National Academy of Medicine

Getting Serious About the Social Determinants of Health

By James R. Knickman
May 09, 2013 | Commentary

We have long known that factors outside of medical care — race, education, housing, income, and other social determinants are the most important drivers of how healthy or sick we are. It is not new information that people of color get unequal health care and have poorer health outcomes than their white counterparts; what is new is how solid the evidence is becoming that race and discrimination alone, regardless of income or education, have a direct negative effect on health.

David R. Williams of the Harvard School of Public Health gave a compelling presentation of some of this evidence during the recent kickoff meeting of the Roundtable on Population Health Improvement of the Institute of Medicine (IOM). Most striking is the research he shared on the impact of race on neonatal mortality rates. White women have the highest risk of poor outcomes if they are age 15-19 when they have their first baby, and the lowest risk if they are in their 20s. For African American women, their best chance of having a healthy baby is at age 15-19; neonatal mortality rates are slightly higher for women in their 20s and approximately 50 percent higher for women in their 30s. Why? Because the older African American women have been living longer with disproportionate amounts of stress, disease, and overall poor health than the white women—a phenomenon known as “weathering.” They have more breast cancer, higher blood pressure, and babies with lower birth weights.


Disclaimer: The views expressed in this paper are those of the authors and not necessarily of the authors’ organizations, the National Academy of Medicine (NAM), or the National Academies of Sciences, Engineering, and Medicine (the National Academies). The paper is intended to help inform and stimulate discussion. It is not a report of the NAM or the National Academies. Copyright by the National Academy of Sciences. All rights reserved.