The health impact of the conditions in which people are born, grow, work, live, and age have been recognized for centuries. However, widespread acceptance of this impact remains contentious, as inequities in morbidity and mortality represent the enduring legacies of displacement, oppression, and systemic discrimination. The World Health Organization estimates that social and structural determinants are responsible for 30% to 55% of all health outcomes. Social determinants of health, structural determinants of health, structural violence, and the need for structural competency are four codependent concepts that must be explored together to develop responsive clinical interventions. Social and structural determinants of health include wealth and social status, geography and neighborhood, employment and labor, and education. Racism is a major driver of social and structural determinants of health in the United States. It is important to differentiate between upstream and downstream approaches to addressing health inequities because addressing upstream factors has a greater impact.
Case 2. HW is a 48-year-old American Indian man who presents to urgent care with persistent debilitating headaches. He has seen physicians only intermittingly over the past 20 years, for a herniated disk 8 years ago and for a workplace injury that resulted in a finger amputation 3 years ago. He takes ibuprofen and his wife’s hydrocodone for phantom pain of his amputated finger. He has had frequent early morning headaches, general weakness, and fatigue. Laboratory evaluation results show an A1C of 7.6 and a glucose level of 463 mg/dL (25.7 mmol/L).
In 1847, the German government sent physician Rudolf Virchow to Upper Silesia (now southeastern Poland) to investigate a typhus epidemic and famine. At the conclusion of his investigation, Virchow reported that the epidemic was not just caused by the infectious agent but also by decades of political misrule and social neglect. He concluded that the outbreak could not be solved by treating individual patients with pharmaceuticals, nor could the famine be stopped with minor changes in food, housing, and clothing laws. Instead, he argued that the lives of the people in Upper Silesia could only be improved with radical action to promote the advancement of the entire population through full and unlimited democracy, education, freedom, and prosperity.1
Despite Virchow’s thorough report, he was labeled a liberal (a dangerous classification in Germany at that time), fired, and kept under surveillance for several years. The episode illustrates that physicians have long recognized there are social and structural determinants of health (SSDoH) and that addressing these issues is contentious and controversial.
Common Language for Health Equity
There are four interrelated concepts when considering how to address health inequities: social determinants of health, structural determinants of health, structural violence, and structural competency. Social determinants of health are the conditions in which people are born, grow, work, live, and age in the context of systems that shape the conditions of daily life.2
The World Health Organization estimates that social and structural determinants are responsible for 30% to 55% of all health outcomes.3 The systems are the structural determinants of health, including rules, laws, and policies, that create, maintain, or eliminate patterns of advantage among socially constructed groups and lead to differences in health outcomes among groups.4
Read the full edition
Get immediate access, anytime, anywhere.
Choose a single edition, 1-year or 2-year full-access subscription.
Earn 4 CME credits for this edition.
