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Elizabeth A. Baker, PhD, MPH, Marilyn M. Metzler, RN and Sandro Galea, MD, DrPH

Elizabeth A. Baker is with the Department of Community Health and Prevention Research Center, School of Public Health, Saint Louis University, St. Louis, Mo. Marilyn Metzler is with the Centers for Disease Control and Prevention, Atlanta, GA. Sandro Galea is with the Center for Urban Epidemiologic Studies, New York Academy of Medicine, New York, NY and the Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, NY.

Correspondence: Requests for reprints should be sent to Marilyn Metzler, RN, Centers for Disease Control and Prevention, Mail Stop K-67, 4770 Buford Hwy, NE, Atlanta, GA 30341-3717 (e-mail: mmetzler{at}cdc.gov).

	INTRODUCTION

TOP INTRODUCTION DEFINING THE ROOT CAUSES... HOW TO FOCUS CHANGE... DEVELOPING, IMPLEMENTING, AND... CONCLUSION References

 
In its 1988 landmark report and again in 2003 in an updated report,^1,2 the Institute of Medicine defined public health as "what we as a society do to collectively assure the conditions in which people can be healthy." The literature describing the relationship between conditions needed for health and health outcomes is as old as the public health endeavor itself and continues to grow, now almost exponentially. That certain conditions commonly referred to as social determinants—including access to affordable healthy food, potable water, safe housing, and supportive social networks—are linked to health outcomes is something on which most of us can agree. The unequal distribution of these conditions across various populations is increasingly understood as a significant contributor to persistent and pervasive health disparities.³ If attention is not paid to these conditions, we will most surely fail in our efforts to eliminate health disparities.

Despite our growing understanding of the importance of social determinants of health, we have had very little guidance in how public health practitioners and systems can influence social determinants in order to address health disparities. Building on and contributing to the successes of medical and behavioral interventions by addressing the conditions that affect people’s health are essential and critical responsibilities of public health researchers and practitioners.²

This issue of the Journal presents a collection of case studies from partnerships in the United States and the United Kingdom that are working to understand and create conditions that can promote health. In October 2003, representatives from the partnerships described their efforts in a forum, "Addressing the Social Determinants of Health Disparities: Learning From Doing," sponsored by the US Centers for Disease Control and Prevention (CDC). Participants shared with academicians, practitioners, and community partners what they are learning as they work to address the social determinants of health disparities in their communities.

The efforts described at this forum represented a range of intervention activities. In addition to those presented here, the case studies included teenagers in New Orleans working to eliminate violence through social actions in their community; health officials in Boston striving to undo racism in a large urban health department; health care providers in Chicago creating culturally appropriate health and social programs for Black males visiting a public health clinic; and a historical case study of health practitioners in rural Mississippi who created a comprehensive community health center to address multiple social determinants of health. Synopses of all case studies presented at the forum can be found at http://www.cdc.gov/sdoh. No one forum can address all the issues relevant to the social determinants of health disparities, but these efforts represent a significant range of promising approaches.

Discussions at the forum focused on why communities chose to address certain disparities over others, their approaches, key challenges they face, and strategies they are devising to help them meet these challenges. Perhaps the greatest lessons can be found in the challenges they face. Chief among these are how to define and acknowledge the root causes of health disparities; choosing where and how to focus efforts to eliminate those disparities; and how to develop, implement, and evaluate solutions.

	DEFINING THE ROOT CAUSES OF HEALTH DISPARITIES

TOP INTRODUCTION DEFINING THE ROOT CAUSES... HOW TO FOCUS CHANGE... DEVELOPING, IMPLEMENTING, AND... CONCLUSION References

 
In all areas of public health, a problem must be clearly defined before potential solutions can be considered. Here, a distinction must be made between addressing health disparities and addressing health inequities (or striving for health equity). Discussions at the CDC forum and a recent article by Braveman and Gruskin⁴ elucidate important differences between these 2 ways of identifying the root causes of systematic differences in health outcomes among different populations.

