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  1. 1. Justice: Mapping the Concept
  2. Reasonable Risks [Injustice is Served - Book 5]
  3. Fallen [Injustice is Served - Book 6]
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Need for more educational and cultural formation. God's dominion b. Jesus and political authority c. The early Christian communities. Political community, the human person and a people b. Defending and promoting human rights c. Social life based on civil friendship. The foundation of political authority b. Authority as moral force c. The right to conscientious objection d. The right to resist e. Inflicting punishment. Values and democracy b. Institutions and democracy c. Moral components of political representation d. Instruments for political participation e.

Information and democracy. Value of civil society b. Priority of civil society c. Application of the principle of subsidiarity. Religious freedom, a fundamental human right B. The Catholic Church and the political community. Autonomy and independence b. Unity of the human family b. Jesus Christ, prototype and foundation of the new humanity c. The universal vocation of Christianity. The international community and values b.

1. Justice: Mapping the Concept

Relations based on harmony between the juridical and moral orders. The value of international organizations b. The juridical personality of the Holy See. Cooperation to guarantee the right to development b. The fight against poverty c. Foreign debt. The environment, a collective good b. The use of biotechnology c. The environment and the sharing of goods d. New lifestyles. Legitimate defence b. Defending peace c. The duty to protect the innocent d. Measures against those who threaten peace e. Disarmament f. The condemnation of terrorism. Social doctrine and the inculturation of faith b.

Social doctrine and social pastoral activity c. Social doctrine and formation d. Promoting dialogue e. The subjects of social pastoral activity. The lay faithful b. Spirituality of the lay faithful c. Acting with prudence d. Social doctrine and lay associations e. Service in the various sectors of social life. Service to the human person 2. Service in culture 3. Service in the economy 4. Service in politics. The help that the Church offers to modern man b. Starting afresh from faith in Christ c. A solid hope d. Index of references Analytical index. Apostolic Exhortation Ap.

Letter Apostolic Letter c. Denzinger - A. Letter Encyclical Letter ibid. Migne q. Continuing to expound and update the rich patrimony of Catholic social doctrine, Pope John Paul II has for his part published three great Encyclicals — Laborem Exercens , Sollicitudo Rei Socialis and Centesimus Annus — that represent fundamental stages of Catholic thought in this area.

For their part, numerous Bishops in every part of the world have contributed in recent times to a deeper understanding of the Church's social doctrine. Numerous scholars on every continent have done the same. It was therefore hoped that a compendium of all this material should be compiled, systematically presenting the foundations of Catholic social doctrine.

It is commendable that the Pontifical Council for Justice and Peace has taken up this task, devoting intense efforts to this initiative in recent years. This work also shows the value of Catholic social doctrine as an instrument of evangelization cf. Centesimus Annus , 54 , because it places the human person and society in relationship with the light of the Gospel. The principles of the Church's social doctrine, which are based on the natural law, are then seen to be confirmed and strengthened, in the faith of the Church, by the Gospel of Christ.

In this light, men and women are invited above all to discover themselves as transcendent beings, in every dimension of their lives, including those related to social, economic and political contexts. Faith brings to fullness the meaning of the family, which, founded on marriage between one man and one woman, constitutes the first and vital cell of society. It moreover sheds light on the dignity of work, which, as human activity destined to bring human beings to fulfilment, has priority over capital and confirms their rightful claim to share in the fruits that result from work. In the present text we can see the importance of moral values, founded on the natural law written on every human conscience; every human conscience is hence obliged to recognize and respect this law.

Humanity today seeks greater justice in dealing with the vast phenomenon of globalization; it has a keen concern for ecology and a correct management of public affairs; it senses the need to safeguard national consciences, without losing sight however of the path of law and the awareness of the unity of the human family.

The world of work, profoundly changed by the advances of modern technology, reveals extraordinary levels of quality, but unfortunately it must also acknowledge new forms of instability, exploitation and even slavery within the very societies that are considered affluent. In different areas of the planet the level of well-being continues to grow, but there is also a dangerous increase in the numbers of those who are becoming poor, and, for various reasons, the gap between less developed and rich countries is widening. The free market, an economic process with positive aspects, is nonetheless showing its limitations.

On the other hand, the preferential love for the poor represents a fundamental choice for the Church, and she proposes it to all people of good will. Contemporary cultural and social issues involve above all the lay faithful, who are called, as the Second Vatican Council reminds us, to deal with temporal affairs and order them according to God's will cf. Lumen Gentium , We can therefore easily understand the fundamental importance of the formation of the laity, so that the holiness of their lives and the strength of their witness will contribute to human progress. This document intends to help them in this daily mission.

Injustice: Gods Among Us Year 5 - Episode 05 - DC Comics in HINDI

Moreover, it is interesting to note how the many elements brought together here are shared by other Churches and Ecclesial Communities, as well as by other Religions. The text has been presented in such a way as to be useful not only from within ab intra , that is among Catholics, but also from outside ab extra. In fact, those who share the same Baptism with us, as well as the followers of other Religions and all people of good will, can find herein fruitful occasions for reflection and a common motivation for the integral development of every person and the whole person.

The Holy Father, while hoping that the present document will help humanity in its active quest for the common good, invokes God's blessings on those who will take the time to reflect on the teachings of this publication. In expressing my own personal good wishes for the success of this endeavour, I congratulate Your Eminence and your collaborators at the Pontifical Council of Justice and Peace for the important work carried out, and with sentiments of respect I remain.

I am pleased to present the Compendium of the Social Doctrine of the Church , which, according to the request received from the Holy Father, has been drawn up in order to give a concise but complete overview of the Church's social teaching. Transforming social realities with the power of the Gospel, to which witness is borne by women and men faithful to Jesus Christ, has always been a challenge and it remains so today at the beginning of the third millennium of the Christian era. For this very reason the men and women of our day have greater need than ever of the Gospel: of the faith that saves, of the hope that enlightens, of the charity that loves.

The reading of these pages is suggested above all in order to sustain and foster the activity of Christians in the social sector, especially the activity of the lay faithful to whom this area belongs in a particular way; the whole of their lives must be seen as a work of evangelization that produces fruit. This work, entrusted to me and now offered to those who will read it, carries therefore the seal of a great witness to the Cross who remained strong in faith in the dark and terrible years of Vietnam.

This witness will know of our gratitude for all his precious labour, undertaken with love and dedication, and he will bless those who stop to reflect on these pages. I invoke the intercession of Saint Joseph, Guardian of the Redeemer and Husband of the Blessed Virgin Mary, Patron of the Universal Church and of Work, so that this text will bear abundant fruit in the life of society as an instrument for the proclamation of the Gospel, for justice and for peace.

At the dawn of the Third Millennium. Jn through which we passed during the Great Jubilee of the year [1]. Jesus Christ is the Way, the Truth and the Life cf. Jn : contemplating the Lord's face, we confirm our faith and our hope in him, the one Saviour and goal of history. The Church continues to speak to all people and all nations, for it is only in the name of Christ that salvation is given to men and women. At the dawn of this Third Millennium, the Church does not tire of proclaiming the Gospel that brings salvation and genuine freedom also to temporal realities. For the time is coming when people will not endure sound teaching, but having itching ears they will accumulate for themselves teachers to suit their own likings, and will turn away from listening to the truth and wander into myths.

Reasonable Risks [Injustice is Served - Book 5]

To the people of our time, her travelling companions, the Church also offers her social doctrine. Discovering that they are loved by God, people come to understand their own transcendent dignity, they learn not to be satisfied with only themselves but to encounter their neighbour in a network of relationships that are ever more authentically human.

They are people capable of bringing peace where there is conflict, of building and nurturing fraternal relationships where there is hatred, of seeking justice where there prevails the exploitation of man by man. Only love is capable of radically transforming the relationships that men maintain among themselves. This is the perspective that allows every person of good will to perceive the broad horizons of justice and human development in truth and goodness. Love faces a vast field of work and the Church is eager to make her contribution with her social doctrine, which concerns the whole person and is addressed to all people.

So many needy brothers and sisters are waiting for help, so many who are oppressed are waiting for justice, so many who are unemployed are waiting for a job, so many peoples are waiting for respect. Condemned to illiteracy? Lacking the most basic medical care? Without a roof over their head? The scenario of poverty can extend indefinitely, if in addition to its traditional forms we think of its newer patterns. These latter often affect financially affluent sectors and groups which are nevertheless threatened by despair at the lack of meaning in their lives, by drug addiction, by fear of abandonment in old age or sickness, by marginalization or social discrimination And how can we remain indifferent to the prospect of an ecological crisis which is making vast areas of our planet uninhabitable and hostile to humanity?

Or by the problems of peace, so often threatened by the spectre of catastrophic wars? Or by contempt for the fundamental human rights of so many people, especially children? Christian love leads to denunciation, proposals and a commitment to cultural and social projects; it prompts positive activity that inspires all who sincerely have the good of man at heart to make their contribution. Humanity is coming to understand ever more clearly that it is linked by one sole destiny that requires joint acceptance of responsibility, a responsibility inspired by an integral and shared humanism.

It sees that this mutual destiny is often conditioned and even imposed by technological and economic factors, and it senses the need for a greater moral awareness that will guide its common journey. Marvelling at the many innovations of technology, the men and women of our day strongly desire that progress be directed towards the true good of the humanity, both of today and tomorrow.

The significance of this document. The Christian knows that in the social doctrine of the Church can be found the principles for reflection, the criteria for judgment and the directives for action which are the starting point for the promotion of an integral and solidary humanism. It is in this light that the publication of a document providing the fundamental elements of the social doctrine of the Church, showing the relationship between this doctrine and the new evangelization [6], appeared to be so useful.

The Pontifical Council for Justice and Peace, which has drawn up the present document and is fully responsible for its content, prepared the text in a broad-based consultation with its own Members and Consulters, with different Dicasteries of the Roman Curia, with the Bishops' Conferences of various countries, with individual Bishops and with experts on the issues addressed. This document intends to present in a complete and systematic manner, even if by means of an overview, the Church's social teaching, which is the fruit of careful Magisterial reflection and an expression of the Church's constant commitment in fidelity to the grace of salvation wrought in Christ and in loving concern for humanity's destiny.

Herein the most relevant theological, philosophical, moral, cultural and pastoral considerations of this teaching are systematically presented as they relate to social questions. In this way, witness is borne to the fruitfulness of the encounter between the Gospel and the problems that mankind encounters on its journey through history. In studying this Compendium, it is good to keep in mind that the citations of Magisterial texts are taken from documents of differing authority.

