11.6 Social Determinants of Health
Katie Baker
Social determinants of health are factors that affect health and are beyond an individual’s control. In 2020, the Centers for Disease Control and Prevention (CDC) launched Healthy People 2030 to address these societal-level determinants through public health initiatives such as access to education, clean water, healthcare, and healthy foods.
Healthy People 2030
Healthy People 2030 divides social determinants of health into five categories:
- Economic stability
- Education access and quality
- Healthcare access and quality
- Neighborhood and built environment
- Social and community context
We will explore some of the Healthy People 2030 goals in each of these categories.
Economic Stability
The goal of this category is to help people earn stable incomes that enable them to meet their healthcare needs. Objectives for improving economic stability include reducing:
- The proportion of individuals living in poverty
- The proportion of families and children experiencing food insecurity
- The proportion of households spending 30% of their income on housing
- The number of workplace injuries
- The number of adults whose arthritis interferes with their work
In terms of employment, objectives focus on increasing employment rates and the number of children who live with at least one parent working full-time while decreasing the number of teens and young adults who are not in school or working (Agency for Toxic Substances and Disease Registry [ATSDR], 2023).
Education Access and Quality
The goal of this category is to expand educational opportunities and help children and adolescents succeed in school. Objectives include:
- Improving high school graduation and college matriculation rates
- Increasing the proportion of 4th and 8th graders with appropriate math and reading proficiency
- Increasing the proportion of young children who participate in early childhood education programs and are developmentally ready for school
- Expanding intervention services for those in need
- Increasing preventive mental health care in schools
- Increasing the proportion of people with disabilities in regular education programs.
These objectives are intended to minimize equity gaps that interfere with many students’ access to higher education, well-paying jobs, and services as they get older (ATSDR, 2023).
Healthcare Access and Quality
The goal of this category is to increase access to comprehensive high-quality healthcare services. Objectives include:
- Reducing emergency room wait times
- Increasing the number of adults, adolescents, and children that use evidence-based preventive care
- Increasing screening rates for lung, breast, colorectal, and cervical cancer, as well as discussions about cancer prevention with healthcare providers (ATSDR, 2023)
Neighborhood and Built Environment
The goal of this category is to create neighborhoods and environments that promote health and safety. Objectives include:
- Reducing adolescent crime
- Improving access to clean water and broadband internet
- Reducing exposures to lead and other environmental hazards
- Improving health and safety discussions in schools,
- Affecting building codes to support individuals with mobility issues
- Reducing motor vehicle deaths
- Increasing access to fluoridated water
- Addressing asthma-related initiatives (ATSDR, 2023)
Social and Community Context
The goal of this category is increasing community and neighborhood support. Objectives include:
- Reducing anxiety and depression
- Reducing the number of children whose parents have been incarcerated
- Increasing voter participation
- Expanding education preparation and preventive healthcare for children and adolescents (ATSDR, 2023)
Looking Forward with Healthy People 2030
The goals for Healthy People 2030 are wide-ranging and touch on many different fields and disciplines. To meet these goals, local, state, and federal agencies must collaborate to benefit the most vulnerable members of society. If you work for a public health organization or a large medical group or hospital, you will likely contribute to the Healthy People 2030 mission. This includes incorporating future initiatives into your work and contributing to these nationwide goals. While Healthy People 2030 is a U.S.-based initiative, its underlying principles apply to health across the globe. As we explore the different social and environmental factors that affect health, keep in mind that the same core factors are involved in determining individual health worldwide.
The Effect of Social Determinants on Our Health
Health Literacy
What is health? The World Health Organization (WHO, 2023) defines health as not only lacking illness or injury but being in a state of “complete physical, mental and social well-being.” This might also be referred to as thriving. When someone is healthy, they are supported emotionally and physically by their personal decisions and environment and are free from any infections, diseases, or injuries caused by external factors. Health includes both mental and physical aspects.
Social determinants of health are factors that influence an individual’s health beyond pathogens, injuries and other physical causes that affect physical, mental, and emotional health. Health literacy includes knowledge of healthy and unhealthy behaviors, as well as an understanding of explanations for illness and injury. For example, a patient who takes a full course of antibiotics to treat an infection and prevent antibiotic resistance, instead of stopping antibiotics as soon as they feel better, shows an understanding of their treatment plan and the need to prevent resistance. Recently, there has been increased focus on improving health literacy around bacterial infections and resistance through public health ads and patient education materials.
Personal decisions about our health, such as what foods and drinks we consume, how much exercise we perform, and our choices around tobacco, drug use, and immunizations, can have lasting impacts on our physical and mental health. Maintaining a healthy diet that includes regular meals and limits overconsumption can lead to positive health outcomes. Something as simple as having access to and eating a regular breakfast can have lasting effects on rates of obesity and diabetes and provide the energy and appropriate blood sugar levels to maintain healthy mood and energy levels, especially during school and work.
