The following manuscript was submitted to the February 2017 Social Medicine Themed Writing Contest.
Health and wellness are more than a simple product of access and initiative, as such a simplified formula is only enjoyed by a very small minority. The equation becomes more complicated as new factors enter, such as unemployment or housing insecurity. Despite their importance as determinants of health, such elements are seldom addressed in the medical interaction between patient and physician, and are thus discarded in the interest of a perceived efficiency. Such factors are described by Woolf and Braveman as “personal resources such as education and income and the social environments in which people live, work, study, and engage in recreational activities.” These elements transcend the simplified access and initiative formula and include food insecurity, homelessness and housing insecurity, education, income, transportation, employment, stress, support structure, race, social position, and even zip code.
Measuring the Social Determinants of Health
Physician and public health scholar Rishi Manchanda characterizes the social factors that affect health as “upstream” influences, suggesting that some antecedent mechanism may be determining lived experience. Further, Manchanda posits that such upstream determinants may have a larger impact than previously assumed. In Schroeder’s review of modern American health, upstream elements are categorized into five domains: genetics, social circumstance, environmental exposure, behavioral patterns, and health care, and Schroeder suggests that each of these domains differentially contributes to premature death. McGinnis, Williams-Russo, and Knickman quantified such contributions based on recent studies, suggesting that access to quality medical care can only account for approximately 10 percent of mortality risk, and that social circumstance, the environment, and behavioral patterns represent 60 percent of mortality risk, leaving 30 percent attributable to genetics. Other studies, such as the New England Healthcare Institute’s population study on the health of Massachusetts residents, have concordant results, reporting the impact of accessible and quality health care at a nominal 10 percent.
As reported by McGinnis et al. and Hubbard, individual behavior may account for 40 to 50 percent of our realized health and wellness. While the term “behavior” implies an equitable agency to choose health or illness, scholars have documented how social factors and personal circumstance affect personal choice, with a classic example being food options in the inner city versus in suburban areas. Research has demonstrated a higher prevalence of fast food restaurants in low-income areas with higher concentrations of ethnic minority groups, and that ethnicity, race and socioeconomic status may play into the issue of food choice. Similar research has been done with the availability of green space, playgrounds, safety, and youth sports programs. It is thus incumbent upon public health scholars to interpret health-seeking behavior with these social determinants in mind, as choosing health may be more socially and monetarily expensive to some groups.
When revisiting the influence of genetics at 20 to 30 percent, research into epigenetics and the intergenerational influence that non-biologic constraints have on our DNA have revealed that even our genetic code may be influenced by our social, physical and behavioral environments. Research on “critical periods” during intrauterine development has demonstrated that aberrations in the extra-uterine environment, such as famine or war, may enable embryonic and fetal programming that can endure a lifetime or more. Baker, Hurtado, Pearson, and Jones among others describe anabolic trade-offs in building tissues to generate a maximally fit organism for the given environment. Although Heard and Martienssen maintain that the impact of epigenetics is difficult to assess, some have made progress in defining where these genetic segments may reside in the genome. In a recent study on the mechanisms of genomic resetting during development, Tang et al. found regions that were resistant to erasing, and were thus genotypically preserved from parent to offspring. These erase-resistant segments amounted to approximately 5 percent of the genome, suggesting that such regions may contain epigenetic segments that can pass through multiple generations.
With the increasing understanding of epigenetics and the roles of the physical and social environments within the context of shaping our health-related behavior, morbidity and mortality are predominantly determined by upstream factors that conventional health care routinely ignores. However, expenditure for such health and wellness is inappropriately concentrated on the most insignificant determinant of such: medical services, which include hospital care, physician services, and the like. Iglehart reported that in 1998, approximately 87 percent of all health spending was allocated toward personal medical care services, while just 3.6 percent of spending went to public health care endeavors. More recently, the New England Healthcare Institute reported that national health expenditure toward medical-specific care represents 88 percent of health spending. Such figures correlate with an ever-increasing real-dollar amount as the percent of GDP spent on health care continues to rise, most recently measured at 17.1 percent in 2013, which translates to roughly $9,000 per capita, making health in the United States one of the most expensive commodities of its kind in the world. However, as the United States funnels the vast majority of its health spending into medical care and the administration of such, poor health indicators would be expected from such an imbalanced investment. As of 2011, the United States was below the average OECD nation in life expectancy at birth, at 78.7 years, yet health care expenditure per capita remains well above all other OECD nations. Additionally, the United States ranked poorly in infant mortality rate at 6.9 deaths per 1,000 live births, further suggesting that more expenditure per the status quo does not necessarily translate to better health for Americans.