Alongside council documents and encyclicals there are also papal addresses and documents drafted by offices of the Holy See. As one knows, but it seems to bear repeating, the reader should be aware that different levels of teaching authority are involved. The document limits itself to putting forth the fundamental elements of the Church's social doctrine, leaving to Episcopal Conferences the task of making the appropriate applications as required by the different local situations[7].

This document offers a complete overview of the fundamental framework of the doctrinal corpus of Catholic social teaching. This overview allows us to address appropriately the social issues of our day, which must be considered as a whole, since they are characterized by an ever greater interconnectedness, influencing one another mutually and becoming increasingly a matter of concern for the entire human family. The exposition of the Church's social doctrine is meant to suggest a systematic approach for finding solutions to problems, so that discernment, judgment and decisions will correspond to reality, and so that solidarity and hope will have a greater impact on the complexities of current situations.

These principles, in fact, are interrelated and shed light on one another mutually, insofar as they are an expression of Christian anthropology[8], fruits of the revelation of God's love for the human person. However, it must not be forgotten that the passing of time and the changing of social circumstances will require a constant updating of the reflections on the various issues raised here, in order to interpret the new signs of the times.

The document is presented as an instrument for the moral and pastoral discernment of the complex events that mark our time; as a guide to inspire, at the individual and collective levels, attitudes and choices that will permit all people to look to the future with greater trust and hope ; as an aid for the faithful concerning the Church's teaching in the area of social morality. From this there can spring new strategies suited to the demands of our time and in keeping with human needs and resources. In short, the text is proposed as an incentive for dialogue with all who sincerely desire the good of mankind.

This document is intended first of all for Bishops, who will determine the most suitable methods for making it known and for interpreting it correctly. Priests, men and women religious , and, in general, those responsible for formation will find herein a guide for their teaching and a tool for their pastoral service. Christian communities will be able to look to this document for assistance in analyzing situations objectively, in clarifying them in the light of the unchanging words of the Gospel, in drawing principles for reflection, criteria for judgment and guidelines for action[12].

This document is proposed also to the brethren of other Churches and Ecclesial Communities, to the followers of other religions, as well as to all people of good will who are committed to serving the common good : may they receive it as the fruit of a universal human experience marked by countless signs of the presence of God's Spirit.

It is a treasury of things old and new cf. It is a sign of hope in the fact that religions and cultures today show openness to dialogue and sense the urgent need to join forces in promoting justice, fraternity, peace and the growth of the human person. The Catholic Church joins her own commitment to that made in the social field by other Churches and Ecclesial Communities, whether at the level of doctrinal reflection or at the practical level. Together with them, the Catholic Church is convinced that from the common heritage of social teachings preserved by the living tradition of the people of God there will come motivations and orientations for an ever closer cooperation in the promotion of justice and peace[13].

At the service of the full truth about man. Ex ; Jn and moves among them cf. By means of the present document, the Church intends to offer a contribution of truth to the question of man's place in nature and in human society, a question faced by civilizations and cultures in which expressions of human wisdom are found. Rooted in a past that is often thousands of years old and manifesting themselves in forms of religion, philosophy and poetic genius of every time and of every people, these civilizations and cultures offer their own interpretation of the universe and of human society, and seek an understanding of existence and of the mystery that surrounds it.

Who am I? Why is there pain, evil, death, despite all the progress that has been made? What is the value of so many accomplishments if the cost has been unbearable? What will there be after this life? These are the basic questions that characterize the course of human life[17]. The direction that human existence, society and history will take depends largely on the answers given to the questions of man's place in nature and society; the purpose of the present document is to make a contribution to these answers. The deepest meaning of human existence, in fact, is revealed in the free quest for that truth capable of giving direction and fullness to life.

The aforementioned questions incessantly draw human intelligence and the human will to this quest. They are the highest expression of human nature, since they require a response that measures the depth of an individual's commitment to his own existence. The fundamental questions accompanying the human journey from the very beginning take on even greater significance in our own day, because of the enormity of the challenges, the novelty of the situations and the importance of the decisions facing modern generations.

The first of the great challenges facing humanity today is that of the truth itself of the being who is man. The boundary and relation between nature, technology and morality are issues that decisively summon personal and collective responsibility with regard to the attitudes to adopt concerning what human beings are, what they are able to accomplish and what they should be.

A second challenge is found in the understanding and management of pluralism and differences at every level: in ways of thinking, moral choices, culture, religious affiliation, philosophy of human and social development. The third challenge is globalization , the significance of which is much wider and more profound than simple economic globalization, since history has witnessed the opening of a new era that concerns humanity's destiny. The disciples of Jesus Christ feel that they are involved with these questions; they too carry them within their hearts and wish to commit themselves, together with all men and women, to the quest for the truth and the meaning of life lived both as individual persons and as a society.

They contribute to this quest by their generous witness to the free and extraordinary gift that humanity has received : God has spoken his Word to men and women throughout history; indeed he himself has entered history in order to enter into dialogue with humanity and to reveal to mankind his plan of salvation, justice and brotherhood. In Jesus Christ, his Son made man, God has freed us from sin and has shown us the path we are to walk and the goal towards which we are to strive. The Church journeys along the roads of history together with all of humanity.

She lives in the world, and although not of the world cf. Jn she is called to serve the world according to her innermost vocation. This attitude, found also in the present document, is based on the deep conviction that just as it is important for the world to recognize the Church as a reality of history and a leaven in history, so too is it important for the Church to recognize what she has received from history and from the development of the human race[19]. The Church, the sign in history of God's love for mankind and of the vocation of the whole human race to unity as children of the one Father [21], intends with this document on her social doctrine to propose to all men and women a humanism that is up to the standards of God's plan of love in history, an integral and solidary humanism capable of creating a new social, economic and political order, founded on the dignity and freedom of every human person, to be brought about in peace, justice and solidarity.

This humanism can become a reality if individual men and women and their communities are able to cultivate moral and social virtues in themselves and spread them in society. Centesimus Annus , God's gratuitous presence. Every authentic religious experience, in all cultural traditions, leads to an intuition of the Mystery that, not infrequently, is able to recognize some aspect of God's face. On the one hand, God is seen as the origin of what exists , as the presence that guarantees to men and women organized in a society the basic conditions of life, placing at their disposal the goods that are necessary.

On the other hand, he appears as the measure of what should be , as the presence that challenges human action — both at the personal and at the social levels — regarding the use of those very goods in relation to other people. In every religious experience, therefore, importance attaches to the dimension of gift and gratuitousness , which is seen as an underlying element of the experience that the human beings have of their existence together with others in the world, as well as to the repercussions of this dimension on the human conscience, which senses that it is called to manage responsibly and together with others the gift received.

Against the background of universal religious experience, in which humanity shares in different ways, God's progressive revelation of himself to the people of Israel stands out. This revelation responds to the human quest for the divine in an unexpected and surprising way, thanks to the historical manner — striking and penetrating — in which God's love for man is made concrete.

These become historical action, which is the origin of the manner in which the Lord's people collectively identify themselves, through the acquisition of freedom and the land that the Lord gives them. The gratuitousness of this historically efficacious divine action is constantly accompanied by the commitment to the covenant, proposed by God and accepted by Israel.

On Mount Sinai, God's initiative becomes concrete in the covenant with his people, to whom is given the Decalogue of the commandments revealed by the Lord cf. Ex Moral existence is a response to the Lord's loving initiative. It is the acknowledgment and homage given to God and a worship of thanksgiving. The Ten Commandments, which constitute an extraordinary path of life and indicate the surest way for living in freedom from slavery to sin, contain a privileged expression of the natural law.

They describe universal human morality. In the Gospel, Jesus reminds the rich young man that the Ten Commandments cf. There comes from the Decalogue a commitment that concerns not only fidelity to the one true God, but also the social relations among the people of the Covenant. The gift of freedom and the Promised Land, and the gift of the Covenant on Sinai and the Ten Commandments are therefore intimately linked to the practices which must regulate, in justice and solidarity, the development of Israelite society. Among the many norms which tend to give concrete expression to the style of gratuitousness and sharing in justice which God inspires, the law of the sabbatical year celebrated every seven years and that of the jubilee year celebrated every fifty years [27] stand out as important guidelines — unfortunately never fully put into effect historically — for the social and economic life of the people of Israel.

Besides requiring fields to lie fallow, these laws call for the cancellation of debts and a general release of persons and goods: everyone is free to return to his family of origin and to regain possession of his birthright. This legislation is designed to ensure that the salvific event of the Exodus and fidelity to the Covenant represents not only the founding principle of Israel's social, political and economic life, but also the principle for dealing with questions concerning economic poverty and social injustices. This principle is invoked in order to transform, continuously and from within, the life of the people of the Covenant, so that this life will correspond to God's plan.

To eliminate the discrimination and economic inequalities caused by socio-economic changes, every seven years the memory of the Exodus and the Covenant are translated into social and juridical terms, in order to bring the concepts of property, debts, loans and goods back to their deepest meaning. The precepts of the sabbatical and jubilee years constitute a kind of social doctrine in miniature [28]. They show how the principles of justice and social solidarity are inspired by the gratuitousness of the salvific event wrought by God, and that they do not have a merely corrective value for practices dominated by selfish interests and objectives, but must rather become, as a prophecy of the future, the normative points of reference to which every generation in Israel must conform if it wishes to be faithful to its God.

These principles become the focus of the Prophets' preaching, which seeks to internalize them. God's Spirit, poured into the human heart — the Prophets proclaim — will make these same sentiments of justice and solidarity, which reside in the Lord's heart, take root in you cf. Jer and Ezek Then God's will, articulated in the Decalogue given on Sinai, will be able to take root creatively in man's innermost being. This process of internalization gives rise to greater depth and realism in social action, making possible the progressive universalization of attitudes of justice and solidarity , which the people of the Covenant are called to have towards all men and women of every people and nation.

The reflection of the Prophets and that found in the Wisdom Literature, in coming to the formulation of the principle that all things were created by God, touch on the first manifestation and the source itself of God's plan for the whole of humanity. In Israel's profession of faith, to affirm that God is Creator does not mean merely expressing a theoretical conviction, but also grasping the original extent of the Lord's gratuitous and merciful action on behalf of man.

