Social Determinants of Equity and Health in the United States

In the United States she is considered black, but in some parts of Brazil she has been told that she looks white, and in South Africa she was considered "colored."

"And so, I have be assigned three different races depending on where I was, based on the social interpretation of me in those different places," Camara P. Jones, M.D., M.P.H., Ph.D. tells OMHRC "If I stayed long enough in any of those settings then my health outcomes would be similar to those of the group to which I'd been assigned even though I have the same genes in all three places."

On May 22 of this year, Jones delivered her presentation titled "Social Determinants of Equity and Social Determinants of Health" [PDF | 194KB] at a conference on "Innovations in Practice and Policy to End Infant Mortality Disparities," during the Higher Knowledge, Higher Service - First College to Community Health Outreach Week in Memphis, Tenn.

Jones says that in the United States being perceived as white is associated with better health.

In her presentation [PDF | 194KB] Jones cited a 2004 survey of general health status, by self-identified and socially-assigned "race," in which people were asked to report excellent or very good health. Among participants, 39.8 percent of respondents who identified themselves as Hispanic and whom others saw as Hispanic said they were in excellent or very good health; 53.7 percent of those who self identified as Hispanic but other people saw as white said they were in excellent or very good health; and 58.6 percent of respondents who self identified as white and other people saw as white said they were in excellent or very good health.

The numbers are similar when comparing American Indians or Alaska Natives (AIAN) to whites.

Jones says that socially assigned race is associated with health status because "we live in a society which has a system of structuring opportunity and assigning value based on socially assigned race, and there is a priori reason why looking white should give you any more of anything, except that we have a system that is structuring it to be that way."

Jones tells OMHRC that one of the predominant social determinants of equity in our society is racism. "It is like the big elephant in the room, we don't talk about it, but it has been historically foundational in our society, yet many people are in denial that it continues to exist and have impacts."

In the first section of her presentation [PDF | 194KB], Jones talked about the need to understand the many levels of health interventions using the analogy of a person walking along a path and then falling off the cliff of good health. An ambulance at the bottom of the cliff represented medical care and tertiary prevention; a net or trampoline halfway down represented safety net programs and secondary prevention; a fence at the edge represented primary prevention; and moving the population away from the edge of the cliff represented adjusting the social determinants of health.

However, Jones says the cliff analogy does not explain how health disparities arise. For her, health disparities arise on three levels: differences in quality of care received within the health care system; differences in access to health care; and differences in life opportunities and stresses that make some individuals and communities sicker than others.

"We are dealing with a three dimensional cliff," Jones says. "At some point there is an ambulance there but maybe it has a flat tire, so it's slower (or) goes off in the wrong direction, or maybe there is no ambulance there, or no net, or no fence, and usually in those parts of the cliff the population is closer to the edge. This three-dimensional cliff illustrates these ways in which health disparities arise."

"The third dimension is to address the social determinants of equity which is why are there different people in different places, and why the resources are not equally distributed, and that means addressing things like racism and other systems of power," according to Jones.

In the second segment of the presentation Jones said that, besides the individual behaviors that are determinants of health such as eating healthy foods, exercise, engaging in safe sex, not drinking and smoking, we need to start talking about social determinants of health which are outside of the individual, beyond genetic predispositions and beyond individual behavior, and in fact are the context within individual behaviors arise.

"Not only does it matter what an individual puts in their mouth, but what that individual puts in their mouth is constrained by what they can afford and what is available in their environment," she adds.

Addressing the social determinants of equity involves monitoring for inequities in exposures and opportunities, as well as for disparities in outcomes. It involves examination of structures, policies, practices, norms, and values, and requires intervention on societal structures and attention to systems of power.

"We need to do both: Address the social determinants of health, including poverty, in order to achieve large and sustained improvements in health outcomes", she says. "And address the social determinants of equity, including racism, in order to achieve social justice and eliminate health disparities."

In the last part of her presentation Jones explained why racism causes illness pointing to three levels of racism: Institutionalized, personally-mediated, and internalized.

"The main message is that we have to at least address the institutionalized racism to set things right, we can address all the levels at the same time but we must at least address the institutionalized racism and the other levels will take care of themselves."

Camara P. Jones, M.D., M.P.H., Ph.D. is the Research Director on Social Determinants of Health at the National Center for Chronic Disease Prevention and Health Promotion of the Centers for Disease Control and Prevention, and Adjunct Associate Professor, Morehouse School of Medicine, Adjunct Associate Professor, Rollins School of Public Health at Emory University.