"Social determinants of health," broadly speaking, refers to social, economic, and political resources and structures that influence health outcomes.⁵ Addressing social determinants of health disparities rests on evidence of the relationship between these determinants and health outcomes. If we frame the issue as one of health inequities, however, we go a step further by suggesting that for groups already disadvantaged by their position in a social hierarchy, reduced access to resources increases their likelihood for poor health outcomes. A focus on health equity calls for addressing the determinants of health (social and medical) that put particular social groups at a disadvantage for good health outcomes.⁴

This poster was developed for the Literacy for Environmental Justice/Youth Envision Good Neighbor Program, which addresses links between food security and the activities of transnational tobacco companies in low-income communities and communities of color in San Francisco. In partnership with city government, community-based organizations, and others, Good Neighbor provides incentives to inner-city retailers to increase their stocks of fresh and nutritious foods and to reduce tobacco and alcohol advertising in their stores.

Participants at the CDC forum noted that public health needs to frame the issue in such a way that these inequities are acknowledged and addressed in our work. Explicitly striving for health equity—defined as the absence of avoidable and unfair differences in the determinants and manifestations of good health and longevity between the most vulnerable groups and groups that are well off ⁶—is critically important if the public health field is to achieve its goals.

	HOW TO FOCUS CHANGE EFFORTS

TOP INTRODUCTION DEFINING THE ROOT CAUSES... HOW TO FOCUS CHANGE... DEVELOPING, IMPLEMENTING, AND... CONCLUSION References

 
A second challenge faced by those working to address social determinants of health inequities is determining where to focus their efforts. Is the most salient factor race/ethnicity, socioeconomic status, sexual orientation, disability status, or something else? The data suggest that groups defined by each of these characteristics have differing access to conditions and resources that enable communities and individuals to be healthy. Therefore, we must consider factors other than the groupings themselves, such as racism or other forms of discrimination as primary contributors to health outcomes.

Conversations at the CDC forum suggest what many of us already know: opinions about which determinant is most important are fairly well polarized and can easily become the focal point of any dialogue. Some participants cautioned that, while it is important to consider the critical determinants of health inequities, arguments about which determinants are most important keep us from recognizing common interests and from uniting to ameliorate unhealthful conditions affecting multiple groups. Most importantly, participants noted that multiple disadvantages and inequities are profoundly associated with poor health.

	DEVELOPING, IMPLEMENTING, AND EVALUATING SOLUTIONS

TOP INTRODUCTION DEFINING THE ROOT CAUSES... HOW TO FOCUS CHANGE... DEVELOPING, IMPLEMENTING, AND... CONCLUSION References

 
Finally, forum participants noted 2 specific challenges they face when developing, implementing, and evaluating programs and policies to ameliorate health inequities. The first challenge is developing appropriate goals and objectives and finding suitable evaluation methods, on the basis of the types of questions asked and the potential audiences for the evaluation results. The second challenge is determining which strategies ensure the greatest impact.

In developing goals and objectives, we must recognize that no single program is going to accomplish our ultimate goal of eliminating health inequities, and that the goals and objectives for a particular program should realistically reflect the potential impact of that program. For example, although our ultimate goal is to eliminate racial inequities in infant mortality rates, we cannot expect this goal to be achieved through a single 3-year program aimed at one of the many determinants of these inequities. It is critical that we be clear and realistic about what we expect to achieve through specific programs or actions, beginning with a discussion of methods that can help us understand and meet social and political challenges. Moreover, we need to develop methods to document the specific steps we took (what worked and what barriers we faced) as well as the intended and unintended consequences of our actions.

One of the problems in developing program goals and evaluation methods is that the information used to define a problem (e.g., statistics gleaned from surveillance systems or hospital records) is limited when it comes to identifying appropriate solutions or when tracking change. It is important that public health practitioners learn to use alternative methods such as photo-voice and qualitative data to define problems and document change. Improving our methods of documentation will help us not only to more effectively document the impact of our efforts but also to make more informed decisions about future courses of action.

In addition to considering multiple methods of documenting program results, we also need to remember that there are different indicators of "success" and that the relative importance of these different indicators to different stakeholders may vary. Long-term support for any program depends on providing stakeholders with the information they need to evaluate the success of that program from their perspective as well as helping them have realistic expectations of the program so they will not be disappointed by a lack of immediate change. We must work together with all stakeholders to outline the steps required to reach our goals and to track our movement toward them, and we must work with the media to better illustrate the social basis of many health inequities.