In fact, God freely confers being and life on everything that exists. Man and woman, created in his image and likeness cf. Gen , are for that very reason called to be the visible sign and the effective instrument of divine gratuitousness in the garden where God has placed them as cultivators and custodians of the goods of creation.

It is in the free action of God the Creator that we find the very meaning of creation, even if it has been distorted by the experience of sin. In fact, the narrative of the first sin cf. Gen describes the permanent temptation and the disordered situation in which humanity comes to find itself after the fall of its progenitors. Disobedience to God means hiding from his loving countenance and seeking to control one's life and action in the world. Breaking the relation of communion with God causes a rupture in the internal unity of the human person, in the relations of communion between man and woman and of the harmonious relations between mankind and other creatures[29].

It is in this original estrangement that are to be sought the deepest roots of all the evils that afflict social relations between people, of all the situations in economic and political life that attack the dignity of the person, that assail justice and solidarity. In Jesus Christ the decisive event of the history of God with mankind is fulfilled. The benevolence and mercy that inspire God's actions and provide the key for understanding them become so very much closer to man that they take on the traits of the man Jesus, the Word made flesh. Is Jesus therefore places himself on the frontline of fulfilment, not only because he fulfils what was promised and what was awaited by Israel, but also in the deeper sense that in him the decisive event of the history of God with mankind is fulfilled.

Jesus, in other words, is the tangible and definitive manifestation of how God acts towards men and women. The love that inspires Jesus' ministry among men is the love that he has experienced in his intimate union with the Father. Jesus announces the liberating mercy of God to those whom he meets on his way, beginning with the poor, the marginalized, the sinners.

He invites all to follow him because he is the first to obey God's plan of love, and he does so in a most singular way, as God's envoy in the world. Jesus' self-awareness of being the Son is an expression of this primordial experience. For Jesus, recognizing the Father's love means modelling his actions on God's gratuitousness and mercy; it is these that generate new life.

It means becoming — by his very existence — the example and pattern of this for his disciples. Jesus' followers are called to live like him and, after his Passover of death and resurrection, to live also in him and by him , thanks to the superabundant gift of the Holy Spirit, the Consoler, who internalizes Christ's own style of life in human hearts. With the unceasing amazement of those who have experienced the inexpressible love of God cf.

Rom , the New Testament grasps, in the light of the full revelation of Trinitarian love offered by the Passover of Jesus Christ, the ultimate meaning of the Incarnation of the Son and his mission among men and women. He who did not spare his own Son but gave him up for us all, will he not also give us all things with him? The Face of God, progressively revealed in the history of salvation, shines in its fullness in the Face of Jesus Christ crucified and risen from the dead.

God is Trinity: Father, Son, and Holy Spirit; truly distinct and truly one, because God is an infinite communion of love. God's gratuitous love for humanity is revealed, before anything else, as love springing from the Father, from whom everything draws its source; as the free communication that the Son makes of this love, giving himself anew to the Father and giving himself to mankind; as the ever new fruitfulness of divine love that the Holy Spirit pours forth into the hearts of men cf.

Rom By his words and deeds, and fully and definitively by his death and resurrection [30], Jesus reveals to humanity that God is Father and that we are all called by grace to become his children in the Spirit cf. Rom ; Gal , and therefore brothers and sisters among ourselves.

Meditating on the gratuitousness and superabundance of the Father's divine gift of the Son, which Jesus taught and bore witness to by giving his life for us, the Apostle John grasps its profound meaning and its most logical consequence. The commandment of mutual love shows how to live in Christ the Trinitarian life within the Church, the Body of Christ, and how to transform history until it reaches its fulfilment in the heavenly Jerusalem.

The commandment of mutual love, which represents the law of life for God's people [32], must inspire, purify and elevate all human relationships in society and in politics. Trinitarian love, the origin and goal of the human person. The revelation in Christ of the mystery of God as Trinitarian love is at the same time the revelation of the vocation of the human person to love. This revelation sheds light on every aspect of the personal dignity and freedom of men and women, and on the depths of their social nature. In the communion of love that is God, and in which the Three Divine Persons mutually love one another and are the One God, the human person is called to discover the origin and goal of his existence and of history.

It follows, then, that if man is the only creature on earth that God has willed for its own sake, man can fully discover his true self only in a sincere giving of himself cf. Christian revelation shines a new light on the identity, the vocation and the ultimate destiny of the human person and the human race. Every person is created by God, loved and saved in Jesus Christ, and fulfils himself by creating a network of multiple relationships of love, justice and solidarity with other persons while he goes about his various activities in the world.

Human activity, when it aims at promoting the integral dignity and vocation of the person, the quality of living conditions and the meeting in solidarity of peoples and nations, is in accordance with the plan of God, who does not fail to show his love and providence to his children. The pages of the first book of Sacred Scripture, which describe the creation of man and woman in the image and likeness of God cf. Gen , contain a fundamental teaching with regard to the identity and the vocation of the human person.

Gen This vision of the human person, of society and of history is rooted in God and is ever more clearly seen when his plan of salvation becomes a reality. Christian salvation: for all people and the whole person. The salvation offered in its fullness to men in Jesus Christ by God the Father's initiative, and brought about and transmitted by the work of the Holy Spirit, is salvation for all people and of the whole person: it is universal and integral salvation.

It concerns the human person in all his dimensions: personal and social, spiritual and corporeal, historical and transcendent. It begins to be made a reality already in history, because what is created is good and willed by God, and because the Son of God became one of us[39]. Its completion, however, is in the future, when we shall be called, together with all creation cf. Rom 8 , to share in Christ's resurrection and in the eternal communion of life with the Father in the joy of the Holy Spirit.

This outlook shows quite clearly the error and deception of purely immanentistic visions of the meaning of history and in humanity's claims to self-salvation. The salvation offered by God to his children requires their free response and acceptance. In fact, the divine plan of salvation does not consign human creatures to a state of mere passivity or of lesser status in relation to their Creator, because their relationship to God, whom Jesus Christ reveals to us and in whom he freely makes us sharers by the working of the Holy Spirit, is that of a child to its parent: the very relationship that Jesus lives with the Father cf.

Jn ; Gal The universality and integrality of the salvation wrought by Christ makes indissoluble the link between the relationship that the person is called to have with God and the responsibility he has towards his neighbour in the concrete circumstances of history. This is sensed, though not always without some confusion or misunderstanding, in humanity's universal quest for truth and meaning, and it becomes the cornerstone of God's covenant with Israel, as attested by the tablets of the Law and the preaching of the Prophets.

This link finds a clear and precise expression in the teaching of Jesus Christ and is definitively confirmed by the supreme witness of the giving of his life, in obedience to the Father's will and out of love for his brothers and sisters. Inextricably linked in the human heart are the relationship with God — recognized as Creator and Father, the source and fulfilment of life and of salvation — and openness in concrete love towards man, who must be treated as another self, even if he is an enemy cf. Mt In man's inner dimension are rooted, in the final analysis, the commitment to justice and solidarity, to the building up of a social, economic and political life that corresponds to God's plan.

The disciple of Christ as a new creation. Personal and social life, as well as human action in the world, is always threatened by sin. Christ's disciple adheres, in faith and through the sacraments, to Jesus' Paschal Mystery, so that his old self , with its evil inclinations, is crucified with Christ. The inner transformation of the human person, in his being progressively conformed to Christ, is the necessary prerequisite for a real transformation of his relationships with others.

It is not possible to love one's neighbour as oneself and to persevere in this conduct without the firm and constant determination to work for the good of all people and of each person, because we are all really responsible for everyone [44]. This path requires grace, which God offers to man in order to help him to overcome failings, to snatch him from the spiral of lies and violence, to sustain him and prompt him to restore with an ever new and ready spirit the network of authentic and honest relationships with his fellow men[46].

Even the relationship with the created universe and human activity aimed at tending it and transforming it, activity which is daily endangered by man's pride and his inordinate self-love, must be purified and perfected by the cross and resurrection of Christ. Man thanks his divine benefactor for all these things, he uses them and enjoys them in a spirit of poverty and freedom. Jesus Christ is the Son of God made man in whom and thanks to whom the world and man attain their authentic and full truth.

The mystery of God's being infinitely close to man — brought about in the Incarnation of Jesus Christ, who gave himself on the cross, abandoning himself to death — shows that the more that human realities are seen in the light of God's plan and lived in communion with God, the more they are empowered and liberated in their distinctive identity and in the freedom that is proper to them. Sharing in Christ's life of sonship, made possible by the Incarnation and the Paschal gift of the Spirit, far from being a mortification, has the effect of unleashing the authentic and independent traits and identity that characterize human beings in all their various expressions.

For by the very circumstance of their having been created, all things are endowed with their own stability, truth, goodness, proper laws and order. There is no state of conflict between God and man, but a relationship of love in which the world and the fruits of human activity in the world are objects of mutual gift between the Father and his children, and among the children themselves, in Christ Jesus; in Christ and thanks to him the world and man attain their authentic and inherent meaning.

In a universal vision of God's love that embraces everything that exists, God himself is revealed to us in Christ as Father and giver of life, and man as the one who, in Christ, receives everything from God as gift, humbly and freely, and who truly possesses everything as his own when he knows and experiences everything as belonging to God, originating in God and moving towards God. The human person, in himself and in his vocation, transcends the limits of the created universe, of society and of history: his ultimate end is God himself [50], who has revealed himself to men in order to invite them and receive them into communion with himself [51].

The human person cannot and must not be manipulated by social, economic or political structures, because every person has the freedom to direct himself towards his ultimate end. We can speak here of an eschatological relativity , in the sense that man and the world are moving towards their end, which is the fulfilment of their destiny in God; we can also speak of a theological relativity , insofar as the gift of God, by which the definitive destiny of humanity and of creation will be attained, is infinitely greater than human possibilities and expectations.

Any totalitarian vision of society and the State, and any purely intra-worldly ideology of progress are contrary to the integral truth of the human person and to God's plan in history. The Church, sign and defender of the transcendence of the human person. The goal of salvation, the Kingdom of God embraces all people and is fully realized beyond history, in God. The Church places herself concretely at the service of the Kingdom of God above all by announcing and communicating the Gospel of salvation and by establishing new Christian communities.

Jn It follows from this, in particular, that the Church is not to be confused with the political community and is not bound to any political system [58]. Indeed, it can be affirmed that the distinction between religion and politics and the principle of religious freedom constitute a specific achievement of Christianity and one of its fundamental historical and cultural contributions.

