Why social determinants of health matter, and what we must do

Recently, my friend Carmen Gonzalez wrote a post for the Occupy Healthcare site in which she highlighted the state of healthcare inequities in the United States.  Carmen's post is brief and pointed: our nation has significant differences in healthcare status and outcomes, often as a result of factors that are largely beyond individual control: ethnicity, income, educational attainment, community resources, etc.

These factors are referred to as a group as "social determinants of health (SDOH)", in that they affect individual health but are not the results of individuals' decisions.  For example: the fact that low-income neighborhoods often lack easy access to nutritious foods and safe places to exercise, meaning that those living in those neighborhoods will have greater challenges following our medical advice to exercise and eat well...not because they might not want to, but because these resources are not readily available to them.  The important role of SDOH in impacting health means that any individual's health status is not simply the result of poor personal choices, but rather an interplay of individual risk factors and the social milieu in which one lives.

In the United States, we have the most expensive healthcare system in the world (as % GDP (pdf), and per capita), while performing at a level far below our economic peers:

• 37th in this WHO analysis (pdf), including lagging behind in infant mortality and adult mortality.
• In this Commonwealth Fund report, the US scored only 64/100 points due to increased costs, lack of improvement in health outcomes, lack of access to care, and increased health disparities.  This report's findings showed how much improvement in outcomes and costs could result if the US worked to address failings in our healthcare system.  If the US healthcare system was on par with the best-performing systems in the world we could save up to 84,000 premature deaths and nearly $114 billion per year on administrative costs.  
• Also from the Commonwealth Fund, this report shows that in the US over 1/4 of Americans struggled to pay their medical bills and 42% skipped needed care.  The Commonwealth Fund recently reported on U.S. Census Bureau data showing that out-of-pocket healthcare costs are significant burdens for Americans, and threaten to push millions of Americans into poverty.

In a recent article in Health Affairs, Steven Woolf and Paula Braveman discussed the impacts SDOH have on individual and population health outcomes.  The full text of the article is not yet available publicly, but in the article Woolf and Braveman note:

• Income correlates directly with health status: higher income, better self-reported health status.  The Health Affairs article reports that "studies of Americans at all income levels reveal inferior health outcomes when compared to Americans and higher income levels."  Woolf et al demonstrated that 25% of deaths in Virginia 1996-2002 could have been avoided if the mortality rates of the five most affluent cities and counties applied statewide, demonstrating the clear impact income has on health.  (reference here)
• Education notably influences health outcomes, both of individuals and families.  Braveman has noted that children's health depends greatly on parents' educational levels (reference here), while Woolf et al have noted that increasing American's educational levels could have greater impacts on health outcomes than biomedical advances.  (reference here)
• Education and income levels are associated with behaviors such as smoking and physical exercise, showing the interrelatedness of these issues.  
• The Health Affairs article also summarizes the ways in which environment influences individuals' habits, both in where people live, where they work, etc.  These influences are reviewed in-depth in this article by Bravemen et al. (pdf)

As a result of the roles SDOH play on individual health, Woolf and Braveman call for a broader approach to improve the health of individuals and (by extension) the performance of healthcare systems.  It is not sufficient to focus on one patient--or even one family--at a time.  Although this individual health care is what most of us think about when we discuss healthcare overall, Woolf and Braveman indicate that it might not be the most important factor in affecting overall health.  Although meaningful, affordable, effective individual access to healthcare is of critical importance, it is not sufficient to bend the curve on system-wide performance or on healthcare costs.  After all, more individual healthcare will mean that the system will be paying for more services, meaning that cost savings will be delayed.  Even if better and more-timely care results in fewer complications and fewer preventable deaths, resulting cost savings will not be evident in the short-term.  Therefore, we must not stop at ensuring individual access to care.

As Woolf and Braveman write in Health Affairs, "[t]he leaders who can best address the root causes of disparities may be the decision makers outside of health care who are in a position to strengthen schools, reduce unemployment, stabilize the economy, and restore neighborhood infrastructure.  Policy makers in these sectors may have greater opportunity than health care leaders to narrow health care disparities." 

So: what can we do to target SDOH and improve the health of individuals and communities? How can we take on this task?  A few proposals include:

• Work to ensure that affordable and effective healthcare is available to all individuals.  Yes, I have argued that SDOH should be our main targets, but each of us experiences our healthcare as an individual and we must ensure that healthcare at this level is safe, effective, affordable, and available to all Americans.  For now, this might mean supporting the Patient Protection and Affordable Care Act (PPACA) as its policies are reforms are implemented.  For me, it means supporting the PPACA as a valuable first step to reform health care even as we acknowledge its gaps and work to address them.
• Get in touch with your national elected representatives.  From the White House to Congress, our elected officials purportedly represent our views.  We must ensure that they hear from us, and we must make sure to advocate on behalf of policies that will improve SDOH.  This might include advocating for environment protection, reforming federal education laws, or supporting policies to improve the economy...but we must be heard.  Find your Senators here, your Representative here, and contact the White House here.
• Remember that many of the policies that affect SDOH are actually determined at the state and local levels.  Find out who your state representatives are by starting here, and then linking to your state.  Remember that your state legislators are likely more accessible than those at the national level.  Keep in touch with them before, during, and after your state's legislative sessions. 
• Find out where and how you can get involved in your local political process.  Vote in elections for mayors and city council, consider attending school board and city council meetings.  Contact your local representatives and ensure that they hear about the policies and decisions that matter to you, and that can affect SDOH.  
• Encourage patients and peers to become involved in our political process.  Help them register to vote.  Help identify issues where they can and should be heard.  Partner with local organizations and action groups to be a productive part of dialogue at all levels of government.  Consider joining programs such as RxDemocracy, or National Physicians Alliance -- both organizations operate from the position that in order to be heard, you must be involved in the process.  

SDOH affect health through various pathways, and to address their impact we need to work at a level above that of the individual while not neglecting the individual.  This means that we must become involved in our political process.  We must call for accountability, while also ensuring that our voices are heard...otherwise, only the voices of large financial contributors will have influence.  We must remember that this is our government, and we should call on our representatives to represent US.  We can work to fix the shortcomings in our political systems...but we must also work to enact change within the systems that exist.

In the same way that other activists call on us to "think global, act local", we must "think about social determinants of health, act to care for the individual patient."  The two cannot be separated, and our duty must be to improve outcomes at all levels: we must make our healthcare system more effective, more efficient, and more affordable.  The status quo is unjust and unsustainable.