Urban Geography of Environmental Justice and the Social Determinants of Health

An interview with Oregon PSR Board Member Patricia Kullberg, MD, MPH

OPSR had the pleasure of speaking with one of our board members, Patricia Kullberg MD, MPH to learn more about the social determinants of health, a modern lens to approach public health by taking into consideration intersectional factors that contextualize health issues within a given community. Join us as Patricia debunks the old fashioned “bad genes, bad behavior, and bad luck” philosophy and begin to understand how underserved communities experience disproportionate health disparities through social determinants.

Patricia Kullberg has been active in the public health industry since the 1970’s, a time when social determinants were being discussed, but not given the proper attention. She stated that the study of social determinants (non-medical factors that affect health outcomes) goes all the way back to the 19th century, but she exclaims, “When a lot of diagnostics and drugs were being developed and medicine was becoming much more effective…there was a point at which the public health side of medicine tried to refashion itself along a more scientific and individualistic model.” This transition occurred in the 20th century when scientific medicine became the primary way to address health outcomes and the focus of public health became treating individuals with medication versus more community based strategies like hygiene and nutrition. Due to these changes public health experts and decision makers have deprioritized the societal and environmental factors that deeply impact community and individual health. Medical professionals like Patricia are advocating for this to change, and for social determinants and their impacts to be taken seriously. 

Population maps that represent information from census data are one tool that Patricia is using to study the impacts of social determinants. Patricia became interested in examining maps of the Greater Portland area when she discovered the correlation between premature death and place of residency. “People in certain census tracts were living 10 years longer on average than those in others,” said Patricia. 

She then continued to list a number of health issues (low life expectancy, asthma, heart disease, and hypertension) that you could clearly see overlapped with areas that had less access to parks, lower education level, and higher unemployment. The visual overlap of these factors indicated a correlation between environmental inequities (such as higher levels of air pollution,) and social factors such as lower income communities.

Patricia adds that there is growing literature about racism within the medical care system. She notes that if someone with asthma faces prejudice while seeking treatment the quality of care they receive will be less, leading to their symptoms becoming worse, increasing the likelihood that they will die of asthma. That’s a very different look at asthma, particularly for people of color than the NIH and other leading medical bodies posit.One example that Patricia used to highlight health conditions presently misunderstood without the consideration of social determinants was asthma. If you look up the National Institutes of Health’s “cause and triggers” for asthma, you’ll find a list of factors that directly correlate with the “bad genes, bad behavior, bad luck” philosophy: 

  • Second hand smoke 
  • Certain germs 
  • Severe respiratory
  • Family history 
  • Allergens: food, dust mites, mold, pollen, pet dander. 
  • Race or ethnicity 
  • Sex 
  • Occupational hazards, certain chemicals or industrial pollutants

If Patricia could revise the NIH list taking consideration social determinants, her list would look like this: 

  • Facing racism and/or xenophobia 
  • Being low-income (not being able to accumulate wealth)
  • Not having access to high quality education
  • Unemployed/poorly employed
  • Living in areas with higher levels of violence
  • Having less access to healthy food
  • Having substandard housing with pest and mold exposure
  • Being more exposed to air pollution

Prejudice and bias of mainstream medical communities was on full display during the COVID-19 Pandemic.  Patricia points out that because early statistics found that black people contracted COVID more often and possessed a higher mortality rate, people speculated that “bad behavior” was the cause. We saw the rise of false accusations such as higher rates of smoking, not taking it seriously, and generally being less healthy. Patricia added that, ”There was even this kind of scolding of the black community about not social distancing and not wearing their masks…” Later, a data study was published suggesting that the real problem was that “black communities were much more exposed to air pollution and they had impaired lung function compared to other populations.” The original “bad behavior” speculations were not true and caused harm to black communities.

Overall, Patricia emphasizes the importance of contextualizing public health with social determinants because “some people estimate as much as 90% of all diseases are multifactorial.” Speaking out against outdated ideas is speaking out against a capitalistic culture that has inherently infiltrated the medicine field. Patricia states that not only do “they get to sell more drugs to treat these illnesses instead of preventing them” but “the whole capitalist economy benefits from being able to not be accountable for the disease that they are helping to produce. They don't have to get rid of the pollution if that COVID outbreak is because ‘people aren't wearing their masks.’ All those enterprises that are damaging the environment, that are treating their workers poorly, and exposing them to occupational hazards, they're all benefiting from that persistent narrative that health is an individual phenomenon and has to do with individual behaviors and genetics.” If we don’t speak out now against the old “bad genes, bad behavior, and bad luck” philosophy, then we cannot create a more equitable health care system in the future. 

Bio: Patricia Kullberg MD MPH trained as a family physician and did her master’s in public health. She worked as a primary care physician and shortly after became the Medical Director for the Multnomah County Health Department for a couple of decades. In addition to her work as Medical Director, she had a part-time primary care practice in downtown Portland serving houseless, chronically mentally ill, substance abusers, immigrants, undocumented, low income, and a racially mixed population. After retiring (about a dozen years ago), she became active with PSR primarily around environmental justice and climate change activities. 

*Census maps sourced from the EPA and U.S. Census Bureau