The Big Tent

CTSI 2016 NIH Renewal Proposal Launchpad

Poverty Matters: Incorporating Social Determinants of Health into the Medical Model

Proposal Status: 

Adverse social circumstances like community violence, unstable housing, food deserts and poverty can have dramatic, negative impacts on the health of vulnerable children. In safety-net settings, the prevalence of these adverse social circumstances is alarmingly high. A 2007 study in a pediatric emergency department demonstrated that over 97% of presenting families had at least one unmet basic social need; over 48% of families reported that within the last 12 months they had either been threatened with or experienced utility shut-offs; and over 30% of families said that they had either reduced the size of their meals or skipped meals because they did not have enough money for food. [1] These collective social needs, often referred to as social determinants of health, are well-documented to cause psychological stress in families.[2] [3]

There is an increasing body of literature that shows an association between aggregate psychological stress over the life course[4] and the risk for the development and severity of numerous chronic diseases[5]. The combined physiological response to environmental, social, and personal stressors is referred to as allostatic load[6]. Allostasis refers to the body’s ability to adapt to stress (physical, psychological, and social) through activation of the sympathetic nervous system, hypothalamus-pituitary-adrenal axis and metabolic system. As the allostatic load increases, this system breaks down and leads to the dysregulation of stress hormones, which causes disease or worsens disease states, and leads to behavioral/developmental and potentially lifelong psychiatric problems.

Correlating disease processes with adverse childhood experiences, and incorporating indicators of social stress and allostatic load into the medical model represents a new frontier in disease management.  There is a need for research to more firmly define the link between social stressors, disease, and the healing process, and to understand the impact of epigenetics on brain development and its relationship to the toxic stressors of poverty.

Incorporating a “Social Determinants of Health” framework into a mechanistic model of disease represents a new direction in disease prevention and management. It would necessitate building a new system of identifying patients’ needs, and would mandate including social determinants of health in disease prevention strategy. It would allow for new areas of drug development,  transform health care delivery systems, health care utilization and training of health care providers. The “Social Determinants of Health” approach has broad implications for both bench research and clinical trials at UCSF and throughout the country.  Moreover, allostatic load is a concept that is exceptionally well suited for T1-T4 research. A CTSI initiative investigating allostatic load would establish CTSI as a leader in this innovative approach to disease and help encourage a paradigm shift in translational research and medicine.

A primary partner on this project would be the UCSF Center for Genes, Environments & Health, which is already doing social and biologic research on allostatic load. In addition to the translational sciences research team, partners include Children’s Hospital & Research Center Oakland (CHRCO), which has a high volume of children significantly affected by social stressors. The Institute of Medicine (IOM) recently published its report on advancing translational research among the CTSA programs and recommended a greater focus on both children and ethnic minorities, with CHRCO this recommendation will be met. The proposed project will appeal to a diverse team from multidisciplinary backgrounds and we foresee the CTSI Community Engagement Program, other UC health care providers, epidemiologists, sociologists, anthropologists, public health experts, and national groups already addressing issues of poverty and health as potential partners.  Lastly, partnerships with community agencies will be essential in building a foundation for community-based participatory research. 

[1] Hanson M, Lawton E. Between a rock and a hard place: The prevalence and severity of unmet legal needs in the pediatric emergency department setting. Medical Legal Partnership for Children. 2007

[2] McEwen BS. Protective and damaging effects of stress mediators. N Engl J Med 1998;338:171-9.

[3] Evans GW et al. The environment of poverty: multiple stressor exposure, psychophysiological stress, and socioemotional adjustment. Child Development 2003;73(4):1238-1248.

[4] Halfon N, Hochstein M. Life course health development: an integrated framework for developing health, policy, and research. Milbank Q 2002;80:433-79, iii


[5] Marmot MG et al. Health inequalities among Britist civil servants: the Whitehall II study. Lancet. 1991 Jun 8;337(8754):1387-93


[6] Wright RJ et al. Seeking an integrated approach to assessing stress mechanisms related to asthma: is the allostatic load framework useful? Am J Respir Crit Care Med 2013;187:115-6


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