Health Status Tied to Social Factors, Not Just Genes, Say Experts

Maybe it’s too simple to say that when it comes to health, “your ZIP code is more important than your genetic code,” but there’s a good deal of truth in that aphorism.

Genes may account for 30 percent of the cause of premature death, but the rest of one’s risk includes behavior patterns, environmental exposure, social circumstances, and the health care system—collectively, the social determinants of health, said Ruth Shim, M.D., M.P.H., at IPS: The Mental Health Services Conference in Washington, D.C., in October.

“Social determinants are inherently political, shaped by the distribution of money, power, and resources locally, nationally, and globally,” said Shim, vice chair for education and faculty development in the Department of Psychiatry at Lenox Hill Hospital in New York. More specifically, health disparities arise from demographic differences like class, race, ethnicity, wealth, and geography. Health inequities, however, are “avoidable, unjust, systemic social and economic policies and practices that create barriers to opportunity.”

Social determinants take their toll on mental as well as general health and can be seen in historical patterns of wealth and poverty, said Michael Compton, M.D., chair of the Department of Psychiatry at Lenox Hill Hospital and a professor of psychiatry at Hofstra Northwell School of Medicine.

Poverty and economic inequality have been growing since 1970, he said. Overall, about 15 percent of Americans live below the poverty line ($24,300 for a family of four), but rates are about 50 percent higher for African Americans and Hispanic Americans.

“But beyond the racial disparities lies the juvenilization of poverty,” he said. “About 40 percent of all children in the United States are poor or near poor.”

However, the effects of poverty on children go beyond living circumstances, he said. Poverty is associated with lower academic performance and impaired cognitive domains, as well as PTSD, depression, anxiety, and drug overdose deaths.

Poverty is also associated with reduced gray matter in the hippocampus, frontal lobes, and temporal lobes. These effects are detectable in infancy and stimulate stress hormones that also affect the structure and function of the brain, leading to impairments in cognition, motivation, and self-efficacy.

“The timing, duration, and intensity of childhood poverty have lifelong effects,” he said. “Many of our patients, especially those with serious mental illnesses, are socioeconomically disadvantaged or impoverished. This often creates so much stress that any expected illness course or treatment response is overwhelmed.”

However, not all children growing up in poverty have poor outcomes, so there is a need to understand how children do well despite growing up poor, he said. “What were the protective factors and how we can promote them?”

Another, often overlooked, determinant of mental health rests on the dinner table, said Alisha Coleman-Jensen, Ph.D., a sociologist with the U.S. Department of Agriculture Economic Research Service in Washington, D.C. In the United States, 15.5 million households are “food insecure,” with people who have skipped at least one meal or haven’t eaten anything for a day.

“People with a mental health disability have the highest probability of food insecurity,” said Coleman-Jensen. “Depression, the diagnosis most studied in this connection, is related to a higher likelihood of food insecurity and probably in a bidirectional manner.”

Panelists suggested various ways to mitigate the stresses of poverty and other social stressors.

Compton called for programs that help parents during the first five years of a child’s life, as well as support for teachers and mentoring programs to provide children with the protective factors that will strengthen their resilience. The country should invest in universal and equal access to health care and equal education as well as robust jobs programs.

“Psychiatrists and other health professionals can collectively use our political power and the trust the public holds for us to advocate for these policies,” he said.

Another grassroots approach to alleviate the stresses of social determinants can be medical-legal partnerships, explained Mallory Curran, J.D., of Mallory Curran Consulting in New York City.

Lawyers working in medical-legal partnerships can help physicians by finding legal solutions to problems that affect the health of patients, such as income supports and insurance, housing, employment, education, and services to enhance personal and family stability.

“Consider us another consultant on your health care team,” said Curran.

But broad social and cultural problems are the most difficult to solve, said discussant Glenda Wrenn, M.D., director of Behavioral Health for the Satcher Health Leadership Institute at Morehouse School of Medicine.

“Our goal is not to try to reach some idealized state but to mitigate problems,” said Wrenn. “But mitigation strategies tend to be one-shot deals because it is hard to take a comprehensive approach.”

In fact, responses to social determinants, like those for other problems, usually are off-loaded to policymakers who often are not well informed about the nature and complexity of these issues or are not aware of what solutions exist and have proven to be effective, she said.

Clinicians must be aware of how the social determinants of health affect how patients present their symptoms, how they make decisions about their treatment options, and how they are involved in their treatment, said Wrenn.

“How can we take into account the incredibly disproportionate burden of all of the most disruptive aspects of our society on the way in which they engage in care?,” she asked. ■