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.

Ian McDowell

(see also: Cultural Factors; Economics of Health; Epidemiologic Transition: Inequalities in Health; Social Class )

Bibliography

Pearl, J. (2000). Casuality: Models, Reasoning, and Inference. Cambridge: Cambridge University Press.

Robert, S. A. (1999). "Socioeconomic Position and Health: The Independent Contribution of Community Socioeconomic Context." Annual Review of Sociology 25:489–516.

Rothman, K. J., ed. (1988). Casual Inference. Chestnut Hill, MA: Epidemiology Resources, Inc.