The idea that health is influenced by social factors is not a new one. The French physician Louis-René Villermé observed in 1830 that mortality patterns were almost perfectly correlated with the degree of poverty in the districts of Paris. The English social reformer Edwin Chatwick noted the differences in living conditions between tradesmen and labourers in 1842 England and their subsequent impact on life expectancy. In 1848, Prussian physician Rudolph Virchow was tasked with writing a report on the typhus epidemic in Upper Silesia. Upon investigating this phenomenon, Virchow noted that the epidemic was intrinsically linked to people’s living and working conditions—particularly substandard housing. His solution was simple but novel—he called for “education, freedom and prosperity” as a lasting solution to the region’s material inequities and poor health outcomes.

Much research has been undertaken since the early 1800s, and there are many resources that examine the SDH in great depth. These textbooks, reports, and scientific articles provide an empirical case for how the SDH impact human health through both material (living conditions and income) and biopsychosocial (stress, social cohesion, social capital, and relative deprivation) pathways. For more information, below are some of the key readings that have helped shape the evidence base on the SDH.

General resources on the SDH

Mikkonen J, Raphael D. Social Determinants of Health: The Canadian Facts. Toronto: York University, School of Health Policy and Management; 2010. Available at: http://www.thecanadianfacts.org/The_Canadian_Facts.pdf.

• This e-text is a valuable resource for health providers, academics, and policy makers in its accessibility and scope. It provides an overview of 14 key SDH and how they impact population health.

Wilkinson RG, Marmot MG, eds. Social Determinants of Health: The Solid Facts. 2nded. World Health Organization; 2003. Available at: http://www.euro.who.int/__data/assets/pdf_file/0005/98438/e81384.pdf?ua=1.

• Originally released in 1998, this 2003 WHO document incorporated the latest and strongest scientific evidence from predominantly UK-based academics on the SDH. It contains information on 10 SDH including stress, early life, unemployment, transportation, and social exclusion.

Poverty, income inequality, and health

Link BG, Phelan J. Social conditions as fundamental causes of disease. J Health Soc Behav 1995:80-94.

• Link and Phelan developed the theory of fundamental causes to explain why the association between socioeconomic status (SES) and mortality has persisted despite radical changes in the diseases and risk factors that are presumed to explain it. They proposed that the enduring association results because SES embodies an array of resources, such as money, knowledge, prestige, power, and beneficial social connections, that protect health no matter what mechanisms are relevant at any given time.

Adler NE, Ostrove JM. Socioeconomic status and health: What we know and what we don’t. Ann N Y Acad Sci 1999;896(1):3-15.

• This article provides a historical overview of the key eras of scholastic research into the SDH. It covers the causal direction of the SES–health gradient, especially from a life trajectory approach. It also explores the current trend of research into the mechanisms by which SES affects health.

Stress and health

Brunner E. Stress and the biology of inequality. BMJ 1997;314(7092):1472–1476.

• Dr Eric Brunner is currently involved in the Whitehall II Study, a follow-up to the famous Whitehall Study that examined cardiovascular disease prevalence and mortality rates among British male civil servants. In this article, Dr Brunner describes the mechanism by which stress (particularly job stress) is related to hierarchy, social position, and cardiovascular disease.

Unnatural Causes: Is Inequality Making Us Sick? Public Broadcasting Service; 2008.

• This four-hour documentary series was met with critical acclaim when it was first broadcast in 2008. The first episode provides a useful overview of the social determinants of health, and lays out the case for how the SDH are stronger predictors of health outcomes than an individual’s genetics or behaviour. The film is focused on the United States, but its findings are equally relevant in a cross-national context.

The population health approach and upstream determinants of health

Rose G. Sick individuals and sick populations. Int J Epidemiol 1985;14(1):32–38.

• Rose’s 1985 article is fundamental reading in population health and is taught in introductory public health and epidemiology courses around the world. The paper’s central idea is that individual and population approaches to improving health are fundamentally different and achieve different aims. This is useful reading for clinicians who are interested in considering “upstream” determinants of health, and how they can affect clinicians in practice.

Coburn D. Beyond the income inequality hypothesis: Class, neo-liberalism, and health inequalities. Soc Sci Med 2004;58(1):41–56.

• This paper was a threshold moment in SDH research, in which the author presented a challenge to the income inequality and psychosocial model of health inequalities. Coburn argues that absolute, rather than relative, income differences underlie the relationships between income and health. He contends that widening income and wealth inequality is linked to worse population health outcomes. Coburn shows that nations that favour a “social democratic” approach to social welfare policy tend to have better population health than those that employ a “neo-liberal” approach.