The Structural Truth of Social Determinants

Public health depends on infrastructure, but our soft language obscures what's really driving outcomes.

The way we talk about public health is filled with vague, well-meaning phrases that obscure the hard systems that make it functional.

The term Social Determinants of Health covers things like housing, mobility, and education. But there isn’t anything particularly “social” about them. They’re infrastructure. These are critical, brick-and-mortar systems that require sustained public investment, planning, and maintenance. Yet, instead of treating them like true determinants, with all the causal weight that word implies, we treat them like context. Something to acknowledge but not repair.

These systems shape both our access to direct medical care and the conditions that make it possible to stay well in the first place. They are our collective responsibility, but in most federal and state health frameworks, they are treated as individual risk factors. Calling them “social” blunts the word “determinants,” effectively scrubbing structural accountability.

Most health professionals understand that well-being depends on more than medicine, and it’s not radical to say that health depends on conditions like stable housing, reliable transit, and decent wages. But our terminology doesn’t reflect that reality. That squishy, imprecise vernacular either inadvertently obscures—or conveniently minimizes—the foundational role of infrastructure in both individual and public health.

The term Social Determinants of Health was coined to distinguish non-medical factors that influence health outcomes—things shaped by where and how people live, work, and interact. “Social” was meant to signal that these are shaped by environment and circumstance, not biology or personal behavior alone. But calling them social abstracts the very concrete systems they comprise. It makes them feel intangible and that’s exactly what allows decision-makers to treat them as collateral.

Some scholars (especially in global and equity-focused public health) use the term structural determinants to refer to certain upstream forces such as institutional power, systemic racism, and extractive economics. It’s a more precise term, but also a more uncomfortable one. If we actually treated these as structural determinants, the people who underfund them aren’t just observers; they’re responsible parties.

When structural determinants are named, it’s often the most abstract and immovable ones like racism, colonial legacies, or global inequity. These are unquestionably real forces, but naming only those as structural leaves housing, transit, and education floating in the “social” bucket, as if they’re somehow less systemic or less direct manifestations of those deeper structural inequities. It’s a neat rhetorical trick that protects decision-makers from accountability on both fronts.

Just look at how public health is typically practiced in the United States: We measure collective success by aggregating individual outcomes such as ER visits, missed appointments, and chronic conditions. We design programs to nudge “good” behavior like walking, hydration, and screenings. But we don’t track whether the neighborhood is walkable, whether the water is clean, or whether the clinic is reachable without a car.

This is essentially structural negligence repackaged as personal responsibility. We’re tracking symptoms and softly blaming individuals while the systems that support their agency and well-being fall apart around them.

Hospital systems and health departments spend millions on education campaigns and taxi vouchers, but rarely join advocates calling for sidewalks, school funding, or transit routes. And I’m not even blaming them for it. Their funding structures reward individual outcomes, so it’s no surprise they focus on individual solutions. Individual behavior is also easier to measure and manage. Fixing transit leaves the appointment to chance, whereas a taxi voucher gets someone there with certainty.

The problem is that those solutions don’t last. They’re brittle, expensive, and limited in scale. A voucher solves one ride; a robust, affordable transit system solves thousands.

It’s critical to remember that stable housing, reliable transit, and access to education do much, much more than improve health outcomes; they quietly prevent a whole category of emergencies. These systems are the front-line fix for half the social crises we keep trying to patch on the back end.

It’s the same pattern I wrote about in the abundance piece: we underfund the systems that would prevent harm, then spend exponentially more trying to manage damage after the fact.

Outside of sheer altruism, health institutions have almost no incentive to push for upstream investment in the determinant systems themselves. Public health interventions are mostly downstream—almost a forensic accounting of deferred cost.

But when government fails to invest in basic infrastructure, the cost of that neglect doesn’t vanish. It shows up later, just as ER visits and Medicaid claims, and lead exposure and chronic illness. The cost is shifted off of public budgets and onto the people who can least afford it, as well as the health systems now responsible for keeping them alive.

Instead of ensuring whether people have what they need to be healthy, we track whether they managed to stay healthy anyway.

If we keep measuring public health as just an aggregate of individual outcomes, we’ll keep neglecting the very systems that make health possible at scale.

Because every bus stop is a health intervention. So is every zoning ordinance and eviction moratorium. Every crosswalk, every grocery store, and every fare reduction. We treat these as planning or budgetary decisions, but they are public health choices. They shape who gets to stay well, who gets to recover, and who is left to just eke by.

This is the beginning of a larger argument: we can’t just name the systems that shape health. We have to measure them, fund them, and evaluate their durability the same way we track cholesterol or ER visits.

Until we call the systems what they are, we’ll keep designing solutions that ignore them.