Precisely for this reason, the Church offers an original and irreplaceable contribution with the concern that impels her to make the family of mankind and its history more human, prompting her to place herself as a bulwark against every totalitarian temptation, as she shows man his integral and definitive vocation[61]. At the level of concrete historical dynamics, therefore, the coming of the Kingdom of God cannot be discerned in the perspective of a determined and definitive social, economic or political organization.

Rather, it is seen in the development of a human social sense which for mankind is a leaven for attaining wholeness, justice and solidarity in openness to the Transcendent as a point of reference for one's own personal definitive fulfilment. The Church, the Kingdom of God and the renewal of social relations. God, in Christ, redeems not only the individual person but also the social relations existing between men. For as many of you as were baptized into Christ have put on Christ. In this perspective, Church communities, brought together by the message of Jesus Christ and gathered in the Holy Spirit round the Risen Lord cf.

Mt , ; Lk , offer themselves as places of communion, witness and mission, and as catalysts for the redemption and transformation of social relationships. The transformation of social relationships that responds to the demands of the Kingdom of God is not fixed within concrete boundaries once and for all. Rather, it is a task entrusted to the Christian community, which is to develop it and carry it out through reflection and practices inspired by the Gospel. It is the same Spirit of the Lord, leading the people of God while simultaneously permeating the universe[63], who from time to time inspires new and appropriate ways for humanity to exercise its creative responsibility[64].

This inspiration is given to the community of Christians who are a part of the world and of history, and who are therefore open to dialogue with all people of good will in the common quest for the seeds of truth and freedom sown in the vast field of humanity[65]. The dynamics of this renewal must be firmly anchored in the unchangeable principles of the natural law, inscribed by God the Creator in each of his creatures cf.

Rom , and bathed in eschatological light through Jesus Christ. This law is called to become the ultimate measure and rule of every dynamic related to human relations. In short, it is the very mystery of God, Trinitarian Love, that is the basis of the meaning and value of the person, of social relations, of human activity in the world, insofar as humanity has received the revelation of this and a share in it through Christ in his Spirit.

The transformation of the world is a fundamental requirement of our time also. To this need the Church's social Magisterium intends to offer the responses called for by the signs of the times, pointing above all to the mutual love between human beings, in the sight of God, as the most powerful instrument of change, on the personal and social levels.

Mutual love, in fact, sharing in the infinite love of God, is humanity's authentic purpose, both historical and transcendent. New heavens and a new earth. God's promise and Jesus Christ's resurrection raise in Christians the well-founded hope that a new and eternal dwelling place is prepared for every human person, a new earth where justice abides cf.

This hope, rather than weaken, must instead strengthen concern for the work that is needed in the present reality. The good things — such as human dignity, brotherhood and freedom, all the good fruits of nature and of human enterprise — that in the Lord's Spirit and according to his command have spread throughout the earth, having been purified of every stain, illuminated and transfigured, belong to the Kingdom of truth and life, of holiness and grace, of justice, of love and of peace that Christ will present to the Father, and it is there that we shall once again find them.

The complete fulfilment of the human person, achieved in Christ through the gift of the Spirit, develops in history and is mediated by personal relationships with other people, relationships that in turn reach perfection thanks to the commitment made to improve the world, in justice and peace. Human activity in history is of itself significant and effective for the definitive establishment of the Kingdom, although this remains a free gift of God, completely transcendent. Such activity, when it respects the objective order of temporal reality and is enlightened by truth and love, becomes an instrument for making justice and peace ever more fully and integrally present, and anticipates in our own day the promised Kingdom.

Conforming himself to Christ the Redeemer, man perceives himself as a creature willed by God and eternally chosen by him, called to grace and glory in all the fullness of the mystery in which he has become a sharer in Jesus Christ [69]. Being conformed to Christ and contemplating his face [70] instil in Christians an irrepressible longing for a foretaste in this world, in the context of human relationships, of what will be a reality in the definitive world to come; thus Christians strive to give food, drink, clothing, shelter, care, a welcome and company to the Lord who knocks at the door cf.

Heir to the hope of the righteous in Israel and first among the disciples of Jesus Christ is Mary, his Mother. Lk , in the name of all humanity, she accepts in history the One sent by the Father, the Saviour of mankind. Is ; The God of the Covenant, whom the Virgin of Nazareth praises in song as her spirit rejoices, is the One who casts down the mighty from their thrones and raises up the lowly, fills the hungry with good things and sends the rich away empty, scatters the proud and shows mercy to those who fear him cf.

Lk Mary is totally dependent upon God and completely directed towards him by the impetus of her faith. The Church, God's dwelling place with men and women. The Church, sharing in mankind's joys and hopes, in its anxieties and sadness, stands with every man and woman of every place and time, to bring them the good news of the Kingdom of God, which in Jesus Christ has come and continues to be present among them[73].

In the midst of mankind and in the world she is the sacrament of God's love and, therefore, of the most splendid hope, which inspires and sustains every authentic undertaking for and commitment to human liberation and advancement. Rev , so that man is not alone, lost or frightened in his task of making the world more human; thus men and women find support in the redeeming love of Christ. As minister of salvation, the Church is not in the abstract nor in a merely spiritual dimension, but in the context of the history and of the world in which man lives[74].

Here mankind is met by God's love and by the vocation to cooperate in the divine plan. Unique and unrepeatable in his individuality, every person is a being who is open to relationships with others in society. Life together in society, in the network of relationships linking individuals, families and intermediate groups by encounter, communication and exchange, ensures a higher quality of living. The common good that people seek and attain in the formation of social communities is the guarantee of their personal, familial and associative good[75].

These are the reasons for which society originates and takes shape, with its array of structures, that is to say its political, economic, juridical and cultural constructs. As an expert in humanity[77], she is able to understand man in his vocation and aspirations, in his limits and misgivings, in his rights and duties, and to speak a word of life that reverberates in the historical and social circumstances of human existence. Enriching and permeating society with the Gospel. With her social teaching the Church seeks to proclaim the Gospel and make it present in the complex network of social relations.

It is not simply a matter of reaching out to man in society — man as the recipient of the proclamation of the Gospel — but of enriching and permeating society itself with the Gospel [78]. For the Church, therefore, tending to the needs of man means that she also involves society in her missionary and salvific work. The way people live together in society often determines the quality of life and therefore the conditions in which every man and woman understand themselves and make decisions concerning themselves and their vocation.

For this reason, the Church is not indifferent to what is decided, brought about or experienced in society; she is attentive to the moral quality — that is, the authentically human and humanizing aspects — of social life. Society — and with it, politics, the economy, labour, law, culture — is not simply a secular and worldly reality, and therefore outside or foreign to the message and economy of salvation.

Society in fact, with all that is accomplished within it, concerns man. By means of her social doctrine, the Church takes on the task of proclaiming what the Lord has entrusted to her. She makes the message of the freedom and redemption wrought by Christ, the Gospel of the Kingdom, present in human history. As the Gospel reverberates by means of the Church in the today of men and women[81], this social doctrine is a word that brings freedom. This means that it has the effectiveness of truth and grace that comes from the Spirit of God, who penetrates hearts, predisposing them to thoughts and designs of love, justice, freedom and peace.

Evangelizing the social sector, then, means infusing into the human heart the power of meaning and freedom found in the Gospel, in order to promote a society befitting mankind because it befits Christ: it means building a city of man that is more human because it is in greater conformity with the Kingdom of God. With her social doctrine not only does the Church not stray from her mission but she is rigorously faithful to it.

The redemption wrought by Christ and entrusted to the saving mission of the Church is certainly of the supernatural order. This dimension is not a delimitation of salvation but rather an integral expression of it[82]. The supernatural is not to be understood as an entity or a place that begins where the natural ends, but as the raising of the natural to a higher plane. In this way nothing of the created or the human order is foreign to or excluded from the supernatural or theological order of faith and grace, rather it is found within it, taken on and elevated by it.

Rom — recovers again its original link with the divine source of Wisdom and Love. As this link was broken in the man Adam, so in the Man Christ it was reforged cf. Redemption begins with the Incarnation, by which the Son of God takes on all that is human, except sin, according to the solidarity established by the wisdom of the Divine Creator, and embraces everything in his gift of redeeming Love.

Man is touched by this Love in the fullness of his being: a being that is corporeal and spiritual, that is in a solidary relationship with others. The whole man — not a detached soul or a being closed within its own individuality, but a person and a society of persons — is involved in the salvific economy of the Gospel. This is especially true in times such as the present, marked by increasing interdependence and globalization of social issues. Social doctrine, evangelization and human promotion.

The Church's social doctrine is an integral part of her evangelizing ministry. Nothing that concerns the community of men and women — situations and problems regarding justice, freedom, development, relations between peoples, peace — is foreign to evangelization, and evangelization would be incomplete if it did not take into account the mutual demands continually made by the Gospel and by the concrete, personal and social life of man[85]. They also include links in the theological order, since one cannot disassociate the plan of creation from the plan of Redemption. The latter plan touches the very concrete situations of injustice to be combated and of justice to be restored.

They include links of the eminently evangelical order, which is that of charity: how in fact can one proclaim the new commandment without promoting in justice and in peace the true, authentic advancement of man? The following sections describe each of these nine determinants and how they shape health outcomes, as well as the disparities within these social determinants of health that contribute to health inequity. To highlight the ongoing work of communities that seek to address the conditions in which members live, learn, work, and play, this section will feature brief examples of communities for each determinant of health.

Education, as it pertains to health, can be conceptualized as a process and as an outcome. The process of educational attainment takes place in many settings and levels e. Within the current social determinants of health literature, the primary focus on education is on educational attainment as an outcome i. There is an extensive body of research that consistently demonstrates a positive correlation between educational attainment and health status indicators, such as life expectancy, obesity, morbidity from acute and. For example, research suggests that babies born to mothers who have not completed high school are twice as likely to die before their first birthday as babies who are born to college graduates Egerter et al.

Death rates are declining among the most-educated Americans, accompanied by steady or increasing death rates among the least educated Jemal et al. The findings on the association between education and health are consistent with population health literature within the international context as well Baker et al. Specifically, trends in data suggest that, over time, the disparities in mortality and life expectancy by education level have been increasing Meara et al. Meara et al. Economic trends and shifting patterns of employment, in which skilled jobs linked to educational attainment are associated with increased income, also have implications for health NRC, This makes the connection between education and health, mediated by employment opportunities, even more important and worth exploring.

