The document discusses the social determinants of health and how population health is shaped by social and structural factors beyond individual biology and behavior. It provides examples of health indicators in the US, such as lower life expectancy and higher rates of obesity, incarceration, and teen pregnancy compared to other developed nations. It argues that health is determined by social conditions like neighborhoods, education, discrimination, and inequality, which are influenced by public policies, the built environment, and social and economic forces. Addressing health issues requires recognizing how social and political factors impact people's lives beyond their control.

1. +
Beyond Biology and
Behavior
Leslie R Lewis, PhD, MPH
Urban Studies & Planning Program, UCSD
Sunday Assembly Lecture
July 26, 2016

2. +
Quickie overview
1. What are we facing: health and social realities in the U.S.
2. Myths & misconceptions about the causes of poor health
and social outcome measures
3. Realities: both population & individual health/wellbeing
are largely shaped by
A. Social and structural determinants
B. Levels of inequality across many axes, and where we
(individually) stand in the socioeconomic and cultural matrix
n (LATER) Discussion: what can we do about this (individually,
as communities, in terms of policy and practice)

3. +
1) What we are facing:
A Small Sampling of Population
Health Markers (health, social)
n Comparatively low life expectancy
n Comparatively high infant mortality rate
n Epidemics of overweight/obesity, diabetes, pre-diabetes

4. +
Infant Mortality
Since
ranking
a
fairly
respectable
12th
in
1960,
the
U.S.
fell
to
an
all-­‐time
low
29th
in
the
world
in
infant
mortality
in
2004,
And
in
2014
we
were
48th
in
the
world
(180th
out
of
228
countries;
228th
being…Monaco)

5. +Prevalence* of Self-Reported Obesity Among U.S.
Adults
by State and Territory, BRFSS, 2014

6. +
If America’s obesity trend
continues at its current pace, all
50 states could have
obesity rates above 44 percent by
2030, according to a new report
from Trust for America’s Health
and the Robert Wood Johnson
Foundation

7. +Exceptionally High
Incarceration Rates
n The U.S. has the highest
incarceration rate in the
world
n we have 2 million
people behind bars-a
fifth of the world
prison population, and
the U.S. is only about
5% of the world
population

8. +
Incarceration Nation
n 500,000 young people are
incarcerated and 2.5 million
are arrested annually
n by the age of 23, "almost a
third of Americans have been
arrested for a crime."[6]
n Race and racism factor in
significantly at every level,
from “stops” to arrests to
booking to conviction to
sentencing to parole chances

9. +
Teen Pregnancy
n The rate in the United States is
improving, but still, about a
quarter of girls in the U.S. get
pregnant before the age of 20
(CDC)
n Roughly 80% of these
pregnancies are unintended
n The U.S. teen pregnancy rate is
substantially higher than in
other western industrialized
nations, and there are significant
racial/ethnic and geographic
disparities in teen birth rates in
the country

10. +
Highest rates of depression &
anxiety
n Across the
industrialized
world
n And our response
is to throw drugs at
it
n 70% of Americans
take at least one
prescription drug

11. +
2) Common (mis)conceptions:
n …health is solely or largely a
function of genetics/biology +
our (often undisciplined)
“lifestyle” behaviors
n …”success” in life is a function of
our good choices and hard work
(and maybe just a little of “having
the right stuff”)

12. +
So, if we’re not doing this:

13. +
Or this….

14. +
Or THIS…

15. +Then we’ll end up like this (and
there is a moral overlay to many
“health problems” in this country)

16. +
But the reality is that our
health is linked to, and
largely a function of, the
social and structural
determinants of our lives

17. +Ehhh…social and structural
determinants?
“What does she mean by this?”

18. +
“I dunno.”

