Efforts to improve child health in the United States have historically positioned the health care system as the focal point for transformative change. With passage of the Affordable Care Act, there have been increasing initiatives to address factors outside the health care system and reform payments to incentivize broader approaches to health. Social determinants of health (SDH) offers a promising approach to translate research from various sectors into cohesive public policy efforts to impact health outcomes (1). The SDH are defined as the circumstances in which people are born, grow up, live, work, and age, that affect a wide range of health, functioning, and quality-of-life outcomes and risks. Within this model, the health care sector represents merely one component influencing health and health outcomes. Various conditions (e.g., social, economic, built environment) and sectors (e.g., business, education, policing) also play critical roles. In this issue, Gargano et al. (2) report on asthma control in adolescents a decade after exposure to the World Trade Center disaster. The authors highlight the association between different SDH and asthma control. Lower household income was associated with worse asthma control. According to the authors, poverty may reduce access to care which in turn impacts ability to effectively control asthma. Adolescents who screened positive for at least one mental health condition had six times the odds of having poorly/very poorly controlled asthma. The authors postulate a number of mechanisms by which this relationship may occur, including mental health conditions impacting the ability to cope with asthma or mental health symptoms interfering with adherence to medical treatment for respiratory symptoms. While studies such as this article represents critical milestones in understanding the cumulative influence of SDH on asthma control, translating evidence into public policy to affect asthma outcomes for children requires more cross-sector study and multi-pronged strategies.

The medical literature on asthma in children has long considered the contributions of SDH on outcomes (3,4,5,6,7). Numerous studies have documented a wide range of SDH factors influencing asthma risk for children. Although the connections between those factors have yet to be fully discerned, they inevitably lead to multi-sector policy solutions. For instance, poor housing conditions (e.g., cockroach infestations, residential crowding), which may predispose residents to viral illnesses and subsequent asthma exacerbations, posit direct causation between SDH and asthma risk (8). However, evidence suggests that factors such as housing conditions do not fully account for the distribution of asthma risk (3). Other, less direct, factors such as caretaker mental health, community violence, and the built environment have been shown to play as large a role, if not larger, in asthma expression (6,7,9,10). How these conditions are interrelated and reinforcing, such as through increased stress, and which are most important to be targeted through policy solutions remains to be elucidated. What is clear, however, is that the most promising policy solutions will likely fall outside the health care realm and will require physicians and other members of the health care team to engage collaborators from multiple sectors, such as housing, city development, and policing.

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