Place matters: Social determinants of health (Part 1 of 2)

Place matters. Hippocrates had this figured out back in 400 BC, but we’re just now catching up. With his classic “On Airs, Waters and [Places],” the father of western medicine recognized that physicians should examine a patient’s environment in order to understand his health.

Fast forward to the 21st century, when a growing body of literature demonstrates that the majority of what drives our health doesn’t necessarily happen in the doctor’s clinic, but in our communities and our everyday lives. In a recent expert report from the Robert Wood Johnson Foundation’s (RWJF) Commission to Build a Healthier America, dramatic differences in life expectancies were found along Washington D.C.’s Metro lines. Just a short 10 metro stop outbound ride on the Blue Line could mean 9 extra years of life.  How can we explain such dramatic disparities in life expectancy across such a short distance in the US, a country that spent $2.7 trillion dollars on health care in 2011?

The social, environmental and economic characteristics of our communities, known as the social determinants of health, drive our health behaviors, which in turn result in vastly different health outcomes. Community differences in environmental quality and exposures, built environment, housing conditions, crime, access to food and recreation areas, educational attainment, economic vitality, social support and other factors strongly affect how much stress we experience on a daily basis, how much pollution we are exposed to, and how socially isolated we feel. These factors have been linked to disability, mortality, chronic diseases, poor birth outcomes, mental health, violence and other risky health behaviors.

These characteristics influence how people address their health as well as access health care. If you lived in a neighborhood where you didn’t feel safe at night, would you go out for an evening walk to get your daily exercise? If the closest place to buy produce was 5 miles away, would you get on a bus for an hour each week to buy tomatoes? Food deserts influence how we eat. Park deserts affect how we exercise. Neighborhoods affect how much chronic stress we experience. And all of this affects the trajectory of our health over our entire lives. The powerful documentary film project, Unnatural Causes, explores how these social determinants affect our health, and how place matters.

This graphic from RWJF’s Beyond Health Care report makes it easy to envision all of the myriad ways that our neighborhoods affect our health:

How can clinicians begin to assess these neighborhood drivers and integrate them into their practice? In the next blog post, "Place matters: Addressing social determinants of health with geomedicine (Part 2),”  we’ll explore examples of geomedicine and spatial epidemiology and provide some practical (and mostly free!) tools that clinicians can begin using in their care.

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