The upstream solution, focused on the source of contamination, would end the factory’s dumping. Although these concepts may make intuitive sense, the causal pathways linking upstream determinants with downstream determinants, and ultimately with health, are typically long and complex, often involving multiple intervening and potentially
interacting factors along the way. This complexity generally makes it easier to study — and address — downstream determinants, at the risk of failing to address fundamental causes. This article focuses on the more upstream social determinants of health—the factors that play a more fundamental causal role and represent the most important opportunities for improving health and reducing health disparities. Figure 2 illustrates the conceptual framework for the RWJF Commission’s work. Although the relationships are more complex, this simplified schema highlights several
important concepts. First, it shows that health related behaviors and receipt of recommended medical care (key downstream determinants of an individual’s health) do not occur in a vacuum. Rather, these factors are shaped by more upstream determinants related to the living and working conditions that can influence health both directly (e.g., through toxic exposures or stressful experiences) and indirectly (by shaping the health-related choices that individuals have
and make for themselves and their families). The diagram highlights how health is shaped not only by living and working conditions, but also by even more upstream determinants that reflect the economic and social resources and opportunities that influence an individual’s access to health-promoting living and working conditions and to healthy choices.