Now Reading: “Behavior is not the whole story” – Social and Economic Determinants are where Health Disparity Begins

Social Determinants – they are the difficult stuff to change, however they may be more influential than all of the individually directed approaches that are out there. I covered a much more thorough analysis in my reading of the Marmot Review (see: Now Reading: Why a focus on lifestyle behavior change may not improve health: The Marmot Review), and this paper is a more concise version of the concepts and research presented there.

Social determinants of health (hashtag: #sdoh), is defined nicely here as:

Exposure to these determinants [of health] is influenced by “upstream” social determinants of health – personal resources such as education and income and the social environments in which people live, work, study, and engage in recreational activities.

The health differences tied to these social differences are huge, trumping what we could do by advising/informing people to change individual decisions they make on a regular basis (if you take into account readiness, uptake, mastery, etc.).

I perceive that there’s been a change in thinking from 1993, to 2002, (and now 2011?) from the landmark studies of their era, as shown below. You can tell the progression from “diseases cause people to die,” to “what people do and who they are cause them to die,” to maybe, “the social milieu that they are a part of causes them to die.” See what you think from the charts I created below, stimulated by the references in this piece:

SDOH Studies Eytan 7659 SDOH Studies Eytan 7660 SDOH Studies Eytan 7661

There are data points in here that are so impressive I went to track them down (and they are real), such as the fact that white households have 20 times the net worth of black households. That’s kind of an “unmentionable” that could come up in an encounter with the health system that makes anything we do less effective.

The authors talk about “health in all policies” – the idea that all social policy has health impacts. We shouldn’t forget those, they may be more important than all the work that the health system does, or the choices people make in their lives. See what you think.


Hit the nail on the head Ted, this is what I’ve been going after. This is Public Health 2.0. Which isn’t always the flashy new tech startup aimed at “changing behavior” through your smartphone.

In an era of budget cutting for social services, you can imagine what the gap between rich and poor will continue to look like. There are surely two Americas being founded based on the caprice of one’s fortune to grow up in geographically and economically favorable conditions. With social mobility narrowing from the poorer ranks into the middle class, these disparities are as good as “life sentences.” Thanks for shining a bright light at this very significant source of health problems.

Ted Eytan, MD