There once was a little boy whose first 2 months of life involved withdrawal from the drugs that were bequeathed to him by his impoverished mother. Herself a survivor of early trauma, she eventually took him out of the hospital and dropped him off with her friends who also used drugs and struggled with day-to-day survival. The extent of neglect and abuse he experienced is not fully known; however, when he should have been toddling, he was kept strapped in a car seat on the floor, and by the time he was 18 months old, his nutritional status was so poor and immune system so compromised that he required hospitalization. After 2 months of painful and frightening poking and prodding, it was determined that he had a significant cytomegalovirus infection, leaving him with persistent hepatosplenomegaly and a swollen belly. A resilient little guy, he regained his strength and was discharged to foster care where it seemed he would languish. Although unjust and certainly through no fault of his own, because he was male, older, and had early trauma and a "checkered past," this sweet boy was considered undesirable for adoption by most prospective parents.

This case illustrates circumstances and outcomes associated with what are classified as "social determinants of health." According to the World Health Organization, these are the "circumstances in which people are born, grow up, live, work and age, and the systems put in place to deal with illness. These circumstances are in turn shaped by a wider set of forces: economics, social policies, and politics."1^(p1)

Evidence shows a distinct "social gradient" in health, meaning that the lower the socioeconomic status, the poorer the health status. This is a global phenomenon that exists in high-income countries just as it does in low-income countries. There is also a cyclical pattern, meaning that those born into situations where health is compromised because of a lack of resources are more likely to be at risk themselves as they age. Those with impaired physical and mental health who have children may be more likely to create situations of neglect or trauma for their children, thus perpetuating a pattern of compromised health. If we link this evidence with the ACE (Adverse Childhood Experiences) Study data, a clear picture emerges whereby poor health status can be self-perpetuating.2

In a report from the Institute of Medicine titled U.S. Health in International Perspective: Shorter Lives, Poorer Health, the point is made that although the United States is one of the wealthiest countries in the world, gains in life expectancy and health have lagged behind other high-income countries. In fact, data reveal that Americans fare worse in the following 9 areas: infant mortality and low birth weight; injuries and homicides; adolescent pregnancy and sexually transmitted diseases; HIV and AIDS; drug-related deaths; obesity and diabetes; heart disease; chronic lung disease; and disability. Overall, Americans die at younger ages than those in most other wealthy countries and this is especially true for women.3

The Institute of Medicine report cited several reasons to explain the health disadvantages seen in the United States, including inaccessibility and cost of health care, excess calorie consumption, drug abuse, drinking and driving, lower seat belt use, use of firearms in acts of violence, income inequality and rates of child poverty, lower social mobility, poor education, overreliance on automobiles, and less physical activity.3

It is difficult to fully explain health outcomes in the United States-and why even those who are not overweight and do not smoke appear to have higher rates of disease than similar groups in comparable countries. No doubt, cultural factors come into play. We know the benefits of social networks, communities, and spiritual life on mental and physical health. These factors provide a safety net that bolsters immune system function and overall health. It is overwhelming to ponder the numbers of children and adults affected by adverse social and familial factors. It is equally daunting to plan interventions to address such an extensive problem. As holistic nurses, some of us are oriented toward looking at the big picture and have the skills to influence and transform social systems. Others of us look at the smaller picture and aim to transform the lives of those in our sphere of influence. Still others must focus mainly on their own healing journey. For many, holistic life work involves a combination of these approaches. Either way, we make a valuable contribution toward improving our environments within and without.

The little boy described in the first paragraph is now a young man. Adopted at the age of 3 years and nurtured by people who could provide resources, stability, and holistic healing interventions, he grew into a different reality than his birth circumstances may have predicted. He experienced loving affection, good nutrition, adventure and play, good sleep in a safe environment, ongoing participation in a faith community, quality education, and creative healing strategies such as guided imagery, aromatherapy, healing body work, and therapy. He is now physically healthy, with a strong body toned by hours of physical work each day. He meets with his counselor weekly simply because he likes the way it makes him feel. He has a beloved long-time girlfriend and feels a part of her family. Substance-free, he has beautiful, luminous eyes that are learning to look with hope toward a future that seems to hold a place and purpose for him. By all standards, this looks like an evolving process of health-and perhaps a surprising case of justice!

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