Perspectives in Biology and Medicine

Perspectives in Biology and Medicine 46.3 Supplement (2003) S1-S8

Organizers' Introduction to the Conference on Social Determinants of Health and Disease

Mark Siegler^* and Richard A. Epstein^†

DURING THE 20TH CENTURY, the health of individuals and populations, especially in developed nations, improved greatly. For example, in the United States, life expectancy at birth increased from 47 years in 1900 to 67 years in 1960. Applying yardsticks such as infant mortality, maternal mortality, life expectancy at birth, or life expectancy at age 50, there was widespread consensus, despite persisting disparities, that health outcomes had improved. There was, however, considerably less agreement on why this was so. Some analysts attributed the improvement to advances in the second half of the 20th century in the science and technology of medicine, advances that included broader childhood immunizations, antibiotics, blood transfusions, safer and more effective surgery [End Page S1] and anesthesia, and drugs to lower blood pressure and cholesterol. Others pointed to improvements in public health, including cleaner and safer water, better housing, improved sanitation, and higher caloric diets, improvements that occurred in the first half of the 20th century. Still others argued that improvements in general social factors—including increased wealth, availability of health insurance, improved community support structures, increased levels of education, and a tendency to equalize power differentials in society (by race, gender, ethnicity, etc.)—were crucial social determinants of improved health outcomes.

Obviously, all three sets of factors contributed to the improvement in health. The level of health and disease in individuals and in society is determined by biological factors such as genetics and disease susceptibility; by personal behaviors such as smoking, overeating, and exercise; by public health measures that provide clean water, better housing, and improved air quality; by the level and availability of medical care and the state of medical technology; and by social factors including education, financial resources, and access to health care.

The "social determinants" perspective is relatively new. It has emerged in the last 30 years as a coherent intellectual movement to challenge and complement the dominant scientific-technical paradigm for explaining the health of individuals and populations. It also has contributed to our understanding of disparities and inequalities in health outcomes. In 1977, the American physician Dr. George Engel provided an early theoretical challenge to the biomedical model when he wrote: "[The] dominant model of disease today is biomedical with molecular biology as its basic scientific discipline . . . it leaves no room within its framework for the social, psychological, and behavioral dimension of illness. [This biomedical model adheres] to a model of disease no longer adequate for the scientific tasks and social responsibilities of medicine." In England, during the 1970s, pioneering work by Thomas McKeown (1979) established the importance of social, non-biological factors on health. At the same time, studies by Michael Marmot began to use social determinants to explain why disparities and inequalities persist in health outcomes even for persons who are employed and have good access to medical services (Marmot et al. 1978).

If the multi-factorial explanation for health and disease was ever doubted, its correctness was reinforced by lessons from AIDS. Prior to the emergence of HIV disease in the 1980s, the United States was confident that medical advances and continued economic progress together were sufficient to control disease and improve health. But confidence in our ability to achieve medical solutions has been shaken by the rise of the AIDS epidemic. Clearly, even in developed countries, control of AIDS requires not just effective anti-viral medicines, but also adjustments in personal behavior, improved public health measures, and changes in such social factors as legal regulations, education, income, and access to care.

In November 2002, a conference was organized at the University of Chicago to examine the general issue of "Social Determinants of Health and Disease." The meeting was organized by faculty from the MacLean Center for Clinical [End Page S2] Medical Ethics and the Law School, and was sponsored also by the Irving B. Harris Graduate School of Public Policy Studies and by the...