Choosing a diet rich in fruits and vegetables can have positive impacts on cardiovascular, gastrointestinal, neurological, and mental health, among other benefits (Angelino et al., 2019). Increased intake of orange and yellow vegetables, for example, provides essential nutrients for healthy vision. Choosing a diet high in preserved and smoked foods will negatively impact digestive and cardiovascular health. For example, eating large amounts of smoked meats, such as bacon, and grilled foods leads to the creation of chemicals that increase our risk of developing various types of cancers (National Cancer Institute, 2017). Also, poor blood sugar control from eating highly processed foods can lead to the development of type 2 diabetes. While some foods linked to poor health outcomes may be enjoyable, their consumption should be limited to reduce health risks.
The amount and type of exercise that we get impacts our mental and reproductive health, as well as the health of our musculoskeletal and cardiovascular systems. Different exercises focus on endurance, flexibility, and cardiovascular health. An exercise routine that includes stretching, weights, walking, and quick bursts of high activity will address all three of these areas. Daily exercise can improve mild depression, premenstrual syndrome, and polycystic ovarian syndrome (Woodward et al., 2020). Daily exercise for 20 minutes or more has also been correlated with lower rates of depression and anxiety (Kandola & Stubbs, 2020).
Overexertion, on the other hand, can lead to injury. It is important for people who are new to exercise to begin slowly and avoid progressing too rapidly through their exercise plans. Regular exercise is preferable to intense sessions on an irregular basis. So-called “weekend warriors” are more likely to sustain injuries than individuals who exercise regularly throughout the week.
While moderate alcohol intake (defined as 1-4 drinks per week) has been associated with improved cardiovascular health (Krittanawong et al., 2022), excessive intake is one of the main causes of mortality in the United States (National Institute on Alcohol Abuse and Alcoholism [NIAAA], 2021).
Tobacco use, whether through smoking, vaping, or chewing, has no long-term health benefits and has substantial negative health effects. According to current research, cigarette smoking is the leading cause of preventable death in the United States (CDC, 2014). It is also a major contributor to other leading causes of death including heart disease, cancer, chronic lower respiratory disease, and stroke (CDC, 2014).
Cigarette smoke exposure not only affects the smoker but also those around them via secondhand smoke. Nicotine in cigarettes can leave a residue on clothing and surfaces and can expose those who come in contact with them to harm without exposure to the smoke itself. This is called third-hand smoke, and it is linked to higher rates of asthma, ear infections, pneumonia, and frequent illnesses in children of smokers (Ferrante, 2013).
While research on vaping and chewing tobacco is less extensive, both have deleterious effects on health. Research shows an association between vaping and chronic obstructive pulmonary disease (COPD) and asthma (Osei et al., 2020) while the use of smokeless tobacco, also known as “chew” or “dip,” has long been linked to cancers of the mouth, tongue, and throat (CDC, 2020).
Like tobacco use, the choice of whether to immunize yourself or your family against preventable illnesses has lasting societal effects. While there are tens of thousands of studies supporting the safety and efficacy of immunizations, some people choose not to immunize based on misunderstandings of science and safety concerns that have been magnified and manipulated for personal and financial gain. Lower rates of immunization have led to outbreaks of serious preventable diseases, such as measles, in the United States in the past decade (Phadke et al., 2016).
As you have read, personal decisions have lasting impacts both individually and societally. Personal choices around diet and exercise will affect our mortality and wellness for many years to come, as well as those who care for us when we can no longer do so. Decisions that affect exposure to others, whether to tobacco smoke or preventable illness, and decisions around consumption of alcohol and drugs that lead to drunk driving, fetal exposure to alcohol or drugs, and crime rates have a lasting effect on families and communities.
In the next section, we will discuss social determinants of health that are rooted in family and religion and how they can affect our physical and mental health. We will consider how individual decisions can affect family dynamics and vice versa, as well as how religious beliefs can affect our health.
Family and Religion
You may wonder how your family and religious beliefs affect your physical, mental, and emotional health. How do you define family? Families can be defined as family of origin, meaning the family in which you grew up, or family of choice, meaning a group of people that you choose to surround yourself with and with whom you have formed close bonds. The behavior modeled by parents, grandparents, siblings, and other role models in the family profoundly impact a person’s beliefs and behaviors surrounding their own health.
Religion can impact physical, mental, and emotional health by instilling values related to bodily autonomy, reproductive choices, sexuality, and death and dying. Many religions also have rules about diet, sexual activity, and respect for our own bodies and those of others. In these ways, our religion of upbringing or choice affects decisions we make about our health and that of our families.
Decisions made by parents around meal planning, cigarette smoke exposure, and support for their children’s socioemotional growth can have effects on the family’s health. Familial relationships, both in an individual household and with extended family can have a profound effect on mental and emotional health as well. For example, building healthy intergenerational relationships can positively affect both older and younger family members.
Also, the decision to distance oneself from an estranged or abusive family of origin necessitates a “chosen family” to provide familial support. A lack of outside support can lead to a person remaining in abusive situations or struggling to survive and thrive on their own.
Conversely, modeling and normalization of unhealthy behaviors, such as poor dietary choices, smoking and drug use, may increase the likelihood of a person making the same decisions. Biological families also contribute genetic factors that predispose individuals to unhealthy outcomes such as cancer, obesity, hereditary diseases, and addictions.