Data from the Behavioral Risk Factor Surveillance System reveal that across all racial groups, adults with higher levels of educational attainment are less likely to rate their own health as less than very good Egerter et al. While the education gradient is present across racial and ethnic groups, it is important to keep in mind that the rates of educational attainment vary across different racial and ethnic groups.

For the — academic year, the high school graduation rate for white students was Americans Kena et al. These rates are consistent with high school diploma and bachelor degree achievement gaps that have persisted since the late s see Figures and Although the literature linking education and health is robust, there is still some debate as to whether or not this relationship is a causal one Baker et al. Issues that have been raised in the course of this debate include the role of reverse causation and the potential influence of any unobserved third variables Grossman, The association between education and health is clearly bidirectional.

Education outcomes are substantially affected by health Cutler and Lleras-Muney, Students living in community conditions that contribute to hunger, chronic stress, or lack of attention to visual or hearing needs are likely to have problems concentrating in class Evans and Schamberg, Unmanaged health conditions e. In short, health issues are much more than minor distractions in the lives of students, especially students living in low-income communities. Census estimates Ryan and Bauman, Despite this overall progress, the gaps between these groups have remained the same for some and increased for others.

Furthermore, there has been little to no progress in closing the gap of achievement between whites and African Americans Ryan and Bauman, A recent study of school trends conducted by the U. Government Accountability Office GAO found that there has been a large increase in schools that are distinguished by the poverty and race of their student bodies GAO, The percent of K—12 schools with students who are poor and are mostly African American or Hispanic grew from 9 percent to 16 percent from to These schools were the most racially.

Moreover, compared with other schools, these schools offered disproportionately fewer math, science, and college preparatory courses and had disproportionately higher rates of students who were held back in 9th grade, suspended, or expelled GAO, The evidence suggests that disparities in education are apparent early in the life course, which reflects broader societal inequities Garcia, In education, these early disparities are evidenced by wide gaps in vocabulary between children from low-income and those from middle- or upper-income families.

Children from low-income families may have fewer words in their vocabulary by age 3, a gap that grows to as many as 4, words by age 7 Christ and Wang, These word gaps directly affect literacy levels and reading achievement Marulis and Neuman, There is substantial evidence that children who do not read at grade level by 7 or 8 years of age are much more likely to struggle academically Chall et al. Both high school graduation rates and participation in postsecondary education opportunities are correlated with early literacy levels. Hence, attention to and investments in early childhood education are generally viewed as an important way to reduce disparities in education Barnett, Although the association between education and health is clear, the mechanisms by which educational attainment might improve health are not so clearly understood.

A keen understanding of the mechanisms could help to inform the most cost-effective and targeted policies or solutions that seek to improve health and, ultimately, promote health equity Picker, Egerter et al. The three major pathways are the following:. In this framework, note that educational attainment is a predictor of health and can either improve or hinder health outcomes depending on. This suggests that policies and practices proven to increase academic performance and reduce education disparities are important to reducing health disparities.

See Box for an example of a community school working to improve educational outcomes. Intervening early is generally considered a high-impact strategy Barnett, However, interventions that support academic achievement in high schools and in postsecondary settings are also important to increasing educational attainment Balfanz et al.

One of the key factors in both high school and college completion rates has to do with how well students transition from one level of the education system to another Rosenbaum and Person, Income can be defined broadly as the amount of money earned in a single year from employment, government assistance, retirement and pension payments, and interest or dividends from investments or other assets Davis et al.

Income can fluctuate greatly from year to year depending on life stage and employment status. Wealth, or economic assets accumulated over time, is calculated by subtracting outstanding debts and liabilities from the cash value of currently owned assets—such as houses, land, cars, savings accounts, pension plans, stocks and other financial investments, and businesses. Moreover, wealth has an intergenerational component, which can have implications for who has access to wealth and who does not De Nardi, Access to financial resources, be it income or wealth, affects health by buffering individuals against the financial threat of large medical bills while also facilitating access to health-promoting resources such as access to healthy neighborhoods, homes, land uses, and parks Davis et al.

Income can predict a number of health outcomes and indicators, such as life expectancy, infant mortality, asthma, heart conditions, obesity, and many others Woolf et al. Income inequality is rising in the United States at a rate that is among the highest in the economically developed countries in the north OECD, The past few decades have seen dramatic rises in income inequality.

In , 17 percent of families lived in upper-income areas, 65 percent in middle-income areas, and 19 percent in lowest-income areas; in , 30 percent of families lived in upper-income areas, 41 percent in middle-income areas, and 30 percent in lowest-income areas Reardon and Bischoff, In , the top 10 percent of workers earned an average income 19 times that of the average income earned by the bottom 10 percent of workers; in the s and s, this ratio was Furthermore, households earning in the bottom 10 percent have not benefited from overall increases in household income over the past few decades; the average inflation-adjusted income for this population was 3.

Disparities in life expectancy gains have also increased alongside the rise in income inequality. From to , life expectancy for the top 5 percent of income earners rose by about 3 years while life expectancy for the bottom 5 percent of income earners saw no increase Chetty et al. Not only are income and wealth determinants of health, but the concentration of poverty in certain neighborhoods is important to recognize as a factor that shapes the conditions in which people live. Concentrated poverty , measured by the proportion of people in a given geographic area living in poverty, can be used to describe areas e.

Concentrated poverty disproportionately affects racial and ethnic minorities across all of the social determinants of health. For example, National Equity Atlas data reveal that in about half of the largest cities in the United States, most African American and Hispanic students attend schools where at least 75 percent of all students qualify as poor or low-income under federal guidelines Boschma, Given that concentrated poverty is tightly correlated with gaps in educational achievement, this has implications for educational outcomes and health Boschma and Brownstein, In , of the 12 million full-time low-income workers between the ages of 25 and 64, 56 percent were racial and ethnic minorities Ross, b.

Regional percentages varied from 23 percent in Honolulu, Hawaii, to 65 percent in Brownsville, Texas Ross, a. Figure shows the proportion of low-income workers of racial and ethnic minority groups across different regions of the United States. The burden faced by low-income people suggests that efforts to advance health equity through income and wealth will need to take into consideration rising income inequality as well as significant geographic variation.

Chetty and colleagues published the largest study of its kind, using 1. The gap in life expectancy for the richest and poorest 1 percent of individuals was A novel contribution of the study is its examination of the income—longevity relationship. In certain local areas, the effect of being at the bottom of the income gradient is more pronounced than in others, with four- to five-fold differences.

This strong local component reinforces the notion suggested by the literature that place matters. Trends in life expectancy also varied geographically, with some areas experiencing improvements and others declines. Others have commented on the limitations of the study Deaton, ; McGinnis, ; Woolf and Purnell, Zonderman et al. They found that while African American men below poverty status had 2. Both African American women and white women living below poverty status were at an increased mortality risk relative to those living above poverty status Zonderman et al.

Infant mortality rates in the United States rank among the highest for developed nations NRC and IOM, , and mortality rates for infants born to low-income mothers are even higher. Studies have shown an inverse correlation between family income and infant mortality Singh and Yu, as well as a positive correlation between income inequality measured with the Gini coefficient and infant mortality Olson et al.

Infants born to low-income mothers have the highest rates of low birth weight Blumenshine et al. Chronic diseases are more prevalent among low-income people than among the overall U. Low-income adults have higher rates of heart disease, diabetes, stroke, and other diseases and conditions relative to adults earning higher levels of income Woolf et al. Researchers have offered various hypotheses about the multiple mechanisms by which income can affect health.

Woolf et al. This is the convergence among populations with low socioeconomic status of multiple physical and psychosocial risk factors such as poor housing and neighborhood quality, pollutants and toxins, crowding. Wealth affects health through mechanisms that are not necessarily monetary, such as power and prestige, attitudes and behavior, and social capital Pollack et al. Even in the absence of income, wealth can provide resources and a safety net that is not available to those without it.

See Box for an example of an initiative seeking to build income and wealth in communities around the country. Employment is the level or absence of adequate participation in a job or workforce, including the range of occupation, unemployment, and underemployment. Work influences health not only by exposing employees to certain physical environments but also by providing a setting where healthy activities and behaviors can be promoted An et al. For most adults, employment is the main source of income, thus providing access to homes, neighborhoods, and other conditions or services that promote health.

The features of a worksite, the nature of the work, the amount of earnings or income, and how the work is organized can affect worker mental and physical health An et al. Many Americans also obtain health insurance through their workplace, accounting for another potential impact on health and wellbeing.

Not only that, but a healthy workforce is a prerequisite for economic success in any industry Doyle et al. The existing literature on the social determinants of health makes it clear that there is a positive correlation between SES and health Adler and Stewart, a ; Braveman et al. Occupational status can be indicative of the types of tangible benefits, hazards, income, fringe benefits, degree of control over work, and level of exposure to harmful physical environments associated with a job Clougherty et al.

While the mechanisms by which occupational status influences health have not clearly been delineated, there is evidence that the type of job does affect such health outcomes as hypertension risk and obesity An et al. On the other end of the spectrum, unemployment is associated with poor psychological well-being McKee-Ryan et al. Zhang and Bhavsar examined the literature to illuminate the causality, effect size, and moderating factors of the relationship between unemployment as a risk factor and mental illness as an outcome. The authors reported that unemployment does precede mental illness, but more research is required to determine the effect size Zhang and Bhavsar, There is also evidence to suggest that emerging adults who are unemployed are three times as likely to suffer from depression as their employed counterparts McGee and Thompson, Burgard and colleagues found that even after controlling for significant social background factors e.

Employment data show disparities in unemployment rates across various racial and ethnic groups and geographic regions, despite the overall progress that has been made in reducing unemployment nationally Wilson, During the fourth quarter of , the highest state-level unemployment rate was Figure shows how disparities in unemployment by race and ethnicity have persisted for more than 40 years, with the exception of whites and Asians.

Disparities in employment between African Americans and whites persist even when level of education, a major predictor of employment, is held equal between the two groups Buffie, Among the employed, there are systematic differences in wages and earnings by race, ethnicity, and gender. According to the U. These disparities are consistent across almost all occupational groups. As with income, the distribution of occupations tends to differ across racial and ethnic groups see Figure Whereas half of Asians worked in management, professional, and related occupations in , only The literature suggests that there are three potential mechanisms through which employment affects health:.

