Social Determinants of Health

In his book Outliers: The Story of Success (Little, Brown & Co., 2008), Malcolm Gladwell highlights the disproportionate number of elite Canadian hockey players born in the first months of the year. This isn’t due to specific zodiac signs governing a propensity for hockey, but instead because the age cutoff in Canada has historically been January 1—a cutoff that sets the stage for cumulative advantage.

Before the age of 10, even a few months’ difference in age can result in significant differences in physiological maturity. So, a hockey player born in January is more likely to be bigger, stronger, and faster than one born in December, potentially receiving more attention from coaches and developing their skills at a faster rate. This could offer them opportunities to play in better divisions, playing with and against better players and receiving better coaching and training, ad infinitum.

As a consequence of this cumulative advantage, there are more NHL players born in January, February, and March than in any other months. So, even at a very early age and for reasons that we have no control over, these social determinants of health can have lifelong impacts on men’s lives.

Socioeconomic determinants of health

Beyond the rink, there are significant implications for cumulative advantage and disadvantage related to social determinants of health. Look at socioeconomic position, for example: a child born into a higher tax bracket is much more likely to be in a higher tax bracket when they’re older.

The best predictor of making money is having money. Conversely, individuals at the lower end of the socioeconomic spectrum may experience the same effect, but in the opposite direction; upward social mobility is challenging (though it’s not impossible).

Let us take a look at the life course trajectories of two hypothetical kids. Joe is born into an affluent neighborhood on the outskirts of a major city, while John lives in subsidized housing with his six siblings in a “rough” part of town in a single parent home.

Joe’s parents are able to afford organic produce, put Joe into private school, and drive him to and from his various sporting activities throughout his childhood. As a result, Joe gets an excellent education that allows him to attend university, secure a job in a top tax bracket, and enjoy an active social life.

On the other hand, John’s father works double shifts to make ends meet, but the only apartment he can afford has a black mold problem that has given John respiratory issues for years. John’s school is oversubscribed, and he’s falling behind because of sick days. To support the family, John takes a construction job and eventually drops out of high school. Years of manual labour and poor self-care have taken their toll on John, and he lives with chronic pain.

In these two examples, you can imagine that two very different states of health and well-being are being experienced by Joe and John in later life. These differences may not necessarily be due to differences in the individuals, but in the broader social and economic circumstances in which they find themselves.

What next?

To address systemic issues such as the negative impact of social determinants of health, we must look to addressing modifiable aspects of lifestyle at the individual level and systemic inequities at the population level.

Physical activity and social connection are two components of lifestyle that can be very cheap and effective in fostering better health and well-being. By making small incremental steps toward healthier behaviours, we may each be able to offset some of the negative effects of cumulative disadvantage.

However, if we’re going to make large-scale changes, a societal shift toward greater equity will be needed at a policy level, which will be a gradual process over many years.