Born to be brave meaning12/5/2023 ![]() 23 While advances in medical care also may have contributed, 23 – 26 most authors believe that nonmedical factors, including conditions within the purview of traditional public health, were probably more important 24 public health nursing, including its role in advocacy, may have played an important role in improved living standards. McKeown attributed the dramatic increases in life expectancy since the 19th century primarily to improved living conditions, including nutrition, sanitation, and clean water. He found that mortality from multiple causes had fallen precipitously and steadily decades before the availability of modern medical-care modalities such as antibiotics and intensive care units. ![]() The limits of medical care are illustrated by the work of the Scottish physician, Thomas McKeown, who studied death records for England and Wales from the mid-19th century through the early 1960s. ![]() Meanwhile, researchers increasingly are calling into question the appropriateness of traditional criteria for assessing the evidence. 4, 6, 7, 17, 18 The relationships between social factors and health, however, are not simple, and there are active controversies regarding the strength of the evidence supporting a causal role of some social factors. 1 – 16 This evidence does not deny that medical care influences health rather, it indicates that medical care is not the only influence on health and suggests that the effects of medical care may be more limited than commonly thought, particularly in determining who becomes sick or injured in the first place. We also discuss challenges to advancing this knowledge and how they might be overcome.Ī large and compelling body of evidence has accumulated, particularly during the last two decades, that reveals a powerful role for social factors-apart from medical care-in shaping health across a wide range of health indicators, settings, and populations. This article broadly reviews some of the knowledge accumulated to date that highlights the importance of social-and particularly socioeconomic-factors in shaping health, and plausible pathways and biological mechanisms that may explain their effects. Evidence has accumulated, however, pointing to socioeconomic factors such as income, wealth, and education as the fundamental causes of a wide range of health outcomes. We use “medical care” rather than “health care” to refer to clinical services, to avoid potential confusion between “health” and “health care.” The World Health Organization's Commission on the Social Determinants of Health has defined SDH as “the conditions in which people are born, grow, live, work and age” and “the fundamental drivers of these conditions.” The term “social determinants” often evokes factors such as health-related features of neighborhoods (e.g., walkability, recreational areas, and accessibility of healthful foods), which can influence health-related behaviors. During the past two decades, the public health community's attention has been drawn increasingly to the social determinants of health (SDH)-the factors apart from medical care that can be influenced by social policies and shape health in powerful ways.
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