The best strategies for ameliorating inequities in social determinants of health are those that reflect local knowledge and a community’s readiness for change, not just "expert" knowledge regarding the best way to create change. One of the most important trends in public health is the inclusion of those who experience health inequities in all aspects of our work; however, this means that we must attempt to identify and engage all subgroups affected by health inequities and ensure that they have the opportunity to fully participate once at the table. Inclusion of community partners means we must honestly and realistically consider which communities are present in our partnerships. A great deal of work suggests, for example, that within various ethnic and racial groups there are significant differences in perspectives and experiences depending on class gradations and gender. We must challenge ourselves and our community partners to include this broad range of perspectives.

In addition to engaging a representative group of community partners, we also need to solicit input from health practitioners and from experts in diverse fields, including education, business, housing, and transportation. Including multiple perspectives requires us to reconsider the assumption that our current methods of planning, assessment, implementation, evaluation, and dissemination are the best methods for addressing health-related issues and to at least be open to the possibility that these methods may not be sufficient for addressing many inequities in the social determinants of health.

	CONCLUSION

TOP INTRODUCTION DEFINING THE ROOT CAUSES... HOW TO FOCUS CHANGE... DEVELOPING, IMPLEMENTING, AND... CONCLUSION References

 
The field of public health provides endless opportunities for innovation. But those opportunities are hindered by a limited vision of public health that fails to recognize the social determinants of health inequities, which in turn limits the willingness to address them. Public health practitioners cannot attempt these change efforts alone. In addition to our traditional partners, we need other partners with an investment in the health and life of communities. Any approach to sustained substantive change in health outcomes takes time, but as is true of any other health intervention, practitioners attempting to assess social determinants of health should and can find more immediate, or intermediate, goals that can be accomplished and celebrated. In doing so, we must use language, frameworks, and methods that engage our wide variety of partners in ways that will lead to practical and sustainable solutions. Only then can we work across our acknowledged differences and participate in actions that unite us in our efforts to eliminate health inequities.

	Acknowledgments

 
We thank all participants at the "Addressing Social Determinants of Health Disparities: Learning From Doing" forum held in Atlanta, Ga, October 28–29, 2003. We thank Mary Northridge for her encouragement in the preparation of this theme issue and Drs Paula Braveman, Walter W. Williams, and Susan Y. Chu for thoughtful comments on this editorial.

Accepted for publication January 3, 2005.

	References

TOP INTRODUCTION DEFINING THE ROOT CAUSES... HOW TO FOCUS CHANGE... DEVELOPING, IMPLEMENTING, AND... CONCLUSION References

 
1. Institute of Medicine. The Future of Public Health. Washington, DC: National Academy Press; 1989.

2. Institute of Medicine. The Future of the Public’s Health in the 21st Century. Washington, DC: National Academy Press; 2003.

3. Woolf S. Society’s choice: the tradeoff between efficacy and equity and the lives at stake. Am J Prev Med. 2004;27:49–56.[Medline]

4. Braveman P, Gruskin S. Defining equity in health. J Epidemiol Community Health. 2003;57:254–258.[Abstract/Free Full Text]

5. Barnett E, Casper M. A definition of "social environment." Am J Public Health. 2001;91:465.

6. Whitehead M. The concepts and principles of equity in health. Int J Health Serv. 1992;22:429–445.[ISI][Medline]

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This Article Extract Full Text (PDF) Submit a response Purchase Article View Shopping Cart Alert me when this article is cited Alert me when eLetters are posted Alert me if a correction is posted Services Similar articles in this journal Similar articles in ISI Web of Science Similar articles in PubMed Alert me to new issues of the journal Download to citation manager Citing Articles Citing Articles via HighWire Citing Articles via ISI Web of Science (6) Citing Articles via Google Scholar Google Scholar Articles by Baker, E. A. Articles by Galea, S. Search for Related Content PubMed PubMed Citation Articles by Baker, E. A. Articles by Galea, S. Related Collections Community Health Health Promotion Public Health Practice Other Race/Ethnicity Socioeconomic Factors Human Rights