Plenary Session I: Research in the Social and Environmental Determinants of Health: A Review and a Prevention Agenda

While it has become apparent that poor social and economic circumstances affect health throughout the life course, it is only in recent years that such an insight has come to be broadly accepted. Relatedly, it might be said that the public health prevention field—like the larger society—continues to grapple with the implications of this understanding. This panel brings together three researchers who have made substantial contributions to an understanding of the various ways in which social and environmental factors shape population health and who are uniquely positioned to offer suggestions about the future of prevention research. The first speaker, Dr. Leonard Syme, offers an historical overview of the field, one which he entered more than 50 years ago. He notes that, at that time, a hostility toward research on social factors predominated, with few people and funders interested in the topic. An explosion of research and teaching over the past several decades has resulted in a new view of social determinants as an important dimension of the health world. Despite this new awareness, hurdles remain. In this talk Dr. Syme outlines a new approach that he sees as necessary in order to disentangle contemporary research in social determinants of health from the clinical model that has come to dominate much of recent social epidemiology. The second speaker, Dr. Sandro Galea, notes that while a robust literature has appeared documenting the role of social and economic factors in shaping disease patterns, our efforts at health promotion and disease prevention typically do not focus on these social and economic conditions, but rather focus on the cognitive and social processes that immediately mediate disease conditions and health states.

Social Determinants of Health: Some History and Thoughts about the Future

Presenter: S. Leonard Syme, PhD

During the last fifty years or so, the study of the social determinants of health and disease has become a major activity in Public Health. There are now several new and impressive textbooks in the field and Social Epidemiology is now a part of the curriculum of almost every School of Public Health.  It wasn’t always this way.  When I began to work in this arena in 1958, things were quite different.  The environment regarding research on social factors was hostile and very challenging.  The National Institutes of Health didn’t know what to do with this topic and none of the major foundations did either. Very few people were interested in this field of research.  The explosion of research and teaching that has characterized the last several decades has changed all that and the understanding of social determinants is now an important dimension of the health world.  With that being said, it is now perhaps important to discuss the future.  Where should research on social determinants be headed?  I will suggest that we are not asking the important questions in our current work and I will suggest that a new approach is needed.  This new approach will need to disentangle itself from the clinical model that has dominated much of social epidemiology in recent years.  This is an awkward argument because the usefulness of our work for clinical medicine is what enabled the field to grow in the first place.   

Dr. Leonard Syme is Professor of Epidemiology and Community Health (Emeritus) at the University of California, Berkeley. His major research interest has been psychosocial risk factors such as job stress, social support and poverty. In doing this research, he has studied San Francisco bus drivers; Japanese living in Japan, Hawaii and California; British civil servants; and people living in Alameda County, California. Dr. Syme has written two books and over 160 published papers. He has been a visiting professor at universities in England and Japan. He was elected to the Institute of Medicine of the National Academy of Sciences and has received several honors related to his teaching and research, among them the Lilienfeld Award for Excellence in Teaching, the J.D. Bruce Award from the American College of Physicians for Distinguished Contributions in Preventive Medicine, the University of California Distinguished Emeritus Professor Award, and the Wade Hampton Frost Lectureship awarded by the American Public Health Association. Now retired, Dr. Syme is Principal Investigator of Health Research for Action Center which is attempting to empower people and communities using printed materials, television, and community resource development.

Social and Economic Factors, the Promotion of Health, and the Prevention of Disease

Presenter: Sandro Galea, MD, MPH, DrPH

The economic patterning of health and disease is well established and has been documented since the onset of systematic collection of vital statistics data.   Persons with lower incomes are more likely to die at a younger age and to experience morbidity during their lifetimes.   Similarly, there is a robust literature documenting the role of social factors in shaping disease patterning.  For example, persons with more social connections are more resilient to health threats; they live healthier and live longer.    However, our efforts at health promotion and disease prevention typically do not focus these social and economic conditions, but rather focus on the cognitive and social processes that immediately mediate disease conditions and health states.  For example, billions of dollars have been spent in the U.S. on research and interventions that aim to change individuals’ risk behavior in order to reduce HIV transmission.   These approaches, ignore the role that social and economic factors play as foundational determinants of population health. In this presentation we shall argue that social and economic factors constrain individual choice sets, limit the potential change individuals can make, and narrow the impact of health promotion efforts that aim to improve individual behavior.   We shall agitate for a broader conception of health promotion to include the optimization of social and economic conditions as part of its remit.

