December 21, 2017

Social determinants affect health our whole lives long


As interest in social determinants grows, more researchers are taking the long view

by Eric B. Larson, MD, MPH, Kaiser Permanente Washington Health Research Institute (KPWHRI) executive director, and Kaiser Foundation Health Plan of Washington vice president for research and health care innovation

Back in the ’90s, when most Alzheimer’s disease scientists were focused on studying errant plaques and tangles in brain neurons, a University of Washington (UW) graduate student named Victoria Moceri took a different tack. While many researchers hoped their work might lead to a “magic bullet” drug for this devastating illness, Victoria was digging into old county census reports from the early 20th century. Her quest? To learn if the socioeconomic status of our study participants’ birthplaces and families might be related to Alzheimer’s disease 70 to 90 years later.

Now, after some 20 years, we are still waiting for an effective drug-based cure for dementia to materialize. But surprisingly, we have much greater appreciation for the discoveries Victoria made: Our participants born in poorer counties had a higher risk of Alzheimer’s. Also, those whose fathers had higher-status jobs fared better than those with low-status dads. Plus, being born to a smaller family and having an earlier rank in the birth order lowered the participants’ risk. Presumably, children benefited long-term if their family had fewer mouths to feed and got more parental attention.

Today, findings like these continue to reveal how risk for a wide range of serious illness is linked to social and environmental factors affecting us throughout our lifespan. Health problems like cardiovascular disease, various cancers, mental health problems, and much more are linked to experiences and exposures that happen prior to conception, during pregnancy, throughout childhood, adolescence, and beyond.

Learning from ‘life course’ theory

Our understanding of such linkages — an approach referred to as “life course” theory — is not new, but I’ve recently noticed that it’s getting more attention from health scientists. Perhaps there’s a burgeoning interest stemming from

  1. increased awareness of our society’s growing income disparities, and 
  2. a need for better upstream solutions to an expanding population of people affected by chronic illness.

Recent examples include a three-part series in The Lancet focusing on “evolutionary public health,” a relatively new, emerging discipline that encourages a widening view of how an individual’s well-being is influenced within the context of life-course trajectories and environmental exposures. Another is an important study from the Cleveland Clinic, which showed how a widely used clinical model for predicting cardiovascular problems systematically underestimated risk among people from socioeconomically disadvantaged neighborhoods.

At Kaiser Permanente, we also have a growing interest in the way social factors affect people’s health across the course of their lives. “Knowing that 80 percent of what creates and destroys health is related to social determinants — i.e., education employment, income, safety, and family and social support — we have no choice as health professionals but to look for early opportunities to intervene and influence choices and other factors that contribute to high rates of chronic and other disease,” writes Kaiser Permanente CEO, Bernard J. Tyson.

It’s a growing pursuit among researchers here at Kaiser Permanente Washington Health Research Institute (KPWHRI), as well — informing our work in areas such as improving treatment for addiction and other behavioral health issues; reducing racial disparities in care, opioid overuse, and vaccine hesitancy; studying how the built environment of neighborhoods is linked to long-term health; and much more.

It’s also a key interest for our Center for Community Health and Evaluation, which is focused on promoting and sustaining healthy communities, and our MacColl Center for Health Care Innovation, which is committed to helping health care practices — including community health centers — integrate community resources into health improvement.

As our work in social determinants of health grows, our researchers are gaining a holistic understanding of factors that affect well-being across the lifespan — one that can bolster prevention, intervention, and implementation efforts, maximizing the public health impact of our work.

Recent summit engages community to find solutions

Such work is enhanced, of course, when we engage with others from a broad range of sectors beyond health care and health research — people who work in areas such as housing, education, civil rights, food security, public policy, and economic development.

We experienced this last month when KPWHRI, along with faculty from the UW School of Public Health, convened a meeting titled “From Health Care to Health: A Summit to Address Community and Social Factors.” About 70 community leaders from across the state attended the event, funded by KPWHRI, UW, the Kaiser Permanente Washington Community Health and Benefit Program, and the Hilde and Bill Birnbaum Endowment to the Group Health Foundation. Attendees identified and prioritized strategies and made connections for addressing needs in six topic areas: early childhood and family support, education, service design and innovation, behavioral health and adverse childhood experiences, and economic security. Work to advance the strategies identified at the summit is underway and will soon result in a set of proposed action agendas intended to “move the needle” in our state around these issues.

Meanwhile, we at KPWHRI remain committed to advancing research that will address social determinants of health across the lifespan, reducing the burden of disease and increasing well-being. And we’re eager to partner with those in our community locally and nationwide to find solutions that will improve health for everyone. It’s all part of Kaiser Permanente’s bold mission “to improve the health of our membership and the communities we serve.”


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See Dr. Larson’s editorial, “Prevention of Late-Life Dementia: No Magic Bullet” in the December 19 issue of Annals of Internal Medicine.

Dr. Eric B. Larson is author of Enlightened Aging: Building Resilience for a Long, Active Life. Please send comments or suggestions to Dr. Larson at