The nature of work and the conditions of a workplace can increase the risk of injury or illness depending on the type of job. For employees in specific sectors e. This is especially true for operators, laborers, fabricators, and laborers An et al. Occupational health can also be shaped by the physical nature of the tasks involved in a given work setting. For example, the health impact of a job that requires intense, laborious physical activity will be different than of a job in which the tasks are primarily sedentary.

There is also emerging evidence suggesting that women working hourly jobs bear a larger burden due to hazardous conditions in the workplace than their male counterparts on outcomes such as hypertension, the risk of injury, injury severity, rates of absenteeism, and the time to return to work after illness Clougherty et al.

The factors that make up this pathway can include work schedules, commute to work, degree of control in work, the balance between effort and rewards, organizational justice, social support at work, and gender and racial discrimination An et al. Longer commute times specifically affect low-income populations, as the cost burden of commuting for the working poor is much higher than for other workers and makes up a larger portion of their household budgets Roberto, The resources and opportunities associated with work can have lasting implications for health.

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Higher-paying jobs are more likely than lower-paying jobs to provide workers with safe work environments and offer benefits such as health insurance, workplace health promotion programs, and sick leave An et al. Box briefly describes a program. Health care is arguably the most well-known determinant of health, and it is traditionally the area where efforts to improve health have been focused Heiman and Artiga, The idea is to promote access to effective and affordable care that is also culturally and linguistically appropriate.

Health care spans a wide range of services, including preventative care, chronic disease management, emergency services, mental health services, dental care, and, more recently, the promotion of community services and conditions that promote health over the lifespan. Although screening, disease management, and clinical care play an integral role in health outcomes, social and economic factors contribute to health outcomes almost twice as much as clinical care does Heiman and Artiga, ; Hood et al. For example, by some estimates, social and environmental factors proportionally contribute to the risk of premature death twice as much as health care does Heiman and Artiga, ; McGinnis et al.

That being said, in March , the Institute of Medicine released a report that demonstrated that even in the face of equal access to health care, minority groups suffer differences in quality of health. The noted differences were lumped into the categories of patient preferences and clinical appropriateness, the ecology of health systems and discrimination, bias, and stereotyping IOM and NRC, Our health systems are working to better understand and address these differences and appreciate the importance of moving beyond individualized care to care that affects families, communities, and populations Derose et al.

This new focus on improving the health of populations has been accompanied by a welcome shift from siloed care to a health care structure that is interprofessional, multisectoral and considers social, economic, structural and other barriers to health NASEM, Arriving at the place of shared understanding concerning the health care needs of individuals, families, and communities has required taking a broader look at health. The triple aim, a framework that aims to optimize health system performance, has helped conceptualize this look, bringing to the forefront the elements that matter most, considering per capita cost, improving the health care experience for patients, and focusing on population health Stiefel and Nolan, In addition to helping create new health care opportunities, the Patient Protection and Affordable Care Act.

ACA has helped mitigate the challenge of access to care. Centers for Disease Control and Prevention CDC , the proportion of people in without health insurance had dropped below 10 percent Cohen et al. Continuing the momentum of improving access to culturally competent and linguistically appropriate care will be a crucial step to improving the health of populations. Culturally and linguistically appropriate care includes high-quality care and clear communication regardless of socioeconomic or cultural background Betancourt and Green, There is limited research studying whether there is a link between culturally appropriate care and health outcomes, but data do exist that indicate that behavioral and attitudinal elements of cultural competence facilitate higher-quality relationships between physicians and patients Paez et al.

Continued work is needed to figure out how to translate increased access to care into improved health outcomes and increased health equity. Social determinants of health are woven through these action areas. In fact, research shows that social determinants of health play a larger role in health outcomes than do medical advances Hood et al. While some disparities in access to care have been narrowing, gaps persist among certain groups of the population. For example, the gaps in insurance that existed between poor and nonpoor households and between African Americans and whites or Hispanics and whites decreased.

This is especially true for chronic conditions that require long-term engagement with the health care system. However, systematic differences in access to care still exist and negatively affect poor households and racial and ethnic minority groups, including Hispanics and African Americans NCHS, see Figure In fact, in people living below the federal poverty level had worse access to care than people in high-income households across all access measures 8 NCHS, People living in low-income households are at an elevated risk of poor health, and access to care is vital for this vulnerable population.

The ACA authorized states to expand Medicaid coverage to adults with low incomes up to percent of the poverty level. From to , the percent of adults who were uninsured declined in all states, with the decline in the number of uninsured being greater in the states that opted to expand their Medicaid programs NCHS, Racial and ethnic disparities in mental health services exist as well.

Members of racial and ethnic minority groups are less likely than whites to receive necessary mental health care and more likely to receive poor-quality care when treated. Specifically, minority patients are less likely than whites to receive the best available treatments for depression and anxiety McGuire and Miranda, Among the barriers to access to care, the. The health care system has an important role to play in addressing the social determinants of health.

At the community level, it can partner with community-based organizations and explore locally based interventions Heiman and Artiga, , creating payment models that take into account social determinants and implementing service delivery models that lend themselves to more community engagement and intervention. Health care systems can center equity by involving the community in decision making, allocating resources to act on the determinants of health in mind, and increasing community-based spending Baum et al. Communities can be viewed as places of change for health systems, allowing for work both at micro and macro levels.

See Box for an example of a community-based health system. Cost-effective interventions to reduce health disparities and promote health equity should be recognized and explored, including attention to the structural barriers that affect access to health services. Housing, as a social determinant of health, refers to the availability or lack of availability of high-quality, safe, and affordable housing for residents at varying income levels. Housing also encompasses the density within a housing unit and within a geographic area, as well as the overall level of segregation and diversity in an area based on racial and ethnic classifications or SES.

Housing affects health because of the physical conditions within homes e. The Center for Housing Policy has outlined 10 hypotheses on how affordable housing can support health improvement Maqbool et al. These range from affordable housing freeing up resources for better nutrition and health care spending to stable housing reducing stress and the likelihood of poor health outcomes e. There is substantive evidence that the physical conditions in homes are important contributors to health outcomes Cox et al. The World Health Organization WHO assessed the evidence in and found that sufficient evidence was available to estimate the burden of disease for physical factors, such as temperature extremes; chemical factors, such as environmental tobacco smoke and lead; biological factors, such as mold and dust mites; and building factors associated.

Since research has added to the areas where the WHO found some, but not sufficient, evidence to estimate the burden of disease, including more clarity on the relationship between rodent allergens and asthma Ahluwalia et al. Data from the National Health and Nutrition Examination Survey show a decrease in blood lead levels between and , with a steep drop between and , probably due to lead being phased out of gasoline, and later a more gradual decrease, perhaps due to a reduction in the use of lead-based paint in housing Jacobs et al.

Conditions in multiunit residential buildings, including whether indoor smoking is permitted, are another dimension of housing that can affect health outcomes. Box Neighborhoods matter for a number of reasons, including their influence on physical safety and access to opportunity. The U. Housing authorities. Families chosen for the experimental group receive tenant-based Section 8 rental assistance that helps pay their rent, as well as housing counseling to help them find and successfully use housing in low-poverty areas.

Two control groups are included to test the effects of the program: one group already receiving Section 8 assistance and another just coming into the Section 8 program. HUD, n. For homeless people, a lack of stable housing contributes to disparities in the social determinants. In addition to having direct ties with lack of employment and income, a lack of housing is also associated with greater barriers to education, lower levels of food security, and reduced public safety.

Compared to the overall population, homeless people have shorter life expectancies, which are attributable to higher rates of substance abuse, infectious disease, and violence Baggett et al. Infectious diseases—including HIV, tuberculosis, and heart disease—have all been linked to shorter life expectancies among homeless people Fazel et al. Other studies have found drug overdose, cancer, and heart disease to be the greatest causes of death among the homeless, with greater barriers to and lower rates of screening, diagnosis, and treatment as contributing factors Baggett et al.

Neighborhoods generally change slowly, but urban neighborhoods are seeing dramatic shifts in demographics and property value and over time are becoming more segregated by income Zuk et al. Gentrification—the process of renewal and rebuilding, which precedes the influx of new, more affluent residents—is a trend that is being observed in urban centers around the country McKinnish et al.

While the literature linking the process of gentrification to health outcomes is not definitive, there is substantial evidence that connects displacement and health outcomes Zuk et al. Displacement can occur as a direct result of a policy or program Freeman and Braconi, , because of recent development and property value increases in an area, or as a result of exclusion from a property for various reasons Levy et al. Displacement has major implications for housing, other social determinants, and the health of communities. According to the CDC, displacement exacerbates health disparities by limiting access to healthy housing, healthy food options, transportation, quality schools, bicycle and walk paths, exercise facilities, and social networks CDC, Displacement can result in financial hardship, reducing disposable income for essential goods and services.

This can have a negative impact on the health of the displaced population, with income being a significant determinant of health CDC, The physical environment reflects the place, including the human-made physical components, design, permitted use of space, and the natural environment. Specific features of the physical or built environment include, but are not limited to, parks and open space, what is sold and how it is promoted, how a place looks and feels, air, water, soil, and arts and cultural expression Davis et al.

All of these physical factors shape the safety, accessibility, and livability of any locale, thus providing the context in which people live, learn, work, and play. This has direct implications for health. The physical environment contributes to 10 percent of health outcomes Remington et al. Additionally, 40 percent of health outcomes depend on social and economic factors, which are intricately tied to the features of the physical environment Remington et al.

Inequities observed between the different physical environments of states, towns, and neighborhoods contribute to disparate health outcomes among their populations. Exposure to a harmful physical environment is a well-documented threat to community health. Such threats include environmental exposures such as lead, particulate matter, proximity to toxic sites, water contamination, air pollution, and more—all of which are known to increase the incidence of respiratory diseases, various types of cancer, and negative birth outcomes and to decrease life expectancy Wigle et al.

Low-income communities and communities of color have an elevated risk of exposure to environmental hazards Evans and Kantrowitz, Emerging considerations for low-income communities include the resulting gentrification and potential displacement of families when neighborhoods undergo revitalization that is driven by environmental clean-up efforts Anguelovski, Access to green space has been demonstrated to positively affect health in many contexts.

Such green space includes both parks and observable greenery. Living in the presence of more green space is associated with a reduced risk of mortality Villeneuve et al. Nature has been shown to relieve stress and refocus the mind. Spending time in parks has been shown to improve mental health Cohen et al. Beyond their benefits to mental health and reductions in stress, parks provide opportunities for increased physical activity. Local parks departments manage more than , outdoor public park facilities across the nation, many of them containing open space, jogging paths, and exercise equipment Cohen et al.

