Caveats and Nuances

Victor R. Fuchs, PhD1

Belief in the importance of the social determinants of health is gaining wide acceptance; this useful development will undoubtedly contribute to better public policy and clinical practice.1 Although the general concept is not contested, several caveats and nuances should be considered.

First, statements such as “social determinants explain half the variation in health” are neither correct nor incorrect; they are incomplete. Assessments of the relative importance of different determinants depend critically on the health variation to be explained. For instance, if the goal was to explain the sharp increase in life expectancy at birth in the United States during World War II, 0.5% per annum from 1940 to 1945, health determinants could be divided roughly into 3 categories: social (eg, income, education, neighborhood), biological (genes), and medical care (quantity and quality, including state of science and technology). Significant biological changes over such a short period as World War II did not contribute to increase in life expectancy. Absent any major scientific or technological change and the diversion of approximately half of all practicing physicians to military service during the war, medical care would be an unlikely explanation. That leaves social determinants such as unusual increases in income, decreases in unemployment, and positive shifts in the national psyche inspired by war as the most likely explanations.

JAMA