19. +
n The conditions in which
people grow, live, work &
age, and
n The structural factors (the
systems, institutions, and
policies meant to educate
citizens, adjudicate,
regulate, aid people in
trouble, etc.) that ultimately
create those conditions
The Social Determinants of health are…

20. +
n Our neighborhoods, largely a function of our
socioeconomic circumstances… that shape our
early childhood experiences (including the
particularly harmful “adverse childhood
experiences”- ACEs)
n The look, feel, safety and “welcomingness” of
that neighborhood, as well as broader
society
n Educational access & conditions
n Experiences of social inclusion or exclusion
n Levels of social support
n Occupational status & conditions
n Community life (social capital, or fear)
n Access to health care
Social determinants of health are the
“upstream” causes, the “causes of the
causes”

21. +
3 A) All of our lives are structured
and shaped by social and
economic policies, by land use
decisions, by broad cultural
beliefs, values and practices

22. +
Health and well being is linked to
the way we design our cities

23. +
L.A.

24. +
Phoenix

25. +
Effects of sprawl:
n In sprawling areas, people:
n Drive more
n Pollute more
n Weigh more
n Are less civically engaged
n Without central, common, shared resources (i.e., rather than only
private, commercial), there is a negative effect on
n Mental health
n Physical health
n Civic/community health (social capital)

26. +Connections between social capital and the
built environment:
n We spend a tremendous amount of time in cars, commuting,
running errands (4000 miles in the car in 1960 to 10,000 miles in
2000)
n Average American works more than any other developed country
except Korea and Australia
n Home-prepared meals far less frequent
n Diminishing space and time for nurturing family, friend, and
neighborhood relationships
n Much less time, energy, and social support for community and
civic engagement (PTA, scouts, religious, political- Bowling Alone)

27. +Our health is closely linked to our
industrialized food system (both through its
direct and indirect health impacts)

28. + …Linked to the levels of chemicals in
our environment (and in our bodies)

29. +Our (poor) health is related to our
time poverty, high stress lives, and
sleep deprivation

30. +Health/Wellbeing is negatively affected
by experiences of stigma, discrimination,
and social exclusion across the lifespan

31. +
3 B) Levels of Inequality play a
significant role in our health
n Inequality is “written” on our bodies,
evident in our neighborhoods, our
schools, our workplaces…
n Where we stand in the socioeconomic
and cultural matrix of the U.S. structures
our opportunities (to the advantage of
some, and the significant disadvantage
of others), and predicts our health

32. +
We see the impacts of our social
policies, our environmental harms, and
our systems failures
n Zip code is the
single greatest
predictor of
health status

33. +Inequality harms not just the
people “at the bottom,” but all of us
n Harm on two levels:
n Bad for the health
of individuals
along a social
gradient
n Bad for whole
societies along
many indices

38. +The conditions in which people live are clearly unequal.
There is an unequal distribution of income, power,
resources, and goods & services.
n We see inequality manifest in all
areas of society (if we care to look).
n How we explain this (and whether
we accept it as “just the way things
are”) matters a great deal (for
politics, policy-pushing, and
psychological well being

39. +Our conditions are shaped by historical
& present-day political, social &
economic forces
n Nobody wakes up and decides they
want to live in poverty or in a slum, to
have a low-paying job with no health
insurance, to work amidst toxic
chemicals that might endanger them
and their children, to be socially
marginalized, to face discrimination
and stigma, or to be economically on
the “lower rungs” of a wildly unequal
society

40. +Unequal conditions are evident
across our communities
40

41. +
People of
Color
Families in
Poverty
Pounds of Regulated
Toxic Substances
Barrio Logan 97% 35% 143,497,000
La Jolla 14% 3% 3,203,992
41
Barrio Logan and La Jolla
Comparison

42. +And the vastly unequal
conditions of our schools

43. +
Inequality can be seen in levels of
tree cover (e.g., Oakland vs Piedmont)
West Oakland Piedmont

44. +
Chicago
Woodlawn Hyde Park

45. +
Comparing two parts of Mexico City
Lomas de Chapultepec, Miguel Hidalgo San Miguel Teotongo, Iztapalapa

46. +And trees and green space matter quite a
bit!

47. +
So, multiple factors well beyond
our individual control are
implicated in our health and
wellbeing, and our life chances
We need awareness building, and
action at many levels (individual,
community, organizational, policy)
Problems at this scale require
collective investment & action

48. +
(But fighting to create a socially just,
culturally diverse, and ecologically
restorative world is really good for your
health and that of communities & the earth)