Social Spotlight

Illustration by Gloria Diianni

In some ways, health is like real estate: Location matters. Probably more than any event in recent memory, COVID-19 has highlighted the relationship between people’s health and their address, along with other factors known as the “social determinants of health.”

We’re not talking just about wealth or whether you live in a grand manse or swank neighborhood. Social determinants encompass whether your neighborhood is safe and well-designed with sidewalks; whether you have access to transportation, healthful food, clean air and water, medical care, education and employment that provides a living wage; your race and more.

“The social determinants of health really focus on the fact that just going to the doctor doesn’t really determine how well you are. It’s the community in which you live and work and play,” and it’s about accessibility, says Patricia M. Tilley, MS Ed., deputy director of the New Hampshire Division of Public Health Services, Department of Health and Human Services. “Your zip code,” Tilley says, “may determine more about your health than almost anything about you.”

Social determinants include a range of physical as well as social factors — how much social support you have, for example, whether you suffer from discrimination, how much stress you experience, but also how much green space is near you, whether you’re exposed to toxic substances, and whether you live in safe housing.

Research indicates that social factors and physical environment together account for about 50% of people’s health status, says Semra Aytur, PhD, MPH, an associate professor in the Department of Health Management and Policy at the University of New Hampshire. Behavior such as eating habits, the ability to exercise and substance misuse, which are greatly influenced by social and physical environmental factors, account for another 30%. After adding those elements together, Aytur says, “we have accounted for over 80% of a population’s health status without even [considering] genetics or medical care.”

While COVID-19 has affected all of us “in profound ways,” Tilley says, it has hit some communities — particularly lower-income individuals — harder than others, reflecting the significance of, among other things, social determinants of health.

People who live in low-income communities and communities of color are often exposed to multiple stressors that are harmful social determinants, Aytur says. They are more likely to be exposed to crime, for example, and air pollution is often concentrated in these communities, which increases the risk of asthma and heightens susceptibility to COVID-19, a lung disease.

Tilley, who sits on the Governor’s Economic Re-Opening Task Force, says that the power of social determinants is such that as the country continues to grapple with the pandemic, “it’s very clear that it’s not about whether we address the social determinants of health or the risks of COVID. We need to address both of those issues with the same sense of urgency.”

And the Granite State is by no means immune to social determinant troubles. “New Hampshire is a great place to live and work and play, but we certainly have … pockets in the state that have real disparity in terms of income and access to services,” Tilley says.

In particular, New Hampshire’s lack of a robust transportation system, rental housing and affordable housing for people with lower incomes commonly present obstacles to good health for many state residents, Aytur says, along with food insecurity. Approximately 12% of children in New Hampshire live in food-insecure environments, she says.

Addressing “the risk that social determinants can pose to us all and also the disproportionate risk that they pose to the more vulnerable members of our community,” Aytur says, might help us as a country improve health, find our way out of the current pandemic, and better prepare for, heaven forbid, future pandemics. “The social determinants of health are really forms of timely prevention — investing in community resilience on all of those different dimensions, whether it’s improving food security, thinking about environmental protection, [or] making sure people have a living wage and paid sick leave. … I consider social determinants to be part of an emergency preparedness response.”

“Whether we frame it as preparing for the next pandemic or [understanding] that we are only as strong as our weakest link,” Aytur says, we need to “make sure that those essential conditions of health are distributed equally and fairly.”