more important than the consequences they were formulated to produce. In addition, social and economic policies may be more cost-effective for maintaining and improving health than increased spending on health care, and hence even constitute alternatives to some current health care spending (Lleras-Muney and Cutler, chap- ter 2, this volume)
Rationale - EXTERNALITIES
Considering their health impact can also benefit the development and implementation of policies which target dimensions of individual well-being and social performance other than health. For example, an education intervention may have larger than expected effects on labor market outcomes because the increase in education has the unintended effect of improving health status, which in turn makes workers more productive or able to provide additional work hours, and hence to receive higher pay. In the public or private sector, deciding whether, when, and how to implement new policies is often influenced by cost-benefit calculation. Given the potential range and size of both positive and negative health outcomes that flow from policy changes, even if totally unintended, health effects can be central factors in decisions about the nature of contemplated changes in public or private policy seemingly unrelated to health. It is therefore increasingly hard to justify not considering potential health impacts in the design, implementation, and evaluation of any contemplated policy change, even in areas which may superficially seem far removed from issues of health and health policy.
