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Cardiovascular disease (CVD) is the number one cause of death around the globe, now accounting for about one in three deaths.1 More than 80% of these CVD deaths take place in low- and middle-income countries.2 Although mortality from CVD in the United States has been declining since the 1970s, heart disease is still the leading cause of death in America as well, accounting for approximately 31.3% of deaths in 2011.3 The US decline in CVD mortality has been attributed to advances in prevention, diagnosis, and treatment. However, if current trends prevail, the prevalence of CVD in the United States is expected to rise 10% between 2010 and 2030.4 This projected rise in CVD prevalence is attributed to a number of factors: an aging populace, an increase in major risk factors (hypertension, lack of physical activity, obesity, and diabetes), and growing socioeconomic inequality that accentuate the deleterious social determinants of health. Further, the clinical advances made in the diagnosis, treatment, and prevention of CVD have not been equally available to all individuals throughout our society.5 The United States is one of the richest nations in the world and spends more per capita on health care than any other nation, and yet America has one of the shortest life expectancies at birth of any industrialized nation, ranking 27th out of 34 Organization for Economic Cooperation and Development countries.6
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This chapter, unlike preceding chapters that have primarily focused on clinical issues and proximal determinants of CVD, explores the social determinants of CVD that operate at the population level. As the World Health Organization (WHO) Commission on Social Determinants of Health noted in its report, “heart disease is caused not by a lack of coronary care units but by the lives people lead, which are shaped by the environments in which they live.”7 The broader social context in which individuals lead their lives has a major impact on health status and ultimately on longevity. CVD is at heart a “lifestyle” disease, driven by our contemporary way of life, marked as it is by the overconsumption of highly processed foods, little physical activity, obesity, use of tobacco products, and elevated levels of chronic stress. But CVD is also a disease propelled by deeply entrenched social inequalities. Decades of research have yielded a large body of literature that clearly exposes the numerous societal factors that have a profound impact on the development of CVD and significantly contribute to the disparities in health and longevity among various populations and subpopulations. This chapter explores the role that social determinants of health play in driving CVD.
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THE SOCIAL DETERMINANTS OF HEALTH
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WHO defines social determinants of health as “the circumstances in which people grow, live, work, and age, and the systems put in place to deal with illness. The conditions in which people live and die are, in turn, ...