Over the past half century cardiovascular death has declined 50%, presumably due to addressing many of the major risk factors—smoking, high cholesterol, hypertension, physical inactivity, and diabetes—according to a New England Journal of Medicine Perspective last week, extolling the progress of traditional medical research and practice.
Though the drop in mortality is admirable, recent longitudinal studies have shown childhood and early adulthood exposures to neighborhood-level factors such as social deprivation, racial segregation, inadequate education, income inequality, low employment status, disrupted social connections, muddled political voice, and physical insecurity also are profoundly influential. This impact is outlined in an American Heart Association twenty-five-page statement published in 2015 entitled, “Social Determinants of Risk and Outcomes for Cardiovascular Disease.”
While biomedical research matures and available therapeutics progress, distribution of treatments will remain inequitable unless social determinants of health are recognized and tackled. The benefits of prevention and treatment are not shared equally across economic, racial, and ethnic groups in America. Addressing access for all may be as influential for the aggregate lowering of cardiac mortality as new biomarkers, personal sensor technology, and artificial-intelligence apps.
Understanding the relationship between education and cardiovascular mortality is illustrative of the influence of non-medical factors on health. Lower levels of educational attainment are correlated with higher risk factors, incidence of cardiovascular events, and cardiovascular related death. These metrics have worsened over the past 25 years for educationally deprived people.
Other sociodemographic factors including income and wealth have been examined, also showing increased cardiovascular risk factors and worse mortality for lower income and wealth, paralleling lower educational levels. Similarly, employment and occupational status have been reviewed, with generally those in higher job classifications enjoying lower cardiac mortality. However, because income, wealth, employment, and occupational status vary during a lifetime, educational level is a better measure for investigating social influence on cardiac mortality.
“Poor socioeconomic conditions in early life appear to make an important contribution to disease risk in adulthood, especially when early-life factors influence the developmental trajectories of important adult risk factors,” according to the AHA paper referenced above. Multigenerational influence is powerful and needs to be addressed to continue the improvement in cardiovascular outcomes achieved during the past half-century.
Traditional diagnostics and therapies along with new innovations can move society just so far. The next major leap forward will be recognizing and decreasing the disparities within society’s social determinants of health. Until the poverty cycle, education disparity, and employment opportunities are diagnosed and treated as medical conditions, spending resources on fancier medicines or complex surgery will not move the nation forward as quickly as has been the case in the past. Focusing now on correcting inequality will have a more profound positive benefit than almost anything else possible.