Finally, financial burdens or low socioeconomic status predisposes families to other risk factors, such as limited access to healthcare, healthy food, clean water and air, as well as recreational spaces and other community resources.
Community, School, and Work
Our communities and the places where we spend most of our time are important factors in our health. Where we go to school or where we work affects us through environmental exposures, school or workplace culture, and support systems. Access to clean water, green spaces, recreational opportunities, physical safety, and low crime rates all play a role in the different facets of health.
Communities can provide positive and negative influences on an individual’s health. As mentioned in the previous section, access to clean water and clean air is not always guaranteed. Access to healthcare, jobs, and a strong school system, which may be a primary source of support for many families, also play a role in the different components of health.
As we saw during the COVID-19 pandemic in the United States, schools play an important role in the community beyond just providing education for children. Some families rely on schools for their children’s meals, and social support at school is an important component of children’s mental and emotional health. Teachers and school administrators play a key role in caring for children, acting as role models, observing health changes, and reporting suspected abuse. Communities formed around schools can provide much-needed support for entire families.
Many school districts rely on levies and taxes, particularly property taxes, to fund programs beyond those provided by state or federal funding. This leads to inequities in resources across districts, based on the value of homes within those districts. Districts that serve families in lower-income regions may lack many of the extracurricular activities and exposure to new technologies provided in more well-off school districts and suffer from lack of repairs and environmental hazards due to poor funding.
Workplace culture and environmental exposures affect all aspects of our health. Some individuals work in environments that put them at risk of occupational injuries, including repetitive motion injuries such as carpal tunnel syndrome or exposure to toxic materials or fumes. Others may work in supportive environments that accommodate their roles as parents or caregivers, providing benefits and amenities beyond those required by law.
In countries that lack universal healthcare, such as the United States, private insurance coverage is often linked to employment. However, some individuals have a work culture that discourages taking time off for illness, and many workers in the U.S. lack health insurance, sick leave benefits, or the financial resources to miss work if they are ill or need to care for a family member. In 2019, approximately 92% of the U.S. population had health insurance, leaving 26.1 million people uninsured. Among the insured, almost 56% obtained coverage through their jobs (Keisler-Starkey & Bunch, 2021).
Society and Culture
Societies around the world have been shaped by laws and regulations intended to support large groups of people living in close proximity. Different countries, and even regions within larger countries, such as cities, counties, and states in the U.S., have distinct governmental laws and unofficial societal norms that affect access to healthcare and social support for residents. Culture can be defined as the institutions, collective beliefs, practices, and art of a specific social group. Within any society, various cultures can coexist, affecting an individual’s access to support, whether by choice or because of factors beyond their control. People can identify with multiple cultures, including ethnic backgrounds, sexual orientations, religious belief systems, countries of origin, or even regional or generational differences.
From governmental institutions providing public health interventions to the types of medical care systems in place (discussed further in Chapter 1), social mores and cultural values affect our healthcare decisions such as those around abortion, birth control, vaccinations, and euthanasia.
In some areas, societal and cultural norms are strongly informed by religious values. These norms include female reproductive rights (such as birth control, abortion, and sexual activity), preventive measures and medical interventions (such as stem cell research, immunizations, and blood transfusions), or issues of death and dying (such as Death with Dignity, suicide, and euthanasia). For example, while Jewish tradition supports palliative and end-of-life care in hospice, “the shortening of life through suicide, assisted suicide, or euthanasia is categorically forbidden” (Kinzbrunner, 2004).
In the following section, we will discuss various forms of public health and explore how public health utilizes three types of prevention (primary, secondary, and tertiary) to help the U.S. population maintain good health.
Attributions
- Figure 3.1: 13584554804 by Army Medicine is released under CC BY 2.0
- Figure 3.2: Measles Awareness Poster by City of Minneapolis Archives is released under CC BY 2.0
Workplace laws are regulated by the Department of Labor (DOL), the Occupational Safety and Health Administration (OSHA), and the Department of Health (DOH). These laws cover a wide range of topics, including fair pay, overtime, workplace safety, and protections against sexual harassment and non-discrimination. In healthcare settings, OSHA enforces regulations designed to protect employees from potential exposure to infectious materials and other health hazards.
Healthcare administration includes careers where people manage and coordinate the operational, financial, and logistical aspects of healthcare organizations to ensure the efficient delivery of medical services and optimal patient care. Healthcare administrators are often responsible for budget decisions, employee management (including hiring and firing), contract negotiations with unionized employees, obtaining credentialing from third-party payers such as insurance companies, and securing sponsorships or large donors for organizational initiatives. They also play an important role in coordinating community events, such as local public health events.
Healthcare administrators are typically salaried employees rather than hourly wage earners. While the position offers a higher salary, it may also require long or extended working hours, which is an important consideration when pursuing this career. However, the field offers a broad range of career opportunities, as discussed below.
Contributions to Patient Care
Healthcare administrators directly contribute to patient care by ensuring that a standard of care is followed by all healthcare providers under their direction. In addition, administrators ensure that their facility is meeting licensing requirements and providing cost-effective care to the community.