Dr. Sandro Galea, MD, MPH, DrPH, is the Anna Cheskis Gelman and Murray Charles Gelman Professor and Chair of the Department of Epidemiology at the Columbia University Mailman School of Public Health.  Dr. Galea is a physician and an epidemiologist.

Dr. Galea’s research program seeks to uncover how determinants at multiple levels—including policies, features of the social environment, molecular, and genetic factors—jointly influence the health of urban populations. His work also explores innovative methodological approaches to population health questions.

His primary focus is on the causes of mental disorders, particularly common mood-anxiety disorders and substance abuse. His work has documented the mental health consequences of mass trauma and conflict worldwide, including as a result of the September 11 attacks, Hurricane Katrina, conflicts in sub-Saharan Africa, and the American wars in Iraq and Afghanistan. 

The National Institutes of Health, Centers for Disease Control and Prevention, and several foundations have funded his research. He has published over 400 scientific journal articles, 50 chapters and commentaries, and 7 books and his research has been featured in The New York Times, NPR, the Wall Street Journal, and many other media outlets.  During Dr. Galea’s tenure as Chair, the Department of Epidemiology has launched several new educational initiatives and substantially increased its focus on five core areas: chronic, infectious, lifecourse, psychiatric/neurological, and social epidemiology. Dr. Galea chairs the New York City Department of Health and Mental Hygiene’s Community Services Board and sits on its Health Board. He is president of the Society for Epidemiologic Research and an elected member of the Institute of Medicine of the National Academies of Science.

Social Mechanisms behind Ethnic/Racial Differences in the Mental Health of Latinos

Presenter: Margarita Alegría, PhD

Minority status has been causally linked to detrimental physical health outcomes but rarely tested to see if it plays the same role in psychiatric illnesses. Knowledge of the relationship between minority status and mental illness is critical as thirty percent of U.S. young adults ages 18-34 are either first or second generation immigrants, integrating as minorities. A perplexing pattern of depressive illness among Puerto Ricans conditional on site of residence (i.e. lower rates if they are living in Puerto Rico as majority and higher or similar rates to non-Latino whites if they are living in the US as minority) underscores the importance of better understanding the transformation that occurs when people migrate and become a minority population. Does the experience of minority status itself convey differential risk for mental illness? Missing from studies is also a nuanced understanding of the process of acculturation and how integration into a host country changes interactions between the individual, the context, and their culture. In this presentation, I describe an innovative approach of how we propose to investigate if and how experiences of minority status as contrasted to those of majority status convey differential risk for depression and anxiety, using Puerto Ricans as a test case. We and others posit that minority status transforms one’s social interactions and amplifies stressors of social disadvantage that negatively impact mental health.  Exploring both ethnic (e.g. attributions of discrimination and racism) and non-ethnic (e.g. low social position) attributions of disadvantaged neighborhoods may capture more of the potential pathogenic contribution of minority status. The Boricua study can identify within-group risk factors (e.g. lower versus higher level of perceived discrimination) and test whether these operate similarly in the Bronx and Puerto Rico. Our methods are guided by our overall purpose: to investigate and understand the causal relationship between the experience of minority status in late adolescence and early adulthood and social and environmental context on risk of depression and anxiety.  

Margarita Alegría, PhD, is the Director of the Center for Multicultural Mental Health Research at the Cambridge Health Alliance and a Professor in the Department of Psychiatry at Harvard Medical School. She currently serves as PI or co-PI of three NIH funded research studies. Dr. Alegría’s published work focuses on the improvement of health care services delivery for diverse racial and ethnic populations, conceptual and methodological issues with multicultural populations, and ways to bring the community’s perspective into the design and implementation of health services. Her publications cover psychiatric epidemiology, health services research, and mental health and substance abuse service disparities. She leads a multi-site randomized controlled trial, testing a patient activation intervention, and a comparative effectiveness trial of a telephone-based depression therapy intervention in primary care. Dr. Alegría has received numerous awards including the 2003 Mental Health Section Award of APHA, the 2008 Health Disparities Innovation Award from the NIMHHD, the 2008 Carl Taube Award from APHA, the 2009 Simon Bolivar Award from the APA, and the 2011 Harold Amos Award from the HMS; and the Award of Excellence from the NHSN on Drug Abuse. In October 2011, she was elected as a member of the Institute of Medicine. In 2012 she received the Frances J. Bonner Award, from the Massachusetts General Hospital Department of Psychiatry, awarded for meritorious service in the mental health field for the ethnic and racial minority community.