The politics of social determinants and the built environment in CDC chronic disease prevention.

摘要

Since 1999, the Centers for Disease Control and Prevention has administered community health programs that aim to treat the structural causes of chronic disease development in the built environment. These programs apply a social determinants model of health care by targeting the social conditions of health inequity and health outcomes rather than focusing more narrowly on individuals as they enter the health care system. Aspects of the built environment that are affected by community health programs include (but are not limited to): increasing opportunities for active transportation, requiring more physical education and healthy food options in schools, building community gardens and establishing farmers' markets in areas with limited access to fruits and vegetables, and/or creating stronger policies to limit tobacco use.;Based on interviews with workers at state and federal agencies and non-profit organizations affiliated with CDC community health programs, and analysis of CDC campaign material, federal white papers, and policy documents, I examine the social implications of state interventions into built environment. First, I position the emergence of a social determinants model of health treatment within broader shifts in public health concerns over the decades prior to community health programs. I focus specifically on the increased attention to chronic diseases in the 1970s, the emphasis on community partnerships as a methodological tool for public health programs in the 1980s, and the proclamation of chronic disease "epidemics" in the 1990s.;Following this account, I examine in greater detail some of problems with existing institutional arrangements for defining and evaluating "social determinants". This examination focuses primarily on the institutional processes for producing and disseminating evidence about built environment interventions, as well as the extensive and essential role of surveillance in visualizing health problems. I conclude that current applications of the social determinants approach perpetuate particular ways of thinking about the relationship between society and health outcomes, while foreclosing the possibility for alternate conceptualizations.