The Root Causes Behind Many Health Problems May Surprise You

You think it’s only medical care that influences your health? The real truth is all around you.

Paula Braveman: "What is it that shapes whether you get sick?" 
Nancy Rothstein Photography
Ronald Brownstein
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Ronald Brownstein
March 13, 2014, 5 p.m.

From her of­fice in the peace­ful and pic­tur­esque Laurel Heights neigh­bor­hood, Paula Brave­man dir­ects the Cen­ter on So­cial Dis­par­it­ies in Health at the Uni­versity of Cali­for­nia (San Fran­cisco) and writes pro­lific­ally on the links between class, race, and health. She spoke re­cently to Na­tion­al Journ­al about the com­plex re­la­tion­ships among op­por­tun­ity, bio­logy, per­son­al re­spons­ib­il­ity, and the way Amer­ic­ans live and die. Ed­ited ex­cerpts fol­low.

A lot of people are not fa­mil­i­ar with the phrase “so­cial de­term­in­ants of health.” What do you mean by that?

We mean the factors apart from med­ic­al care that have a power­ful in­flu­ence on health.

In as­sess­ing Amer­ica’s over­all health, how im­port­ant are the so­cial de­term­in­ants, such as poverty and dis­par­it­ies in in­come and edu­ca­tion, versus med­ic­al care?

There are people who [con­clude] about 10 per­cent of pre­ma­ture mor­tal­ity is due to lack of ac­cess and/or de­fi­cien­cies in med­ic­al care. If I had to guess, I’d say maybe 20 per­cent [is med­ic­al care].

That would mean roughly 80 per­cent of pre­ma­ture mor­tal­ity is re­lated to the so­cial de­term­in­ants?

Once you’re sick, you want med­ic­al care. But what is it that shapes wheth­er you get sick and how sick you get? It’s the cir­cum­stances in­to which you were born, you grow up, you live, you work.

I think people aren’t sur­prised that very wealthy people are a lot health­i­er than very poor people. But what is strik­ing about your re­search is that at each rung of the in­come or edu­ca­tion­al-at­tain­ment lad­der, people get bet­ter out­comes than those who are one rung lower. What are the im­plic­a­tions of that?

If you just see a dif­fer­ence between the poor and every­body else, I think it’s easi­er to say, “You know, the poor are poor be­cause they were lazy, they wer­en’t smart, they don’t take care of them­selves.” That doesn’t fit. Don’t tell me that people with in­come levels three to four times the fed­er­al poverty level are lazi­er and not as smart as people with in­comes four to five times the poverty level.

Your pa­pers also show that at the same in­come level, Afric­an-Amer­ic­ans will of­ten have worse health out­comes than whites. Why is that?

One [reas­on] is un­meas­ured so­cioeco­nom­ic dif­fer­ences, and the oth­er is stress. With­in the same in­come quin­tile, blacks have far less wealth than whites. At the same in­come or edu­ca­tion level, blacks are more likely to live in so­cioeco­nom­ic­ally de­prived neigh­bor­hoods, and there is a grow­ing lit­er­at­ure that strongly sug­gests the char­ac­ter­ist­ics of neigh­bor­hoods can af­fect health as well. Also, so­cioeco­nom­ic hard­ship is stress­ful, but [for Afric­an-Amer­ic­ans] at all levels of the lad­der, there is also the stress of liv­ing in a so­ci­ety in which, his­tor­ic­ally, the group that you be­long to has been as­sumed to be in­feri­or.

How does class af­fect health, in terms of bio­logy?

If I ex­per­i­ence stress, one re­gion of my brain, the hy­po­thal­am­us, sig­nals an­oth­er re­gion of my brain, the an­teri­or pitu­it­ary, that I’m stressed. And then the an­teri­or pitu­it­ary sends a sig­nal to my ad­ren­al glands, which then pump out cortisol and oth­er stress hor­mones. If I’m just stressed acutely, it doesn’t look like that’s usu­ally dam­aging. But if I face chron­ic stress, my ad­ren­als are con­stantly pump­ing out the cortisol, which can cause dis­reg­u­la­tion of im­mune sys­tems [and] in­flam­ma­tion. In­flam­ma­tion and im­mune phe­nom­ena are thought to be be­hind a lot of chron­ic dis­ease.

Many un­healthy be­ha­vi­ors are more pre­val­ent in lower-in­come fam­il­ies than more-af­flu­ent ones. What is the role of per­son­al choice?

I think it’s silly to say there’s no role for per­son­al re­spons­ib­il­ity. Even those of us who are pretty priv­ileged know that it’s hard eat­ing right, ex­er­cising. But the mis­take is neg­lect­ing to ask, what is it that shapes per­son­al be­ha­vi­ors? We have a huge body of lit­er­at­ure that doc­u­ments how be­ha­vi­or is shaped by the con­texts in which people live and work. And then how those con­texts are shaped by their op­por­tun­it­ies. Do we think it’s an ac­ci­dent that [good] be­ha­vi­ors are ar­rayed so­cioeco­nom­ic­ally? Where does this all be­gin? Is it the choice of a child to be born in­to a poor fam­ily?

Stephanie Czekalinski contributed to this article.
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