Health Equity

Better Essays
Nursing in 3D: Diversity, Disparities, and Social Determinants

The Social Determinants of Health: It’s
Time to Consider the Causes of the Causes

Paula Braveman, MD, MPHa
Laura Gottlieb, MD, MPHb

During the past two decades, the public health community’s attention has been drawn increasingly to the social determinants of health (SDH)—the factors apart from medical care that can be influenced by social policies and shape health in powerful ways. We use “medical care” rather than “health care” to refer to clinical services, to avoid potential confusion between “health” and “health care.” The World Health Organization’s Commission on the Social Determinants of Health has defined SDH as “the conditions in which people
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McKeown attributed the dramatic increases in life expectancy since the 19th century primarily to improved living conditions, including nutrition, sanitation, and clean water.23 While advances in medical care also may have contributed,23–26 most authors believe that nonmedical factors, including conditions within the purview of traditional public health, were probably more important;24 public health nursing, including its role in advocacy, may have played an important role in improved living standards.27 Another example of the limits of medical care is the widening of mortality disparities between social classes in the United Kingdom in the decades following the creation of the National Health Service in
1948, which made medical care universally accessible.28
Using more recent data, Martinson found that although health overall was better in the United Kingdom than in the United States, which lacks universal coverage, disparities in health by income were similar in the two countries.29 Large inequalities in health according to social class have been documented repeatedly across different European countries, again despite more universal access to medical care.30–32
Another often-cited example of the limits of medical care is the fact that, although spending on medical care in
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