According to Cohen et al. Individuals who are not as physically active face a greater risk of heart disease, diabetes, and cancer James et al. In fact, about 9 percent of premature deaths in the United States are attributable to inactivity Lee et al. The usage of neighborhood parks and the associated health benefits are not equally distributed across communities.

Research shows that recreational facilities are much less common in low-income and minority communities, though parks are more evenly distributed Diez Roux et al. Moreover, the size and quality of park facilities vary based on race and income Abercrombie et al. Accordingly, in low-income communities, residents are less likely to use parks Cohen et al. Beyond race and income, other disparities exist in park use.

While seniors represent 20 percent of the population, they account for only 4 percent of park users Cohen et al. In communities described as food deserts, there is limited access to affordable and quality food. When there are fewer supermarkets, fruit and vegetable intake is lower, and prices are higher Powell et al. This makes achieving a healthy diet difficult for local residents. Research indicates that a poor diet is associated with the development of cancer, diabetes, hypertension, birth defects, and heart disease Willett et al. The distribution of supermarkets is not equitable in the United States.

Neighborhoods housing residents of lower socioeconomic status often have fewer supermarkets. Discrepancies also exist between racial and ethnic groups Powell et al. Underserved communities turn to small grocery or corner stores to serve their food needs, but these businesses rarely provide the healthy selection offered by larger supermarkets. Moreover, food is most often higher priced in such stores. Access to and the density of alcohol outlets are also associated with health outcomes in communities. In local areas where liquor store density is higher, alcohol consumption rates in the community are also higher Pereiram et al.

Alcoholism has been linked to diseases such as cancer, anemia, and mental illnesses. Moreover, alcohol outlets can serve as nuisance businesses, with their clientele bothering others in the neighborhood, decreasing the sense of security, and detracting from social cohesion.

There is also evidence that links high-density alcohol outlet areas with higher rates of crime and substance use. In urban environments, a higher concentration of liquor stores is found in low-income, African American, and Hispanic communities, contributing to an elevated risk of alcohol-associated disorders in these neighborhoods Berke et al. Climate change has become a public health concern Wang and Horton, There is a growing recognition that the physical environment is undergoing changes caused by human activity, such as through the production of greenhouse gases IPCC, Human health is intricately linked to the places where we live, learn, work, and play.

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The air we breathe, the surrounding temperature, the availability of food, and whether there is access to clean water are all important ingredients to a healthy life, and the changing climate will affect all of these areas Luber et al. Not only do polluting emissions make air quality worse in the short term, but climate change itself will worsen air quality.

Poor air quality exacerbates previous health conditions such as asthma and chronic obstructive pulmonary disease, and air pollution is associated with cardiovascular disease and many other illnesses. The changing climate is also causing a shift in seasons, which can affect pollen production and therefore seasonal allergies. Overall, with the changing climate there will be more extreme weather events such as increasing drought, vulnerability to wildfires, floods, hurricanes, and winter storms—all with subsequent health impacts from displacement, stress, or primary physical harm.

The changing temperature is even having an impact on infectious diseases. New infectious diseases that spread via a vector, such as a tick or. There is also a risk for an increase in food-related and waterborne illness caused by the changing temperatures and the survival of various infectious agents. Food insecurity, which is already a challenge in many locations, is at risk of worsening due to higher food prices, poorer nutritional content, and new challenges with distribution.

Although climate change will affect everyone, certain communities and groups will be more vulnerable to these effects. People with preexisting medical conditions, children, elderly populations, and low-income groups are at increased risk for poor outcomes. Existing health disparities that are due to social, economic, and environmental factors have the potential to be even more affected by climate change.

However, climate change also presents a significant opportunity. Given the existential threat to humanity, there is now a great deal of momentum to mitigate and adapt to climate change. Companies are pursuing new business opportunities, governments are forming international agreements, and policies are being implemented at the national, sub-national, state, regional, and local levels to affect change.

Many of these policies to adapt to and mitigate climate change are also the key components in creating healthier, more equitable, and resilient communities. There are many co-benefits, and the policies, if implemented correctly, have the potential to significantly improve health outcomes and reduce health disparities Rudolph et al. Examples of climate change mitigation and adaptation policies with co-benefits to build healthier, more equitable places include. Climate change will affect the physical environment in unprecedented ways.

To mitigate and adapt to climate change will require multi-sector collaboration and approaches to effect systems change. Many of the same. In the social determinants of health literature, transportation is typically discussed as a feature of the physical or built environment TRB and IOM, This report highlights transportation as a separate determinant of health because of its multifaceted nature: pollution and. Transportation consists of the network, services, and infrastructure necessary to provide residents with the means to get from one place to another Davis et al.

If designed and maintained properly, transportation facilitates safe mobility and is accessible to all residents, regardless of geographic location, age, or disability status. However, current research suggests that transportation costs are a barrier to mobility for households in poverty, which are disproportionately represented by African. Long commute times and high transportation costs are significant barriers to employment and financial stability Roberto, Brookings researchers have concluded, based on analyses of census data, that the suburbanization of poverty is disproportionately affecting proximity to jobs for poor and minority populations as compared with their nonpoor and white peers Kneebone and Holmes, ; Zimmerman et al.

Transportation presents unevenly distributed negative externalities, including air pollution, noise, and motor vehicle—related injuries and deaths that are more prevalent in low-income and minority communities with poor infrastructure Bell and Cohen, ; US DOT, Low-income and minority populations are more likely to live near environmental hazards, including transportation-related sources of pollution and toxic emissions such as roadways, bus depots, and ports McConville, ; NEJAC, ; Perez et al.

Active transportation—the promotion of walking and cycling for transportation complemented by public transportation or any other active mode—is a form of transportation that reduces environmental barriers to physical activity and can improve health outcomes Besser and Dannenberg, ; Dannenberg et al. Since the midth century, road design and transportation planning have centered on the automobile, with multiple and interconnected consequences for health and equity IOM, The relationship between physical activity and health is well established and was summarized by the U.

Task Force on Community Preventive Services, The evidence on the relationship among active transportation, physical activity, and health has been accumulating more recently. Since then, Pucher et al. CDC has developed a set of transportation recommendations that address all of the facets described above and has also developed a Transportation Health Impact Assessment Toolkit.

Department of Transportation DOT have also developed a Transportation and Health Tool to share indicator data on transportation and health. There have been multiple national initiatives in the past two to three decades aiming to improve livability and sustainability in places across the United States, and transportation equity is a mainstay of much of this work. See Box for an example of a regional transportation planning agency that seeks to improve access to transportation. Environmental Protection Agency in to help U. How the social environment is conceptualized varies depending on the source Barnett and Casper, ; Healthy People , For the purposes of this report, the social environment can be thought of as reflecting the individuals, families, businesses, and organizations within a community; the interactions among them; and norms and culture.

It can include social networks, capital, cohesion, trust, participation, and willingness to act for the common good in relation to health. Social cohesion refers to the extent of connectedness and solidarity among groups in a community, while social capital is defined as the features of social structures e. A systematic review found associations between trust as an indicator of social cohesion and better physical health, especially with respect to self-rated health.

Furthermore, it revealed a pattern in which the association between social capital and better health outcomes was especially salient in inegalitarian countries i. The social environment in a community is often measured as it relates to mental health outcomes. For example, social connections between neighbors i. Factors such as exposure to violence, hazardous conditions, and residential instability are all associated with depression and depressive symptoms Diez Roux and Mair, It is important to note that high levels of social capital and a strong presence of social networks are not necessarily guarantors of a healthy community.

In fact, they can be sources of strain as well as support Pearce and Smith, Some studies explore the potential drawbacks of social capital, such as the contagion of high-risk behaviors e. McNeill et al. The social environment interacts with features of the physical environment at the neighborhood level to shape health behaviors, stress, and, ultimately, health outcomes Diez Roux and Mair, For example, a built environment that is poor in quality i.

Other research points to the role of physical activity as a potential pathway by which the social environment affects health outcomes such as obesity Suglia et al. At the community level, an important element of the social environment that can mediate health outcomes is the presence of neighborhood stressors. While the occurrence of stress is a daily facet of life that all people experience, chronic or toxic stress, in which the burden of stress accumulates, is a factor in the expression of disease McEwen, Stressful experiences are particularly critical during early stages of life, as evidenced by the adverse childhood experiences study Felitti et al.

For low-income communities, stressors are salient because of the lack of resources, the presence of environmental hazards, unemployment, and exposure to violence, among other factors McEwen, ; Steptoe and Feldman, See Box for an example of a community working to combat these stressors. This applies as well to children in low-income households, who are more likely to experience multiple stressors that can harm health and development Evans and Kim, , mediated by chronic stress Evans et al. Chronic stress due to adverse neighborhood and family conditions has been linked to the academic achievement gap, in which children living in poverty fall behind those in better-resourced neighborhoods Evans et al.

Furthermore, stress and poor health in childhood are associated with decreased cognitive development, increased tobacco and drug use, and a higher risk of cardiovascular disease, diabetes, depression, and other conditions County Health Rankings, Public safety and violence are significant, intertwined social determinants of health, but they are also each significant indicators of health and community well-being in their own right.

Public safety refers to the safety and protection of the public, and it is often characterized as the absence of violence in public settings Davis et al. Since the late s, homicide and suicide another form of violence have consistently ranked among the top leading causes of death in the United States Dahlberg and Mercy, Violent victimization affects health by causing psychological and physical injury, which can lead to disability and, in some cases, premature death. Beyond the risk of injury and death, violent victimization also has far-reaching health consequences for individuals, families, and neighborhoods.

Furthermore, research shows that simply being exposed. Violent victimization and exposure to violence have been linked to poor health outcomes, including chronic diseases e. There is also research that indicates a link between neighborhood crime rates and adverse birth outcomes such as preterm birth and low birth weight Egerter et al.

Violence and the fear of violence can negatively affect other social determinants that further undermine community health.

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Violence rates can lead to population loss, decreased property values and investments in the built environment, increased health care costs, and the disruption of the provision of social services Massetti and Vivolo, ; Velez et al. In addition, violence in communities is associated with reduced engagement in behaviors that are known to promote health, such as physical activity and park use Cohen et al.