Administrators also work closely with community physicians seeking admitting privileges and help maintain the facility's visibility and involvement in the community. By organizing public health events and outreach programs, administrators support the health of their community. They may also be involved in planning and developing programs aimed at enhancing patient healthcare.
It is important to distinguish healthcare administrators from office managers or clinical directors, who perform more of the day-to-day management tasks, such as reception, billing, scheduling, inventory, and customer service. Because the career path to administration requires a higher degree, it may be more of a long-term goal for someone like Alma from the chapter overview.
Career Opportunities in Healthcare Administration
Healthcare administration offers a variety of career opportunities. For positions such as chief nurse, degrees in the relevant fields (e.g., IT, HR, and nursing) can be supported with master’s degrees in business or administration. Many positions also allow employees to move up through the ranks, and some companies provide tuition assistance for achieving the appropriate business degree for advancement.
To pursue a career in healthcare administration at an executive level, individuals must earn either a master’s degree or PhD in healthcare or hospital administration. Many successful individuals in this field also hold a master’s of business administration (MBA). These positions are more about administration than healthcare, so a strong background in healthcare is not always required.
Chief Nurse
The chief nurse, sometimes referred to as the chief nursing officer (CNO), is responsible for all nursing staff in a healthcare facility, whether it is a clinic or a hospital. This position reports directly to the chief executive officer (CEO) or chief operating officer (COO) of the facility.
Vice President
Most hospitals and some larger clinical practices have vice presidents who oversee various areas of the organization, including human resources, patient services, and information technology. This position typically receives input from department directors or heads and reports directly to the chief executive responsible for their division.
Chief Executive Positions: CEO/CFO/CTO/COO
Executives such as the chief executive officer (CEO), chief financial officer (CFO), chief technology officer, and chief operations officer (COO) oversee different components of hospital administration. They receive reports from the vice presidents of their respective divisions and are responsible for making high-level decisions that impact the hospital's operations. These executives report to a board of directors on how they are fulfilling the organization's mission and vision, as well as on maintaining the business success of the hospital group.
President
While the CEO manages the broader business vision and strategy, the president of a hospital is typically more focused on the daily operations. When both positions are present in an organization, the president usually reports to the CEO, who in turn reports to the board of directors, which may represent shareholders or investors.
INFECTIOUS DISEASES THAT CHANGED THE WORLD
Unit Authored by:
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Sharon Beaumont-Bowman, SLP.D. Graduate Program Director, Department of Communication Arts, Sciences, and Disorders, Brooklyn College.
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Michael Bergen, AuD, CCC-A. Director, Speech Language Hearing Center, Brooklyn College and CUNY Doctoral Audiology Program, Founding Faculty Member.
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Lesley L. Green-Rennis, EdD, MPH, MCHES. Chairperson, Professor, Health Education Department, Borough of Manhattan Community College – City University of New York.
Goals:
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To examine major pandemics throughout history, their impact, and the public health response to each.
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To examine the impact of social phenomena on the origin, transmission, and control of infectious disease pandemics.
Learning Objectives:
Students will:
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Have an awareness and understanding of pandemics throughout history.
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Think critically about key issues related to the public health management of pandemics.
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Describe the social and economic impact of pandemics on societies and populations.
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Compare major infectious disease pandemics and their public health response to COVID-19 and its public health response.
Throughout history, epidemics have had an historical impact equal to that of wars, revolutions and economic crises. In The Historical Importance of Epidemics, Professor Frank Snowden explains the significant impact of pandemics throughout history and warns that epidemic diseases still pose a major threat to human well-being. According to Snowden, infectious diseases are too important to leave solely to doctors. They are part of the big picture of historical change and have had an impact on religion, the arts, colonial expansion, the establishment of New World slavery, the rise of modern medicine and on strategies of public health.
Disease can be thought of existing in levels within communities. These levels help understand the potential threat of disease and dictate the public health response. The Centers for Disease Control and Prevention’s (CDC) Epidemic Disease Occurrence explains that disease can be sporadic, endemic, or hyperendemic and can rise to the level of an epidemic or pandemic.
Many infectious diseases are zoonotic, caused by microorganisms that spread between animals and people. Zoonotic diseases can spread from animals to humans through direct contact, indirect contact, via vectors, or through food and/or water systems. Pandemics happen when new (novel) disease causing agents emerge which are able to infect people easily and spread from person to person in an efficient and sustained way (https://www.cdc.gov/flu/pandemic-resources/basics/index.html).
Though science has come a long way in understanding infectious diseases, diseases of the past as well as novel emerging diseases, are a constant threat to public health (https://www.coursera.org/learn/epidemics). Complex issues related to social networks, food safety and security, and environmental ecosystem destruction necessitate a holistic, not siloed approach to understanding and addressing epidemic diseases.
