Public Health Terminology: It is important for medical students and physicians to be familiar with the terminology used in discussing public health and population health. Please use this lexicon as a reference during your training.
In this foundational article, social epidemiologists Bruce Link and Jo Phelan argue three main points:
social conditions (e.g., SES, inequality, racism, segregation) have a causal effect on health and well-being,
to understand patterns of disease prevalence and incidence, we need to contextualize risk factors and understand what conditions put people “at risks of risks” (i.e., people in poor neighborhoods have an elevated risk of exposure to crime which increases the risk of stress accumulation), and
researchers need to acknowledge that social conditions are not just distal causes of disease, they are FUNDAMENTAL causes, meaning that the relationship between the social conditions (e.g., SES) and health is robust and will remain present even as the risk factors for disease and the leading causes of disease/death change.
This is because high SES individuals are afforded flexible resources that they can use to avoid risks and minimize the consequences of disease.
McLeroy, Bibeau, Steckler and Glanz are generally credited with creating the social ecological model of care. A quick Google search for the social ecological model will reinforce how widely it has been adopted. There are numerous community, state, national and international organizations that utilize this model in their programs.
Think back to your session in immersion on the social history. How often do you think beyond the individual and interpersonal factors that influence you and your patients health?
“The social determinants of health are the conditions in which people are born, grow, live, work and age. These circumstances are shaped by the distribution of money, power and resources at global, national and local levels. The social determinants of health are mostly responsible for health inequities – the unfair and avoidable differences in health status seen within and between countries.”
– From the World Health Organization
From the Oxford English Dictionary
Diet: The kinds of food that a person, animal, or community habitually eats. ‘a vegetarian diet’
Epigenetics: The study of changes in organisms caused by modification of gene expression rather than alteration of the genetic code itself. ‘epigenetics has transformed the way we think about genomes’
Disparity: A great difference. ‘economic disparities between different regions of the country’
Epigenetics, Social Determinants of Health and the Social Ecological Model
Keep the social determinants of health in mind while reading “Diet, the Gut Microbiome, and Epigenetics” by Hullar et. Al. The field of epigenetics is in its infancy. Consider how access to certain foods and environmental conditions may increase or decrease an individual’s cancer risk.
Remember the social history session from immersion? When you last took a social history was it in the context of the social ecological model? Think about your last patient encounter. Place that patient within the social ecological model. How has their life and health been influenced by individual, interpersonal, organizational, community and policy level interactions?
Racial Disparities in Cancer Treatment and Outcomes
Not that “Disparities in Cancer Care and Outcomes” was published in the Journal of the American College of Surgery. This article “explores radical disparities in the context of cancer surgery.” Take note of Figure 1. Do you think the steps present in this figure might help you explore disparities in outcomes in other conditions? How is it similar to the social ecological model? How is it different?
“A young couple who are interested in starting a family come to you to discuss undergoing genetic carrier testing prior to trying to conceive. Both members of the couple are healthy and there is no known history of genetic disease in either patient’s background. However, the husband does have a younger brother affected by Down Syndrome who lives semi- independently in a group home. They each self-identify as being of Caucasian (not Irish or French Canadian) ethnicity and report no known Ashkenazi or Jewish Ancestry.”
“They are now aware of a wide range of recessive genetic conditions for which they could be tested. They simply want to avoid having a child with a truly devastating prognosis such as Tay-Sachs disease. Therefore, they request a test of the HEXA gene only.”
Should you honor this request or recommend that the couple consider carrier testing for additional genetic conditions instead?