The perception of safety is a key indicator of violence in a community that is associated with health. For example, people who describe their neighborhoods as not safe are almost three times more likely to be physically inactive than those who describe their neighborhood as extremely safe Prevention Institute, The perception of safety is also important for mental health. There is research that suggests that perceived danger and the fear of violence can influence stress, substance use, anger, anxiety, and feelings of insecurity—all of which compromise the psychological well-being of a community Moiduddin and Massey, ; Perkins and Taylor, At the community level, fear of crime and violence can undermine social organization, social cohesion, and civic participation—all key elements in a social environment that is conducive to optimal health Perkins and Taylor, Low perception of safety can also undermine the efforts of a community to improve the built environment through the availability of parks and open space to promote physical activity Cohen et al.

Violence is not a phenomenon that affects all communities equally, nor is it distributed randomly. The widespread disparity in the occurrence of violence is a major facet of health inequity in the United States. Low-income communities are disproportionately affected by violence and by the many effects that it can have on physical and mental well-being.

The conditions of low-income communities concentrated poverty, low housing values, and high schools with low graduation rates among others , foster violence and put residents at an increased risk of death from homicide Prevention Institute, This holds true for other types of violence as well.

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Living in poor U. Criminologists attribute the disparities in neighborhood violence not to the kinds of people living in certain neighborhoods but to the vast differences in social and economic conditions that characterize communities in the United States. This is because there are specific racial and ethnic groups, such as African Americans, Hispanics, and Native Americans, who are vastly overrepresented.

Residential segregation, which has been perpetuated by discriminatory housing and mortgage market practices, affects the quality of neighborhoods by increasing poverty, poor housing conditions, and social disorder and by limiting economic opportunity for residents Prevention Institute, As a result of the racial—spatial divide in community conditions, the violent crime rate in majority nonwhite neighborhoods is two to five times higher than in majority white neighborhoods.

This is especially true for youth of color, particularly males. Overall homicide rates among to year-old African American males African American males 15 to 19 years old are six times as likely to be homicide victims as their white peers Prevention Institute, More specifically, African American males ages 15 to 19 are almost four times as likely to be victims of firearm-related homicides as white males Prevention Institute, In terms of exposure to violence, African American and Hispanic youth are more likely to be exposed to shootings, riots, domestic violence, and murder than their white counterparts Prevention Institute, This has major implications for trauma in communities that are predominantly African American or Hispanic.

Native American communities also suffer from a disproportionately high violent crime rate that is two to three times higher than the national average Prevention Institute, Box briefly describes a public health—oriented model to address violence in communities. Child abuse and neglect are two important measures of community violence that can affect physical and mental health.

The Institute of Medicine and the National Research Council published a report that cited abuse and neglect during childhood as a contributor to the following health-related outcomes: problems with growth and motor development, lower self-reported health, gastrointestinal symptoms, obesity, delinquency and violence, and alcohol abuse IOM and NRC, In , Felitti and colleagues published a pivotal study which demonstrated a link between adverse childhood experiences and the leading causes of death in adults at the time.

The authors found a strong, graded association between the amount of exposure to abuse or household dysfunction and multiple risk factors e. Child abuse and neglect not only affect health directly, they also affect outcomes within the other social determinants of health, such as education, work, and social relationships IOM and NRC, While the overall rates of child maltreatment have been declining since , rates are still much higher for African American Child abuse and neglect are often accompanied by family stressors and other forms of family violence IOM and NRC, As discussed above, the conditions of concentrated poverty in a neighborhood are associated with violence incidence.

According to the Prevention Institute, the higher the percentage of families living below the federal poverty level in a neighborhood, the higher the rate of child maltreatment Prevention Institute, Hate crimes, which may or may not involve physical violence, are often motivated by some bias against a perceived characteristic. Among hate crimes motivated by bias toward a particular ethnicity in , almost 48 percent of the victims were targeted because of anti-Hispanic bias UCR, As is the case with other types of violence, exposure to hate crime violence can have pernicious effects on health.

For lesbian, gay, bisexual, and transgender LGBT persons specifically, exposure to hate crimes at the community level has been linked to increased rates of suicide among youth, marijuana use, and all-cause mortality Duncan and Hatzenbuehler, ; Duncan et al. Discrimination in general, which by definition is the driving factor behind the perpetration of hate crimes, has been shown to affect the health of individuals and communities.

Whether it be perceived discrimination in everyday encounters or systemic discrimination in housing policies, this type of unequal treatment has been associated with major depression, psychological distress, stress, increased pregnancy risk, mortality, hypertension, and more health-related outcomes Dolezsar et al. The criminal justice system is a key actor, setting, and driver of public safety as it relates to health equity.

The past 40—50 years have seen a large-scale expansion of incarceration, which has had lasting effects on families and communities Cloud, ; Drake, This expansion has affected racial and ethnic minority groups, and particularly men Drake, Research suggests that disproportionately more Hispanics and African Americans are confined in jails and prisons than would be predicted by their arrest rates and that Hispanic and African American juveniles are more likely than white juveniles to be referred to adult court rather than juvenile court Harris, When those who were formerly incarcerated are released back into their communities, successful reentry is hindered by a number of obstacles, such as stigma, limited employment and housing opportunities, and the lack of a cohesive social network Lyons and Pettit, All of these factors are vital to achieving optimal health, and for communities with high rates of incarceration, the absence of these opportunities can lead to a diminished capacity to combat crime and mobilize for resources Clear, It is important to examine the patterns and effects of mass incarceration because it not only affects the health of incarcerated populations but also has a detrimental effect on multiple determinants of health in communities.

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Mass incarceration has contributed to the breakdown of educational opportunities, family structures, economic mobility, housing options, and neighborhood cohesion, especially in low-income communities of color Cloud, Neal and Rick examined U. Census data from. In addition, communities with high levels of incarceration have higher rates of lifetime major depressive disorder and generalized anxiety disorder Hatzenbuehler et al. Wildeman estimated the effects of incarceration on population-level infant mortality rates, and his findings suggest that if incarceration rates remained the same as they were in , the infant mortality rate in would have been 7.

A keen understanding of the precise mechanisms by which incarceration affects the health of specific populations and contributes to health inequity is needed to reduce disparities in key health outcomes such as infant mortality. The root causes of health inequity begin with historical and contemporary inequities that have been shaped by institutional and societal structures, policies, and norms in the United States.

As discussed in this chapter, these deeply rooted inequities have shaped inequitable experiences of the social and other determinants of health: education, income and wealth, employment, health systems and services, housing, the physical environment, transportation, the social environment, and public safety. Conclusion Based on its review of the evidence, the committee concludes that health inequities are the result of more than individual choice or random occurrence.

They are the result of the historic and ongoing interplay of inequitable structures, policies, and norms that shape lives. These structures, policies, and norms—such as segregation, redlining and foreclosure, and implicit bias—play out on the terrain of the social, economic, environmental, and cultural determinants of health. The current public health interest in the role of place, including communities, stems from significant empirical epidemiological evidence.

As discussed in this chapter, there are a range of factors that contribute to health and that need to be more extensively studied. These include factors beyond the individual domain, such as living and working conditions and economic policies at the local, state, and national levels that are. This recognition that inequities in social arrangements and community factors shape life opportunities is not new; it was asserted as early as by W. Du Bois in his address regarding the role of social status and life conditions in shaping health and inequities.

Despite the increasingly widespread recognition in the field, many public health efforts continue to target individuals and are most often disease specific. Building the science base for how to move upstream to improve population health has begun. While our understanding of the role of the social determinants of health, including features of the physical and social environments, has greatly improved over the last several decades, the scientific progress has not been so great on how, when, and where to intervene. Progress on how to move upstream in taking action has developed much more slowly than progress in the ability to describe the role of context and community-level factors that shape the major causes of morbidity, mortality, and well-being Amaro, Improving the science of population health interventions, place-based approaches, and strategies to improve health equity will require a workforce of scientists and practitioners equipped to develop the requisite knowledge base and practice tools.

Specifically, models for the training of population and place-based scientists and practitioners are needed to develop the research required to guide upstream approaches—including place-based interventions—that will address the contextual factors that shape major public health problems such as obesity, interpersonal violence, infant and maternal health, cardiovascular diseases, infectious diseases, substance abuse, and mental health disorders. For example, training models such as the interdisciplinary team science McArthur Model described by Adler and Stewart could be expanded to integrate public health practitioners and community leaders alongside research leaders Adler and Stewart, b.

Translating knowledge on the social determinants of health into practice requires at least four essential areas of expertise:. Considering the distinct fields of expertise required for these components and theory, the approaches to intervention and measurement stem from different disciplines and have often been developed without significant interchange. Researchers face significant challenges. Thus, academic institutions involved in the training of population and place-based scientists need to integrate these diverse bodies of knowledge—including theory, methods, and tools from diverse disciplines.

Models for the transdisciplinary training of researchers, practitioners, and community partners are needed. Academic institutions need to develop models for intra-professional workforce training on place-based and community-level implementation science and evaluation that target improving population health and addressing health inequities. See Chapter 7 for more on. The social determinants of health, while interdependent and complex, are made up of mutable factors that shape the conditions in which one lives, learns, works, plays, worships, and ages.

As highlighted in the boxes throughout this chapter, communities around the country are taking it upon themselves to address these conditions. Chapter 4 will discuss why communities are powerful agents of change, along with discussing the conditions necessary for successful and sustainable outcomes.

Chapter 5 will provide an in-depth overview of nine communities that are addressing the root causes of health inequities. Abercrombie, L. Sallis, T. Conway, L. Frank, B. Saelens, and J. Income and racial disparities in access to public parks and private recreation facilities. American Journal of Preventive Medicine 34 1 :9— Acevedo-Garcia, D.

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Educational Psychologist 42 4 — Barnett, E. Barnett, W. Baum, F. Begin, T. Houweling, and S. Changes not for the fainthearted: Reorienting health care systems toward health equity through action on the social. American Journal of Public Health 99 11 — Baum, S. Ma, and K. Education pays: The benefits of higher education for individuals and society. Trends in Higher Education. The College Board. Bearman, P. Suicide and friendships among American adolescents. American Journal of Public Health 94 1 — Bell, J. The transportation prescription: Bold new ideas for healthy, equitable transportation reform in America.

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Chugh, and S. Implicit discrimination. American Economic Review 95 2 — Besser, L. Walking to public transit: Steps to help meet physical activity recommendations.