(Bats, Ducks, and Pandemics: An Introduction to One Health Policy). According to Snowden, how we deal with infectious diseases may be an important factor in whether and how we survive as a species (The Historical Importance of Epidemics)
Infectious diseases are experienced differently from chronic disease and give rise to distinctive fears and anxiety. Chronic diseases can have massive impact, but do not give rise to scapegoating, mass hysteria, outbursts of religiosity, or works of literature and art. Epidemic diseases are distinctive and leave a particular legacy in their wake. Throughout human history, infectious diseases have been the most important cause of suffering and death (The Historical Importance of Epidemics).
Infectious diseases are one of the major causes of death, responsible for a quarter to one-third of mortality worldwide. People living in low-income countries are far more likely to die of a communicable (infectious) disease than a noncommunicable (chronic) disease. Despite a global decline from the years 2000 to 2019, six of the top 10 causes of death in low-income countries were communicable diseases.
A Historical Guide to Pandemic Responses is a series of short essays written by medical historians on previous epidemics and our responses to them. The essays act as “signposts” to highlight historical research on prior responses to rapidly spreading disease among populations (https://www.hopkinsmedicine.org/news/articles/a-historical-guide-to-pandemic-responses).
Pandemics not only have social and public health effects, but also impact the economy as well.
In Pandemics and Financial Assets, Dr. Nzar Mohammad Alsharari discusses the ill effects of pandemics on the economy and presents how the financial markets and financial institutions were influenced by and responded to pandemics.
The CDC outlines the public health response to pandemics in their e-learning course Introduction to Public Health.
| Time Period | 1331-1770 |
| Causative Agent | Yersinia Pestis |
| Transmission | Bubonic is transmitted through exposure to infected material through a break in the skin or from the bite of an insect, Pneumonic plague is transmitted from person to person through respiratory droplets via coughing or sneezing |
| Symptoms | Flu-like, fever, headaches, vomiting, swollen lymph nodes |
| Epidemiology | 40-60% of Europeans died from 1347-1352; mortality rate of 30-75% |
The bubonic plague is a highly infectious disease caused by the bacteria, Yersinia Pestis. Archaeological evidence suggests its existence as far back as 542 C.E. Symptoms include fever, headaches, vomiting, swollen and painful lymph nodes (buboes) and acral necrosis (dark discoloration of the skin) (https://www.cdc.gov/plague/symptoms/index.html). There are three common clinical forms of the plague: 1) Bubonic; 2) Pneumonic; and 3) Septicemic. Plague symptoms and clinical manifestations depend on how the patient was exposed to the plague bacteria. Most victims of the plague died within four to seven days after infection.
The Black Death was the devastating epidemic of the bubonic plague which struck Asia and Europe in the mid-1300s. The great pandemic of the 14th century is also known as the “Great Pestilence,” the “Great Plague,” and the “Great Mortality.” It began in 1331 in Southwestern China and spread through Asia to the Mediterranean via trade routes. In October 1347, a Genoese ship docked in Messina, Sicily, bringing with it rats infected with the bubonic plague (Brief History of Pandemics-Pandemics Throughout History).
As a result, both of its extreme virulence and the strictness of the measures imposed to combat it, the plague significantly disrupted traditional customs of dealing with death. This disruption made itself felt not only in religious belief and burial practices but also in art, architecture, and literature. European culture was profoundly shaped by the experience of the plague, as witnessed by the advent of symbols such as “vanitas” and the danse macabre in iconography, as well as the visual representations associated with the new cults of plague saints. The successful containment of the plague might be seen to have exercised a similarly powerful effect in shaping the philosophical project of the Enlightenment, in that the measures taken to ward off death gave material substance to theoretical claims of progress. (Open Yale Course: HIST 234: Epidemics in Western Society Since 1600, Lecture 5). The period of the Black Death was the first time society implemented organized anti-plague measures (i.e., quarantine, isolation, and systems of sanitation control that included observation stations, isolation hospitals, and disinfection procedures)
In Pandemic Disease in the Medieval World: Rethinking the Black Death, writers compare the Black Death and Ebola epidemics. Each essay focuses on a different aspect of comparison. For example, one essay analyzed the impact of the Black Death on the Jewish community in Tarrega as an example of how the pandemic lead to escalating attacks on social minorities The essays highlight the need to understand local outbreaks and how mathematical modeling can be used to detect early, “silent” phases of transmission.
| Time Period | 4th century CE- 1977 |
| Causative Agent | Variola virus |
| Transmission | Droplets from the nose or mouth (cough & sneeze) |
| Symptoms | Fever, headache, severe fatigue, severe back pain, vomiting |
| Epidemiology | Naturally occurring smallpox was eradicated worldwide by 1980 |
Smallpox is a serious infectious disease caused by the variola virus. While the origin of smallpox is unknown, the growth of civilizations and exploration is blamed for the global spread of the virus. People who had smallpox had a fever and a distinctive, progressive skin rash. Once the first sores appeared in the mouth and throat, they were contagious and remained contagious until their last smallpox scab fell off. The virus was spread when they coughed or sneezed and droplets from their nose or mouth spread to other people. Most people with smallpox recovered, but about 3 out of every 10 people with the disease died. Many smallpox survivors have permanent scars over large areas of their body, especially their faces. Some were left blind. Smallpox was eradicated as a result of vaccination: the last natural outbreak of smallpox in the United States occurred in 1949. https://www.cdc.gov/smallpox/about/index.html
In the eighteenth century, smallpox succeeded plague as the most feared disease.
