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Look Upstream: Recognizing the Social Determinants of Health

February 23, 2024

By: Emily DeWalt, Prevention Specialist

Our health is impacted by the choices we make. Exercising the recommended amount, getting enough sleep, eating nutritious foods, and avoiding alcohol and drugs all contribute to the status of our health and wellbeing. We often think of our health as something within our power- something we have control over and perhaps have the “discipline” to keep up. According to public health research, this not the full story.  

Health related choices and behaviors are all influenced by something referred to as the Social Determinants of Health (SDOH). The CDC defines the SDOH as “preventable differences in the burden of disease, injury, violence, or opportunities to achieve optimal health that are experienced by socially disadvantaged populations.” These difference can be broken down into what we refer to as upstream factors (occurring before an outcome) and downstream factors (the outcomes that leave an impact).

Economics and the built environment are upstream factors that affect people on a macro-level. The quality of these systems contribute to the quality of the downstream factors, such as access to healthcare, education and other community resources. The connection between these determinants is widely acknowledged amongst public health researchers, but policy change to address the disparities has been slow. This blog will be focusing on the upstream factors that set the stage for the downstream factors, and what that means for substance use today.

Poverty is an upstream factor that plays a significant role in population health. There are a myriad of reasons why someone might live below the poverty line (which is an individual income below $12,880) with many of them extending beyond the individual’s control. Systemic racism and discrimination contributes to the poverty problem, which leads to limited access to quality healthcare and education, which then decreases employment opportunities. Someone trying to get out of poverty has many factors working against them.

Disparities in socio-economics have a rippling effect. The same is true for another upstream factor- the built environment. Someone might think of different environments as state versus state, or city versus city, but disparity can be found even within the same neighborhood. According to the American Academy of Family Physicians, life expectancy gaps of up to 25 years have been identified between different neighborhoods within the same city. Such a profound difference suggests disparities in health outcomes amongst these populations.

Some of the ways a neighborhood puts people at a disadvantage is with barriers to exercise including a lack of sidewalks, parks, and recreational facilities. Access to nutritious food is difficult if a neighborhood is in a food desert, or a location more than 1 mile from the nearest grocery store. Pollution and other toxins in the environment can make someone more susceptible to respiratory infections or even lung cancer. All of these factors suggest there is much more to good health beyond choosing to live a healthy lifestyle.

In the 1970s, President Nixon prioritized drug enforcement and punishment with what he called a “war on drugs.” This drug war logic persists today where drugs are heavily criminalized, and those in possession or caught using drugs are punished. This is a political act, an upstream factor, that has made lasting negative health effects on individuals that use drugs. Cohen et al. argues that this has exacerbated health disparities by denying housing and employment as well as increasing incarceration because of drugs. The authors go on to say that the legal actions taken around drugs undermine key SDOH through punishment instead of providing healthcare. Medical providers can help this issue by reducing the impact of criminalization during healthcare service and engage in policy reform that promotes better health for drug users.

The many cause-and-effect relationships that influence SDOH make the country’s health crisis complex. Because there are so many systems in place that work against disadvantaged populations, it will take effort from multiple entities to reduce the health disparities. Political action needs to be taken to change the economic and environmental upstream factors that negatively impact public health.

Thanks for checking out this blog! We hope you enjoyed the read. 😊


1.      American Academy of Family Physicians (2024). Advancing Health Equity by Addressing the Social Determinants of Health in Family Medicine. Last viewed February 14, 2024. Available at:

2.      Healthy People 2030 (2024). Social Determinants of Health Literature Summaries. Last viewed February 14, 2024. Available at:

3.      Cohen et al (2022). How the war on drugs impacts social determinants of health beyond the criminal legal system. Last viewed February 2014, 2023. Available at:


1.      Centers for Disease Control (2024). 5 Domains of Social Determinants of Health. Last viewed February 14, 2024. Available at:

2.      DirectorPrep (2024). Rainbow Ripple. Last viewed February 14, 2024. Available at:

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