Will Your Zip Code be fateful for your health?

Periodically, we need to remind ourselves about the very important role that social determinants play in everyone’s health, including our own. Social determinants are those things that diminish our life chances, such as poverty, or enhance them, such as social supports. In turn, our life chances greatly influence our health.

Indeed, your ZIP code can be fateful for your health. If you live in a ZIP code where most people are very poor or near poor, then subtract 5 years off of your life expectancy.

Your education also can be fateful. If you did not graduate from high school, subtract 4 years off of your life expectancy.

And these losses can be cumulative. If you are both poor and you did not graduate from high school, then subtract 9 years off of your life expectancy—unless we intervene.

We have learned that negative social determinants, such as poverty and lack of education, dramatically increase the likelihood that one will have fewer life chances and will be exposed to trauma—physical, emotional, sexual. That’s how these negative determinants play a role in causing illnesses, whether mental or substance use conditions, or heart disease and diabetes. In turn, these illnesses also can cause early death. 

By contrast, positive social determinants can have a salutary effect on health. A nurturing family is a positive social determinant. Strong social support from close friends is another.

Thus, social determinants play a very large role in one’s life chances. Of great importance, we can mitigate the effects of negative determinants, and we can enhance the effects of positive determinants. For example, although we cannot prevent poverty, we can reduce its negative effects; we also can increase social support through enhanced friendship circles.

Healthy people

A moment’s reflection will suggest that the negative and positive social determinants can serve as very important guides to interventions designed to prevent disease and early death, while promoting better health. Thus, the national Healthy People 2020 initiative designated social determinants as foundational to good health.

Behavioral healthcare now has a wonderful opportunity to develop community strategies to address the effects of social determinants. Critical guidelines for doing this already have been developed by Sir Michael Marmot of the UK, the pre-eminent international leader in this area. His work has been employed successfully by the British Health Service and by the City of London.

Community strategies to address social determinants are a careful blending of clear goal definition, policy development and implementation, and targeted action. For example, a local community could set the goal to give every child in the community the best life chances possible. Subsequently, all current local policies would be reviewed to determine whether they promote or inhibit this goal, and what policy changes would be necessary to accelerate the implementation of the goal. Then a targeted set of health, education, and social interventions would be implemented.

• Health—Does the child actually see, communicate, and walk at age-appropriate levels?
• Education—Can the child read, count, and think at age-appropriate levels?
• Social—Does the child live in an environment that is nurturing, free of alcohol and drugs, and free of physical and sexual abuse?

Work on the social determinants will provide an excellent occasion for our field to become engaged in critical upstream efforts to promote health and to prevent disease and early death. It also will serve to help to introduce the field to population interventions using public health strategies. (The American Public Health Association already has embraced work on the social determinants as its major mission.)

If we are to fare well in the era of the Affordable Care Act and to actualize the social justice values that underlie our work, then skill in addressing social determinants will be a must for each of us.