Smallpox is viral and transmitted by contact and airborne inhalation. Unlike plague, smallpox can exist as an endemic as well as an epidemic disease, https://oyc.yale.edu/history/hist-234/lecture-6
The COVID-19 pandemic marks the 300th anniversary of the Boston smallpox epidemic of 1721. The epidemic ultimately resulted in an early effort at preventive medicine through vaccination, resulting in a successful public health campaign to eradicate the disease. https://cuny-bc.primo.exlibrisgroup.com/permalink/01CUNY_BC/ljnr3v/cdi_proquest_miscellaneous_2622961987
| Time Period | 1817- |
| Causative Agent | Vibrio cholerae bacteria |
| Transmission | Food or water contaminated with cholera bacteria |
| Symptoms | Vomiting, profuse diarrhea, thirst, leg cramps, restlessness or irritability |
| Epidemiology | At-risk areas include peri-urban slums, and camps for internally displaced persons or refugees, where minimum requirements of clean water and sanitation have not been met. |
Cholera is an acute diarrheal illness caused by infection of the intestine with Vibrio cholerae bacteria. People typically get sick when they swallow food or water contaminated with cholera bacteria. The resulting infection is often mild but can sometimes be severe and life-threatening. Large epidemics are often related to fecal contamination of water supplies or street vended foods. https://www.cdc.gov/cholera/general/index.html
Asiatic cholera was the most dreaded disease of the nineteenth century. An intense fear provoked by the disease was its symptoms: not only did cholera exact a degrading and painful toll on the human body, it also struck suddenly, and was capable of reducing the seemingly healthy in a period of hours. A second major reason for the disease’s significance was its overwhelming predilection for the poor, https://oyc.yale.edu/history/hist-234/lecture-10
Seven pandemics of cholera have been recorded since the first pandemic in 1817. Overcrowding, poverty, insufficient water, and sanitation facilities increase the risk for cholera outbreaks, https://pubmed.ncbi.nlm.nih.gov/31395455/. Cholera persists as a major cause of illness and death worldwide, with more recent epidemics in Zimbabwe (2008-2009) and Haiti (2010), https://pubmed.ncbi.nlm.nih.gov/22099113/
| Time Period | 1700s-Present, 1918 Pandemic (1918-1919) |
| Causative Agent | Segmented negative-sense RNA virus, of the influenzavirus genus in the Orthomyxoviridae family. |
| Transmission | Droplets from the nose or mouth (cough & sneeze) |
| Symptoms | Very high fever, dry cough, headache and body aches, sore throat, chills, runny nose, loss of appetite, extreme fatigue |
| Epidemiology | Persons of all ages, estimated incidence of approximately 8% in the U.S. |
The diagnosis of the flu is not a new one and while a single case of the flu does not cause alarm, the potential for widespread exposure and illness does. Professor Robert Dingwall, of Nottingham Trent University, provides an historic overview of the seasonal flu, avian flu and a flu pandemic (https://www.oercommons.org/courses/flu-pandemic-how-prepared-are-we-3)
Records of influenza, dating back to the 1700s, suggest a pattern of one major pandemic every century. Among the pandemics for which there is documentary evidence, the outbreak of 1918-1920 is by far the greatest, https://oyc.yale.edu/history/hist-234/lecture-20
Dr. Michael Gregor provides an interesting overview of the birth of influenza, that was presumed not to exist before the domestication of animals. While this is an older source, the information remains relevant when discussing the history of influenza. https://youtu.be/7_ppXSABYLY
The Influenza Encyclopedia is a storehouse for stories about the places, people, and organizations that battled the American influenza epidemic of 1918-1919. Included are stories from all 50 U.S. states and documents how communities across the country did what they could to stem the rising tide of illness and death as well as how many gave their time and their lives to care for the ill. (Influenza Encyclopedia).
In an historical retrospective review of the impact of the 1918-1919 influenza pandemic, a panel of experts discusses how the pandemic affected daily life in the United States and what lessons can be learned and applied to planning today. Pandemic Influenza-Past, Present, Future: Communicating Today Based on Lesson from the 1918-1919 Influenza Pandemic U.S. Department of Health and Human Services Centers for Disease Control and Prevention October 17, 2006 The Oak Ridge Institute for Science and Education
| Time Period | Descriptions of polio-like illnesses have been around since antiquity with multiple epidemics in the 19th and first half of the 20th century |
| Causative Agent | Poliovirus |
| Transmission | Person to person spread via fecal-oral or oral-oral routes |
| Symptoms | Low grade fever, sore throat, stiffness of the neck, back, or legs, headache, vomiting, possible paralysis |
| Epidemiology | 70% of infections in children are asymptomatic |
The Open Yale Course: Poliomyelitis describes the history of poliomyelitis, better known as polio, focusing on the large public health campaign designed to eradicate it. The campaign was modeled after the successful smallpox initiative, although due to differences in the diseases, was more limited in success. Sanitary improvements in many nations across the globe helped to contribute to it being considered a “social disease in reverse” in that large populations in more industrialized nations had no natural immunity to the virus, resulting in outbreaks in these areas. Diagnosis was also often delayed or not correctly made because physicians were not trained or expecting to identify it. Additionally, incorrect assumptions were made about transmission, slowing development of a vaccine. The video further describes the steps leading toward the successful development of vaccines, the involvement of Salk and Sabin, the impact of the March of Dimes, the fact that the US President (FDR) had been paralyzed from polio, as well as the large-scale vaccination initiatives implemented within schools and elsewhere.
