The Social Determinants of Health: Finding Causation in a Sea of Correlation
The social determinants of health by Marmot and Wilkinson are a list of social circumstances that impede or positively influence good health. Pointing out barriers to achieving health, the social determinants set the backdrop for justice-based bioethics. Access to good jobs in which one has agency or discretion and a living wage and access to good food are social considerations that improve health. Poverty, drugs, unemployment, unsafe or poor working conditions, stress, and anxiety are impediments to good health. A culture of inclusion and productivity and social support is also a social determinant, the lack of which impedes health.
The social determinants of health are generally described as increasing (or decreasing) risks. Research strongly establishes the correlations. More research may explain some of the reasons for the strong correlations between poor health and social circumstances. The important takeaway is that policy changes that improve social and economic status should positively influence population health. But questions remain about whether the populations in places where such policies tend not to be adopted are simply hopeless.
In the US, states with more poverty and low minimum wages tend to have higher obesity rates. Often a narrative of personal responsibility is embedded in the prevailing political culture, making it all the more perplexing that such a narrative does not extend to health and wellness. In parts of the United States where social policy is slow to change, minimum wage faces opposition, wages and working conditions are harsh, and unemployment is high, people face more health problems. I wonder to some degree whether the social determinants should be called social correlations. They do strongly go along with poor health. There is no denying them. But do they actually cause ill-health? They are not presented as causal, but in some interpretations, they may drown out attention to causes.
What if we fixed diet first? A food-first approach might alleviate the health burden of diseases related to obesity and stress. While a stressful job and income insecurity are social ills, a healthy diet may reduce some of the risks. The detrimental effects of stress may be mitigated by food and lifestyle. In California, Medicaid ((Medi-Cal) held a three-year study of diet-first solutions to chronic illness. Now, medically suitable meals are covered by Medi-Cal. The California program could be replicated by Medicaid in other states. Hunter College NYC Food Policy Center and the Center for Food as Medicine did a recent study on food as medicine, focusing on foods capabilities in restoring health and treating disease. In the context of the social determinants, the widespread use of food to prevent disease may be a useful tool that has been bucketed within its own policy structure for too long. A few changes like ending subsidies for unhealthy foods, Medicaid coverage for vegetables or changes to fund SNAP and have stricter requirements built in, revising the Farm Bill to encourage only healthy and meatless farming, requiring states to have more accessible stores with high volumes of affordable produce as a condition of Medicaid funds, an end to the pervasive advertising of unhealthy foods and drinks, and taxes on sodas and junk foods, etc. could impact health favorably. Ideas abound—some are considered controversial and some would be less impactful than others. The tax options would tend to be regressive. But the adult obesity rate is almost 43 percent and exploring diet and exercise may do justice to the issue of fair allocation of good health.
Obesity prevention and social policies based on the social determinants of health should occur simultaneously. But for those people stuck in low-income jobs, or in places where social policies reflect austerity, and where employers are not meeting the social concerns of workers, a dietary approach should be tried. In areas where addressing the social determinants through policy looks slow-going and unlikely, immediate attention to diet could influence health outcomes. Analyzing causal relationships could shed light on the social determinants of health.
But first, researchers may have to speak out about causation more clearly. I would argue that poverty and low incomes, for example, may lead to poor eating, poor self-care, no time to cook, no money to shop, little exercise, and stress. But low incomes do not have to lead to those things. The logic is not that “if poverty, then poor health.” (In logic, that would mean that poor health is a necessary outcome of poverty.) There are missing premises necessary to make an educated conclusion. If poverty, there is an increased likelihood of poor food choices. If one makes enough poor food choices, there is a higher likelihood of obesity and diet-related illness, heart disease, high blood pressure, and some cancers. The ideas that poverty correlates to poor health and that poverty causes poor health are often conflated. That leads to the assumption that widespread social ills must be resolved before health issues resolve. That might not be true. We see by the data that some people in poverty are quite healthy. While genetics may partly account for positive health profiles, so might better diets and exercise. The other social determinants work that way as well. They are not exactly causes of ill-health and should be reframed perhaps not as determining health, but as influencing behaviors, diet, mood, and sedentariness. Counter influences on those would then play a greater role.
Policy may not fix your boss or your paycheck imminently, but food choices can positively impact your health nonetheless. It is incumbent upon society to resolve social issues that correlate to ill health, yet the call to immediately alter food policy and to create incentives to eat healthy foods and to exercise should not be drowned out while we wait for low incomes to grow, unemployment to decrease, workplaces to value workers and allow them more agency, people to experience less financial stress, commutes to shorten, etc. Rather than a let-them-eat-cake approach to health and wellness where all people are told to add prioritizing their own health to their already burdened daily routine, changes should rely on rewards, incentives, common sense, and education. The social determinants are an excellent framing of a best-case scenario to strive for—in the meantime, some vegetables and a treadmill may do more than we realize. Some policies should support trying that.