Reviewer: Ellyn E Cavanagh, PhD, MN,BSN(Tender Care Pediatric Services, Inc.)
Description: This book covers the social or non-medical determinants of health care, which are shaped by social policies and forces within the U.S. The term "social determinants of health" emerged within the past 20 years as scholars examined the causative factors for the poor health status in the U.S. relative to other affluent countries. The WHO Commission (2008) defines the social determinants of health as "the conditions in which people are born, grow, live, work and age" (p. 5). This book uses the upstream/downstream metaphor to illustrate causal pathways leading to health outcomes. The upstream refers to power and social values: policies, laws, and entrenched practices such as structural racism. The downstream refers to living and working conditions a person experiences across their entire lifetime, triggering biological mechanisms that determine good or ill health: quality of schools, air and water pollution, and crowded housing. The book focuses on health disparities, particularly on how upstream determinants such as poverty and racism influence one's experience with health-damaging exposures, vulnerability after exposure over years or generations, the ability to pay to have exposures mitigated or removed, and social support. It addresses reducing social inequality through better policies and improving social cohesion. Discriminatory policies in housing and the criminal justice system mired in generations result in cycles of poverty and poor health. The goal is to enhance health equity, distributing resources, opportunities, and conditions for better outcomes. The book takes an in-depth look at the practicality of addressing this moral imperative built on the knowledge gained from studies on social determinants since 2004. The chapters examine how health disparities are created and perpetuated: Income and Wealth; Education; Stress; Racism; Early Childhood Experiences; Neighborhood Context; Housing; Work; and Behaviors. Each chapter concludes with bulleted key points and discussion questions.
Purpose: The book's purpose is to help readers dissect the social determinants of health concept by exploring what influences health in the U.S. population, including non-medical factors — the health-damaging or promoting conditions determined by access to resources or opportunities shaped by public policies, laws, practices, and beliefs, such as systemic racism. The goal is to provide readers with insight into the root causes of upstream social determinants of health by translating evolving science into accessible and meaningful content for wider audiences. These objectives are met by introducing readers to: health disparities and differences in health among socially disadvantaged people (marginalized, excluded, oppressed); examples of how social disparities are created and perpetuated by differences between groups of people in power, resources, and opportunities; racism and structural racism as a fundamental upstream factor and effective strategies to improve health across all racial and ethnic groups; the role of chronic exposure to stress and health damaging effects; and housing instability (residential crowding, homelessness, substandard housing) and its contribution to health disparities and poor health outcomes.
Audience: The book is written for public health scholars, public policy students, medical and nursing students, and community leaders. The content is designed to stimulate change at the policy level and may be appropriate for law students. The book meets the needs of its intended audience. The author is a recognized authority with credentials, publications, and an affiliation with the Robert Wood Johnson Foundation.
Features: The introduction explores factors that produce health disparities over a lifetime, causal pathways between social determinants and health outcomes, and the challenges in addressing social determinants. It builds foundational knowledge, provides graphics, and presents a comprehensive list of well-defined terms, such as "gerrymandering" (p. 125), "redlining" (p. 123,194), and "Gini coefficient" (p. 39). Chapter 2 on Income and Wealth overviews how accumulated wealth influences population-level health, and what occurs when economic inequality creeps into a nation; the central concept is that wealth distribution within a population affects health outcomes. Countries with less inequality in income and wealth are generally healthier. The chapter explores obstacles posed by economic disadvantage and interventions to improve resources for low-income families. Chapter 3 on Education discusses knowledge and skill acquisition, social support, working conditions, and health benefit plans. Obstacles to gaining an education are largely determined by access to income. The discussion of income, wealth, education leads into Chapter 4 on Stress and other social determinants, such as racism. It presents the term "toxic stress," along with concepts such as "weathering" and the fact that racism is a significant stressor. Chapter 5 addresses racism as an upstream factor causing racial disparities in health by triggering multiple downstream factors. It presents excellent illustrations, including the Racism Iceberg (p. 121) and Figure 5.2 showing how racism may damage health (p. 127). Chapter 6 on Early Childhood Experiences addresses how favorable conditions lead to optimal development, while adverse experiences lead to both social and health disadvantages in adulthood and future generations. Economic investment in early education, such as high-quality daycare and preschool, has consistently demonstrated long-term advantages, and the book lists several successful programs (p. 168-172). Chapter 7 on Healthy and Unhealthy Places describes the ways in which neighborhoods influence health. Between 2000-2010, the number of Americans in poor neighborhoods grew by 56%. Chapter 8 on Housing, Health, and Health Disparities describes how people living in poverty have no place to go. Family groups in need of housing are in danger of becoming homeless because of a lack of affordable housing. Chapter 8 covers Work and Health, reviewing how organizational justice, workplace discrimination, and work-related resources (such as health insurance and paid sick leave) influence health care. The book concludes with a chapter on how behaviors influence health. It provides an excellent illustration of the upstream-downstream causal pathway (p. 273). Mass incarceration, racism, acquired wealth/lack of resources, education, stressful conditions, and housing (and the built environment) each factor into whether individuals acquire health-related behaviors or can remove a health obstacle. The unique features of the book include consistent writing between chapters, linking of concepts, and building of knowledge for learners. The Key Points and Questions for Discussion are helpful, and the definitions in each chapter are thorough. One shortcoming is the lack of real cases to illustrate the key points in the chapters.
Assessment: This book covers current knowledge about the key aspects foundational to understanding the social determinants of health, upstream or root causes, and how these influence the downstream effects on health outcomes. One of the best aspects of the book is how it builds the framework in the introductory chapter and presents the central thesis: solutions aimed at bridging health inequities should recognize the relationships between a variety of economic, political, legal, social, and physical factors and health. This book is excellent and led me to research more about social determinants of health and how they impact the entire healthcare system, economy, educational system, and communities we live in. The chapter on racism provoked me to look back into the April 2015 Freddie Gray crisis in Baltimore, and I was able to apply all the content in this book to his case. This book should follow up with a second edition discussing programs using the social determinants to improve outcomes. Areas that need to be explored include violence prevention and adverse childhood events (especially children exposed to substances in utero).