The World Health Organization (WHO) website provides an overview with symptoms and treatment, and highlights how two of the three types of polio have been eradicated, while poliovirus type 1 continues to be present in Pakistan and Afghanistan.
ASBMB Today (American Society for Biochemistry and Molecular Biology) highlights how the polio vaccine made its way from lab to public distribution with video, data and photos which describe the large public health campaign designed to eradicate the disease.
| Time Period | Peak 18th-19th centuries |
| Causative Agent | Mycobacterium tuberculosis |
| Transmission | Respiratory droplets |
| Symptoms | Persistent cough, chest pain, coughing up blood, weight loss, no appetite, fever, chills, night sweating, fatigue |
| Epidemiology | One of the most common infections in the world. Estimated that about ¼ of the world’s population are infected. |
The CDC highlights that the history of tuberculosis (TB) can be traced back more than 9000 years in humans, via remains of a mother and child found in the Middle East region. Written descriptions of TB can be found as early as 3300 years ago in India. It is estimated that from the 1600s to the 1800s, approximately 25% of all deaths in Europe and the US were attributable to TB, a form of which during that period was frequently referred to as “consumption.”
The Open Yale Course Tuberculosis (I): The Era of Consumption traces the earlier history of the pulmonary disease consumption, discusses whether it should be classified as epidemic, endemic, or both, and follows its progression and upsurge in increasingly industrialized areas. The video covers the earlier history of transmission and symptomatology through discovery of the mycobacterium tuberculosis in 1882 by Robert Koch, as well as the varied ways it can be transmitted, and the various organs and tissues of the body it can impact, as highlighted by images within the presentation. The video additionally covers the social impact of the disease, with references to sweatshop factories, cramped living conditions in homes and within institutions such as prisons, and to well-known people, such as royalty and famous writers who contracted the disease. It also describes how individuals who contracted the disease sometimes made “health migrations,” in search of an environmental climate more conducive to respiratory health. It also describes how TB influenced romantic works such as those from Emily Bronte and Victor Hugo.
While consumption was sometimes romanticized during the period leading up to Koch’s discovery, the Open Yale Course: Tuberculosis (II): After Robert Koch highlights a shift in the way in which TB was addressed once it more consistently became known as an infectious danger. What is referred to as the “war on TB” resulted in an increase in sanatoria, an international movement which became a growing way to address the disease via dietary changes, isolation, and increased outdoor time which served as a quarantine treatment for the disease. The video covers research and treatment through the earlier part of the 20th century until the ultimate introduction of antibiotics in the 1940s. While not eradicated (despite projections that it would be eliminated in the US by 2010), antibiotics did result in significant decline in TB cases from the 1950s through 1985. However, starting in the 1950’s drug-resistant TB strains began to increase. Between 1970 and 1990 there were numerous outbreaks of drug-resistant tuberculosis. A rise in drug-resistant TB increased numbers worldwide, with pandemic levels in Europe and sub-Saharan Africa. As with other diseases, there has been an overrepresentation of the disease in minority and other underserved populations. The CDC differentiates Active vs Latent TB in this article.
| Time Period | 1981-Present |
| Causative Agent | Human immunodeficiency virus |
| Transmission | Via bodily fluids (i.e., blood, semen, rectal fluids, vaginal fluids, breast milk) |
| Symptoms | Fever, chills, rash, nigh sweats, muscle aches, sore throat, fatigue, swollen lymph nodes, mouth ulcers |
| Epidemiology | AIDS-related deaths have been reduced by 64% since the peak in 2004 and by 47% since 2010. In 2020, around 680,000 people died from AIDS-related illnesses worldwide, compared to 1.3 million in 2010 |
Chris Beyrer described four decades of the emergence, impact, and response to the global HIV/AIDS pandemic in a Lancet article which compares and contrasts various aspects of COVID-19, including issues of equity, geography, and the focus of research scientists on development of treatments and vaccine. The trials, tribulations and timeline of a COVID-19 vaccine compares development to that of an HIV vaccine.
The video Open Yale Course: AIDS covers the background, transmission, scale, epidemiology, societal effects, and public health strategies associated with HIV/AIDS through 2010. The outbreak began in the early 1980s, peaked approximately ten years later before declining until 2001; however, it then experienced an upturn which continued into the 2010s. It is now common knowledge that HIV can be transmitted via the exchange of infected bodily fluids such as blood, breast milk, and semen. As we have seen with other pandemics, early reports of the disease created uncertainty which delayed response to its spread. In this case, since early reports were of infections among gay men, the stigma attached to the media coverage focused on this population while the spread was not limited to a singular population or geography.
