Efforts to improve health in the U.S. have traditionally looked to the health care system as the key driver of health and health outcomes. However, there has been increased recognition that improving health and achieving health equity will require broader approaches that address social, economic, and environmental factors that influence health. This brief provides an overview of these social determinants of health and discusses emerging initiatives to address them. Key Findings Social determinants of health are the conditions in which people are born, grow, live, work and age that shape health. This brief provides an overview of social determinants of health and emerging initiatives to address them. It shows:  Social determinants of health include factors like socioeconomic status, education, neighborhood and physical environment, employment, and social support networks, as well as access to health care. Addressing social determinants of health is important for improving health and reducing longstanding disparities in health and health care. There are a growing number of initiatives to address social determinants of health within and outside of the health care system. Outside of the health care system, initiatives seek to shape policies and practices in non-health sectors in ways that promote health and health equity.Within the health care system, there are multi-payer federal and state initiatives as well as Medicaid-specific initiatives focused on addressing social needs. These include models under the Center for Medicare and Medicaid Innovation, Medicaid delivery system and payment reform initiatives, and options under Medicaid. Managed care plans and providers also are engaged in activities to identify and address social needs. For example, 19 states required Medicaid managed care plans to screen for and/or provide referrals for social needs in 2017, and a recent survey of Medicaid managed care plans found that almost all (91%) responding plans reported activities to address social determinants of health. Many challenges remain to address social determinants of health, and new directions pursued by the Trump Administration could limit resources and initiatives focused on these efforts. The Trump Administration is pursuing a range of new policies and policy changes, including enforcing and expanding work requirements associated with public programs and reducing funding for prevention and public health. These changes may limit

Addiction to tobacco, alcohol, and other drugs inflicts a substantial toll on Americans, measurable in terms of deaths and illnesses, social costs, and economic costs. With approximately 60 million smokers, 14 million dependent on alcohol, and 14 million users of illicit drugs, more than one fourth of Americans over age 15 has a physiological dependence on at least one addictive substance. As a result, nearly 590,000 deaths--about a quarter of all deaths in the United States--are caused by addictive substances: 105,000 from alcohol abuse, 446,000 from tobacco use, and 39,000 from addictive drugs in 1995. The magnitude of addiction's impact on morbidity is also great, causing approximately 40 million illnesses and injuries each year. The economic burden of addiction is estimated at greater than $400 billion every year, including health care costs, lost worker productivity, and crime. Less quantifiable, but equally important, are the social costs to families and communities of addiction. Children of substance-abusing parents are more likely as adults to become plagued by addiction and its related problems. Passive exposure to tobacco smoke affects nonsmokers; drug and alcohol abuse are risk factors for crime and incarceration, family violence, fatal and permanently disabling accidents, birth defects, and divorce. Combined, the effects of tobacco, alcohol, and drugs inflict a greater toll on the health and well-being of Americans than any other single preventable factor.

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A change of strategy was instituted in the West and Central Africa Smallpox Eradication Program in the fall of 1968. High priority was given to eliminating smallpox foci rather than limiting activities to mass vaccination. The progress of the program since September 1968 shows that the change in emphasis resulted in active surveillance activities which discovered more smallpox cases than the official reporting system. All known smallpox outbreaks were investigated in 1969. Vaccination totals did not suffer from the^hange in emphasis. The attack on smallpox foci successfully prevented the expected seasonal increase in 1969 and resulted in an interruption of smallpox transmission throughout West and Central Africa. epidemiology; immunization; preventive health services; smallpox; vaccination 'From the Smallpox Eradication Program, Center for Disease Control,

With the advent of the 21st century, science and technology were expected to be formidable forces that would hopefully improve population health and well-being. 1 Furthermore, these forces would drive a rapidly changing and interconnected world, with communities and nations worldwide sharing common rewards (eg, economic development, health, and welfare) and facing common risks (eg, pandemics, chronic noncommunicable diseases, environmental damage, nuclear weapons, climate change). In this context, effective governance and communications were to be cornerstones for delivering the promise of science and technology for enhancing public health. Yet the response to the coronavirus disease 2019 (COVID-19) pandemic in the US, one of the world's science and technological powerhouses, has not realized these hopes. 2 Furthermore, the pandemic has exposed critical weaknesses in the institutional systems specifically intended to protect and harness science and technology to promote personal and public health. The pandemic is thus a clarion call for a thoughtful examination of ways to bolster and modernize systems that support and guide science, technology, and public health. History suggests that major crises, such as wars, natural disasters, and pandemics can serve as a tipping point for proactive collective action. For example, reflection and lessons in the aftermath of World War II led to the creation of progressive institutions for that time, such as the United Nations, the World Health Organization (WHO), and the National Health Services in the UK. The current moment presents an opportunity to think boldly and to imagine a better world beyond the tragedy of the COVID-19 pandemic. Despite enormous scientific and technological accomplishments, such as the rapid development and testing of diagnostics, therapeutics, and vaccines, the response to the pandemic has unveiled vulnerabilities in society and in the scientific independence of public health institutions. 3,4 There have been escalating attacks on science and expert opinion, an intrusion of partisan politics into public agencies, especially the Centers for Disease Control and Prevention (CDC) and the US Food and Drug Administration (FDA), and absence of national coordination. These venerable and trusted public health institutions have become targets of direct and dangerous partisan political interference, which has often discredited science, in general, and the scientific independence and voice, in particular, of these institutions. An added problem has been the spread of misinformation in social media, which has also undermined public trust in science and public health communication. It is