Addressing SDOH is a priority for CDC. Authors of a new commentary in the Journal of Public Health Management and Practice describe how the agency has undertaken multiple steps to ensure that efforts to address SDOH fall within CDC’s broader health equity strategy.

Social determinants of health (SDOH) are considered major drivers (upstream causes) of health outcomes and health care costs. It is estimated that more than 50% of poor health outcomes are driven by SDOH factors ranging from structural racism to socioeconomic conditions, to food and housing insecurity. During the COVID-19 pandemic this became abundantly clear as we saw major racial and ethnic disparities in COVID-19 morbidity and mortality. Health care is moving towards screening for social needs of patients. But health care can only provide part of the solution. Community interventions that address upstream causes of health disparities are required and this positions public health to be a critical contributor to evidence-based SDOH strategies.

The Centers for Disease Control and Prevention (CDC) is deeply committed to improving SDOH. Historically, addressing upstream causes were part of public health’s lifeblood. For example, John Snow in 1854 correctly identified a water source as the cause of a deadly cholera outbreak in London. Throughout history, public health experts have moved to address underlying social conditions ranging from poor housing construction, to plumbing to air quality. Today, public health is well-positioned to focus on the upstream SDOH. The following visual (Figure) illustrates the importance of working upstream on the social and economic factors in coordination with those leading midstream and downstream activities.

Without community health efforts that strive to assure ample access to affordable, stable housing, healthy food, education and internet access, referring patients for social needs will be met with frustration and inadequate support. Public health can fill a myriad of roles to address SDOH. Public health can act as a changemaker supporting and informing policy efforts and interventions. Public health can convene stakeholders across multiple sectors to work effectively together. In fact, this is now required as a component of public health department accreditation. Public health can also supply data that is critical for decision making and help integrate information to make it useful for the public. New sources of data via such tools as PLACES¹ and the Environmental Justice Index² can guide action at the local, state, tribal and territorial levels. Public health also has a successful track record of collaborating with leaders from other sectors to influence outcomes and behavior. For example, partnerships with those from multiple sectors — such as housing and transportation — can help shape the built environment

What Are We Doing at CDC

At CDC, we have a history of groundbreaking work in the SDOH area. For instance, the Racial and Ethnic Approaches to Community Health (REACH) programs within the National Center for Chronic Disease Prevention and Health Promotion have targeted food and nutrition security, tobacco policy, built environment, and connections to clinical care. The National Center for HIV, Viral Hepatitis, STD, and TB Prevention has combatted racism, homophobia, transphobia, and other forms of discrimination to help mitigate negative factors influencing disease. The National Center for Injury Prevention and Control has developed evidence-based strategies to diminish adverse childhood events (ACEs). And these are just a few examples. But now, CDC is supporting a cross-agency effort to address SDOH, amplifying existing efforts and integrating SDOH activities into its quest for health equity.

With a cross-agency taskforce, CDC has developed a high-level framework to guide its work on SDOH and serve as a resource for state local, territorial, and tribal partners. This approach has identified 6 pillars – namely Policy and Law, Infrastructure and Capacity, Community Engagement, Partnerships and Collaboration, Data and Surveillance, and Evaluation and Evidence building. All of these reflect how CDC can support the field and engage with other sectors to address SDOH.

The Future

We, as leaders at CDC, feel that the effort to address SDOH is at a critical juncture. While noteworthy steps have been taken, the COVID-19 pandemic illustrated what happens when SDOH are not addressed. A resilient population requires a healthy community that engages multiple partners and addresses the opportunities and policies required for success. Public health, with CDC as the nation’s leading public health agency, must support the field in these efforts. The keys to success are understanding the evidence, aligning across sectors, engaging the community, and investing in the public health mission. Long-term health improvement for the current and next generations depends on it.

1. Centers for Disease Control and Prevention. Places: Local Data for Better Health. 2022 [updated April 4, 2022; cited 2022 June 22]; Available from: https://www.cdc.gov/places/index.html.
2. Centers for Disease Control and Prevention. National Environmental Public Health Tracking. 2022 [updated February 17, 2022; cited 2022 June 22]; Available from: https://www.cdc.gov/nceh/tracking/topics/EnvironmentalJustice.htm.

Read Our Commentary in the Journal of Public Health Management and Practice:

• Social Determinants of Health—An Approach Taken at CDC

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Karen Hacker, MD, MPH, is the Director of CDC’s National Center for Chronic Disease Prevention and Health Promotion. She served as Director of the PA Allegheny County Health Department and is also an expert in community-based participatory research. She received her MD from Northwestern University and MPH from Boston University.

John Auerbach, MBA, is the Director of Intergovernmental and Strategic Affairs at CDC. As such, he is a lead strategic advisor on CDC engagement with the government agencies and other external partners. Over the course of a thirty-year career, he has held senior public health positions at the federal, state, and local levels. 

Robin M. Ikeda, MD, MPH, is the Associate Director for Policy and Strategy at the Centers for Disease Control and Prevention, where she oversees performance monitoring, program evaluation/improvement, and policy analysis. She previously served as the agency’s Deputy Director for Noninfectious Disease.
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Celeste Philip, MD, MPH, is the Deputy Director for Non-Infectious Diseases (DDNID) at CDC responsible for providing leadership and guidance to CDC′s four non-infectious disease centers to advance the agency’s cross-cutting, non-infectious disease priorities such as data modernization, health equity, social determinants of health, and diversity, equity and inclusion.

Debra Houry, MD, MPH, is the Acting Principal Deputy Director of CDC and director of CDC’s National Center for Injury Prevention and Control. She served as an associate professor at Emory University and emergency physician at Grady Memorial Hospital. Dr. Houry received her MD and MPH degrees from Tulane University.