While advancements have been introduced which have limited deaths, living with HIV as a chronic disease presents challenges, including those associated with the expanded use of expensive drug cocktails. The Yale Course additionally highlights how the disease continues to be rampant in sub-Saharan Africa, where half of the world’s HIV infections exist, and life expectancy at birth dropped to below 50 years of age (and, in some areas, to below 40 years of age) for the first time since the 1950s, largely due to HIV. The AIDS pandemic has currently globally stabilized but it has also transformed with concerning spread in certain parts of the world and with increased impacts to ethnic minority populations.
A Timeline of HIV and AIDS covers the history of HIV/AIDS in the U.S. from the first reported cases in 1981 to present day.
| Time Period | 2019-Present |
| Causative Agent | SARS-CoV-2 |
| Transmission | Respiratory droplets and contaminated surfaces |
| Symptoms | Fever, chills, cough, loss of taste or smell, sore throat, nausea or vomiting, fatigue, muscle aches, headache, diarrhea, shortness of breath |
| Epidemiology | Globally, as of 7:41pm CEST, 18 May 2022, there have been 520,372,492 confirmed cases of COVID-19, including 6,270,232 deaths, reported to WHO |
In December, 2019, a cluster of patients in Wuhan, Hubei Providence, China were diagnosed with pneumonia of unknown etiology. All the cases were connected to the Huanan Seafood Wholesale Market in Wuhan. January 2020, Chinese authorities identified and isolated the novel coronavirus as the causative agent of the outbreak. The first confirmed case in the U.S. was discovered in Washington state, later in January. In March 2020, the World Health Organization declares COVID-19 a pandemic. (https://www.cdc.gov/museum/timeline/covid19.html). Despite significant advances in science and medicine, the COVID-19 pandemic spread rapidly and caused major impacts around the world.
The highest percent of COVID-19 cases are among non-Hispanic White people. However, racial and ethnic minority groups are disproportionately represented among COVID-19 cases. The percent of cases for racial and ethnic minority groups are higher than the percent of these populations within the total U.S. population. Comparing the percent of cases and the percent of the total U.S. population by race and ethnicity provides an indication of disparities. This comparison is not exact because not all geographic areas report COVID-19 case data by race and ethnicity. Non-Hispanic White people represent a majority of the U.S. population (60%), followed by Hispanic or Latino people (18%), non-Hispanic Black people (12%), non-Hispanic Asian people (6%), non-Hispanic people who identify with more than one race (3%), American Indian or Alaska Native people (1%), and Native Hawaiian or other Pacific Islander people (less than 1%). Among people aged less than 50 years, and notably among children aged less than 18 years, a noticeably higher percent of COVID-19 cases are among Hispanic or Latino people compared with the percent of the total U.S. population. Hispanic or Latino children represent 25% of the U.S. population aged less than 18 years (https://www.cdc.gov/coronavirus/2019-ncov/community/health-equity/racial-ethnic-disparities/increased-risk-illness.html).
Recent studies have consistently found that among those tested for COVID-19, non-Hispanic Black, Hispanic or Latino, and people who identify with more than one race and are non-Hispanic were more likely to have positive test results as compared with non-Hispanic White or non-Hispanic Asian people. Comparing percent of COVID-19 test results that were positive (percent positive) among racial and ethnic populations can be helpful for understanding the spread of COVID-19 in the community. It is important to continue to monitor access, testing, and results to understand trends in transmission and groups that may be disproportionately affected by COVID-19. It is important to understand why people are getting tested and to recognize if reasons change over time or are different for particular groups. For example, people who have easier access to testing may be more likely to get tested sooner after onset of symptoms or known exposure or more often. People who do not have easy access to testing may wait until they are sicker before getting tested (https://www.cdc.gov/coronavirus/2019-ncov/community/health-equity/racial-ethnic-disparities/increased-risk-illness.html).
The social distribution of COVID-19 exposure factors (density of place of residence, overcrowded housing and working outside the home) are described in detail by Bajos et. al (https://bmjopen.bmj.com/content/11/11/e052888). Multinomial regressions were used to identify changes in social variables (gender, class and race) associated with symptoms of anosmia/ageusia (partial or full loss of smell/loss of taste). Women were more likely to report symptoms during the peak and after. Racialized minorities accumulated more exposure risk factors than the mainstream population and were at higher risk of anosmia/ageusia during the peak and after. By contrast, senior executive professionals were the least exposed to the virus with the lower rate of working outside the home during lockdown. They were more affected than lower social classes at the peak of the epidemic, but this effect disappeared after the peak.
As of April 2022, COVID-19 is the third leading cause of death after heart disease and cancer. Like past pandemics, the COVID-19 outbreak has been particularly detrimental to members of those social groups in the most vulnerable situations, (i.e., people living in poverty, older persons, persons with disabilities, and indigenous peoples). Early on, evidence indicated that the health and economic impacts of the virus were borne disproportionately by poor people. Overall death rates are highest among non-Hispanic American Indian/Alaskan Native and non-Hispanic Black or African American people.
