SOCIAL DETERMINANTS

Any case of a disease results from a long and complex chain of characteristics, circumstances, and events. The terms used to refer to the stages in this causal chain are not well agreed upon, however. Causal factors are loosely grouped into precipitating causes, which refer to agent factors, such as a virus, and some aspects of the host, such as inadequate nutrition which increases susceptibility. The events and environmental factors that give rise to the immediate causal factors are often termed "determinants." These include biological, physical, and social circumstances. Determinants account, in some measure, for the underlying rates of disease in a population, while variations in these rates are explained by risk factors. The social determinants of health include socioeconomic circumstances, social structure and function, and cultural factors. Social determinants refer to broad patterns and not to individual details—the state of being married would constitute a risk factor for some conditions, while the cultural and economic circumstances that lead to high divorce rates might form a social determinant of mental health in a particular population.

 

The use of the term "determinants" deserves some clarification. In most instances it does not imply a deterministic relationship, as might hold in chemistry, for example. Nor does it imply the absence of free will. Instead, determinants refer to macrosocial influences that affect health, such as poverty or social strife, and that would prove very difficult for an individual to alter.

 

Perhaps the broadest social determinant of health is a country's level of social and economic development. This is related to patterns of longevity, health, and disease, but the relationship is dynamic and far from simple, and economic development and health status influence one another. Patterns of disease shift as a country's economy grows, producing the epidemiologic transition from a pattern of short life expectancy and high mortality due to infectious disease, to a pattern of long life expectancy and deaths due mainly to noninfectious chronic diseases that are typical of industrial countries. Social determinants influence health through many intervening factors, such as the quality of sanitation, medical care, or food distribution systems. Examples are provided by the twentieth-century adverse impact on health seen in Eastern European countries in the former Soviet bloc.

 

While social determinants undoubtedly exert much of their influence through individual behaviors that promote or prevent disease, it is also clear that disease patterns cannot be fully explained in terms of individual behaviors. Health behaviors form the tip of an iceberg of social forces that also include contextual variables such as social mores, urbanization, and political changes, which seem to exert direct effects on health.

 

Our understanding of the social determinants of health remains in its infancy; there is little understanding of many details relating to how health is determined. Social epidemiology is still looking for its Pasteur to explain the processes involved. Current explanations are akin to stating that a car works when you put gasoline in and turn the key.

CULTURAL IDENTITY

The classic definition of culture, written in 1871 by Edward Burnett Tylor, states that "culture … is that complex whole which includes knowledge, belief, art, morals, law, customs, and any other capabilities and habits acquired by man as a member of society" (Primitive Culture). In 1952, Kroeber and Kluckhohn cited 164 definitions of culture, ranging from "learned behavior" to "ideas in the mind." Culture depends upon an ability, possessed by humans alone, called symboling, which consists of "assigning to things and events certain meanings that cannot be grasped with the senses alone." (Encyclopaedia Britannica 1997, p. 847). Language is an example of symboling.

CULTURAL DIVERSITY IN THE UNITED STATES

For more than two hundred years, the United States has been the most culturally diverse country in the world. At the beginning of the twenty-first century, this diversity grew with the influx of more and more cultures from around the globe. Racial and ethnic minorities have been the fastest-growing segments of the U.S. population, making up almost 23 percent of the total population in 1990 and 25 percent of the population in 2000. Non-white children accounted for one-third of all children under nineteen in the United States in the year 2000.

 

Culture can affect how chronic and disabling conditions are defined and treated. For example, white Americans typically emphasize physical survival and functional capacity, and they therefore tend to battle against chronic conditions and disabilities that they see as being inflicted on them. In contrast, many Asian cultures emphasize living in harmony with nature; a chronic condition is therefore seen as part of the normal cycle of life. A person's culturally based health beliefs and practices determine what problems are recognized as needing traditional Western medical care, and whether someone will follow through with prescribed treatment, change lifestyle behaviors, or reduce exposure to environmental factors associated with an illness. Because of historic inequalities and racism in the health care system, many African Americans delay seeking health care. Beliefs about health and illness also influence community responses to health communication messages designed to promote health and prevent disease. Language and cultural differences often hinder communication between public health professionals and members of minority populations.

 

To understand cultural identity in the context of public health it is important to focus on the worldviews of the communities and people in need of health services. The meaning of words used to describe disease and adaptive behaviors needed to maintain good health must be examined in the light of a diverse cultural environment. People live their lives as simultaneous members and participants in a multiplicity of social contexts. An individual's cultural identity can be shaped not only by race and ethnicity, but also by age, gender, family configuration, religion, socioeconomic status, education, occupation, sexual orientation, political ideology stage of acculturation, and place of upbringing (rural, urban, or suburban).

 

Epidemiology enables public health professionals to systematically assess the health status of various populations. However, when morbidity and mortality data is used without an appreciation for the social context, unintended consequences can result. For example, it is not uncommon to use surveillance data to describe populations as "intravenous drug users," "homeless," "high risk," and "hard to reach." While such catergorization enables public health professionals to focus scarce resources where the need is greatest, it also stigmatizes the very people in greatest need of assistance. Ethnic and racial minority populations have historically suffered from the way in which public health data is presented to the policy makers and the general public. A prominent example of this is the figures regarding "crack mothers" and "crack babies" made prevalent by the media in the 1990s.