Social Deter

1. Social Determinants of Health
and Health Equity
Virginia Rural Health Action Conference
Charlottesville, Virginia
October 8, 2012
Steven H. Woolf, MD, MPH
VCU Center on Human Needs
Department of Family Medicine
Virginia Commonwealth University

2. County Life Expectancies by Race
Murray CJL, Kulkarni SC, Michaud C, Tomijima N, Bulzacchelli MT, et al. PLoS Medicine
Vol. 3, No. 9, e260 doi:10.1371/journal.pmed.0030260

3. Male life Female life
General Female–male difference
America expectancy expectancy
description in life expectancy
at birth at birth
1 Asians 82.8 87.7 4.9
White low-income
2 rural 76.2 81.8 5.6
Northland
3 Middle America 75.2 80.2 5.0
White poor
4 Appalachia/ 71.8 77.8 6.1
Mississippi Valley
Western Native
5 Americans
69.4 75.9 6.6
Black middle
6 America
69.6 75.9 6.4
Black poor rural
7 South
67.7 74.6 6.9
Black high-risk
8 urban
66.7 74.9 8.2
Murray CJ, Kulkarni S, Ezzati M. Eight Americas: new perspectives on U.S. health
disparities.
Am J Prev Med 2005;29(5 Suppl 1):4-10.

4. WHO Conceptual Model
From: A Conceptual Model for Taking Action on the Social Determinants of Health.
Geneva: World Health Organization, 2010

6. Beyond the Clinical Setting

7. Role of Personal Health Behaviors
Cause Estimated deaths
Tobacco 400,000
Diet/activity patterns 300,000
Alcohol 100,000
Microbial agents 90,000
Toxic agents 60,000
Firearms 35,000
Sexual behavior 30,000
Motor vehicles 25,000
Illicit use of drugs 20,000
Source: McGinnis and Foege. JAMA 1993;270:2207-12.

8. The importance of behavioral and social factors
Policies to promote child Policies to promote economic
and youth development development and reduce poverty
and education,
infancy through college Policies to promote
healthier homes,
neighborhoods,
Economic & Social schools and
Opportunities and Resources workplaces
Living & Working Conditions
in Homes and Communities
Medical Personal
Care Behavior
HEALTH
Robert Wood Johnson Foundation Commission to Build a Healthier America
www.commissiononhealth.org

9. “Downstream” determinants
• Access to healthy foods • Tobacco and alcohol
• Physical activity • Healthy housing
• Safe neighborhoods
• Clean air and water
• Safe working conditions

10. “Health in All” Policies
• Transportation
• Land use
• Built environment
• Taxes Health and
• Housing illness
• Agriculture
• Environmental justice
• Etc.

11. “Upstream determinants”
• Inadequate education
• Unemployment
• Declining income and net worth

12. Am J Public Health. 2004;94:2078-81

13. Figure 1. Potential Lives Saved by Improvements in Age-Adjusted Mortality Rates in the
United States, 1991-2000
Age-Adjusted Mortality
1,700,000 1,700
Rate (per 100,000)
1,500,000 1,400
1,300,000 1,100
1,100,000 800
Potentially Averted Deaths
900,000 500
in the United States
700,000 200
500,000 -100
300,000 -400
176,633
100,000 -700
-100,000 -1,000
1991 1992 1993 1994 1995 1996 1997 1998 1999 2000
US deaths potentially averted each year by secular improvements in age-adjusted
mortality rates
Cumulative deaths potentially averted after 1990
US age-adjusted mortality rate
Legend: Age-adjusted death rates taken from: Table 35. Death rates for all causes, according to sex, race, Hispanic
origin, and age: United States, selected years 1950-2001, accessed at
ftp.cdc.gov/pub/Health_Statistics/NCHS/Publications/Health_US/hus03/Table035.xls. Potentially avertable deaths
calculated as described in text and Table 1.
From: Woolf SH, Johnson RE. Am J Public Health 2004;94:2078-81

14. Figure 2. Difference in Age-Adjusted Mortality Rates of Whites and African Americans in 1991-
2000 and Potential Lives Saved if the Rates Had Been Comparable
Age-Adjusted Mortality
1,700,000 1,700
Rate (per 100,000)
1,500,000 1,400
1,300,000 1,100
1,100,000 800
886,202
900,000 500
Resolving Disparities
Avertable Deaths by
700,000 200
500,000 -100
300,000 -400
100,000 -700
-100,000 -1,000
1991 1992 1993 1994 1995 1996 1997 1998 1999 2000
African American deaths potentially averted each year by correcting disparity in
age-adjusted mortality rates
Cumulative deaths potentially averted after 1990
African American male age-adjusted mortality rate
White male age-adjusted mortality rate
African American female age-adjusted mortality rate
White female age-adjusted mortality rate
Legend: Age-adjusted death rates taken from: Table 35. Death rates for all causes, according to sex, race, Hispanic origin, and
age: United States, selected years 1950-2001, accessed at
ftp.cdc.gov/pub/Health_Statistics/NCHS/Publications/Health_US/hus03/Table035.xls. Potentially avertable deaths calculated as
described in text and Table 2.
From: Woolf SH, Johnson RE. Am J Public Health 2004;94:2078-81

15. Am J Public Health. 2007;97:679–683

16. 250,000
Deaths (per year) potentially
averted in the United States
200,000
150,000
100,000
50,000
0
-50,000
1996
1997
1998
1999
2000
Year 2001
2002
Deaths potentially averted by medical advances (see footnotes)
Deaths potentially averted by eliminating education-associated excess mortality (see footnotes)
Am J Public Health. 2007;97:679–683

17. www.humanneeds.vcu.edu

18. Poverty in South Delta, Mississippi

19. Life Expectancy in South Delta,
Mississippi

20. Am J Public Health. 2010;100:750-5

21. Proportion of Deaths in Virginia Associated With
Reduced Household Income
30
25
20
Proportion of
deaths that
15
would be
averted (%)
10
5
0
1990
1991
1992
1993
1994
1995
1996
1997
1998
1999
2000
2001
2002
2003
2004
2005
2006
Am J Public Health. 2010;100:750-5

23. Page County, Virginia

24. www.countyhealthcalculator.org

25. Annual Costs (Health Care And Program Spending), Three Layered Intervention Scenarios,
Year 0 To Year 25.
Milstein B et al. Health Aff 2011;30:823-832
©2011 by Project HOPE - The People-to-People Health Foundation, Inc.

27. Contact Information
• Steven H. Woolf, MD, MPH
Center on Human Needs
Department of Family Medicine
Virginia Commonwealth University
804-828-9625
• swoolf@vcu.edu