Structural Violence and Social Exclusion
The disparate results illustrated above can be explained by health inequities that exist in the United States, particularly within the scope of understanding the social determinants of health. In his report on mortality as an indicator of economic success or failure, economist and scholar Amartya Sen reflects on the discrepancy between monetary input and a lack of significant health output, stating, “There is, of course, plenty of [poverty] in the world in which we live. But more awful is the fact that so many people — including children from disadvantaged backgrounds — are forced to lead miserable and precarious lives and to die prematurely. That predicament relates in general to low incomes, but not just to that. It also reflects inadequate public health provisions and nutritional support, deficiency of social security arrangements, and the absence of social responsibility and of caring governance.”
Unfortunately, the inequities that fuel the apparent disparity between spending and measurable health status appear to be built into a system that precludes success of the marginalized or those struggling to overcome structural barriers such as food or housing insecurity in their search for wellness.
Recognizing Social Determinants of Health
Such inequity is difficult to ignore, particularly for primary health care providers who work with complex patients on a myriad of complicated complaints. However, providers receive little training with respect to adequately understanding social determinants of health. According to a large Robert Wood Johnson Foundation (RWJF) survey of 1,000 American physicians, participants overwhelmingly agree (87 percent) that unmet social needs are directly leading to worse health regardless of social class; however, the majority (80 percent) also confessed an uncertainty in their capacity to address such social needs. Further, the RWJF study found that physicians would be willing to write prescriptions for social needs such as fitness programs, nutritional food, or transportation assistance, and that such recommendations may represent as much as 1 out of every 7 they write. When extrapolated nationally, such a figure corresponds to nearly 600 million potential prescriptions (14.3 percent of 4.02 billion annual prescriptions in the United States) for social needs that are being identified by providers, but not written due to systematic limitations.
Such limitations are embodied within the structural difficulties of delivering health care in the context of a sick-oriented care model that is procedure-driven and reserves no time for addressing complex social dilemmas. In addressing the reluctance of health care providers in responding to social issues such as domestic violence, Lavis, Horrocks, Kelly, and Barker suggest that such trepidation may be linked to the providers’ confidence and comfort with a potential course of action. They suggest, “The prospect of ‘opening a Pandora’s box,’ and thus engaging in a long-term intervention, where the possibility of further symptoms and injuries is likely before any potential resolution, involves the probable loss of protection from emotional involvement that the medical model and its discursive practices currently afford. Indeed, long-term interventions may necessitate liaison with external agencies, such as refuges, shelters and advocates whose models of responding and associated practices appear at odds with the medical discourse.”
Further, studies show that time restrictions in primary care encounters can trigger a similar phenomenon. In Sugg and Inui’s survey of North American physicians’ response to domestic violence, one participant explained, “I think that some physicians, and I do the same thing, if you are very busy and have lots of patients waiting, you just don’t ask a question that you know is going to open a Pandora’s box. Even if it crosses your mind, you don’t ask.”
Such structural barriers that appear built into the care model may explain the discrepant input versus output discussed earlier, and suggest that no amount of expenditure that is solely concentrated in a system with such built-in restraints can overcome the remaining and woefully neglected 90 percent of what contributes to health and wellness.
Addressing Social Determinants of Health Directly
Although social structures can restrict individuals from realizing their full health potential, public health projects can target inequities in a way that generates a higher potential for healthy behavior from both the clinician and patient perspectives. As Peruvian theologian Gustavo Gutierrez argues, empowering communities in the face of such structural violence ought to be framed in the lens of justice and responsibility, proposing, “The poor are a by-product of the system in which we live and for which we are responsible. They are marginalized by our social and cultural world. They are oppressed, exploited proletariat, robbed of the fruit of their labor and despoiled of their humanity. Hence the poverty of the poor is not a call to generous relief action, but a demand that we go and build a different social order.”
Although the prospect of building a different social order seems laborious, pockets of communities in the United States have been successful at reframing illness and wellness in a way that promotes more comprehensive care. Successful organizations such as HealthPartners, Highland Health Advocates, HealthBegins, and even international programs such as the Comprehensive Rural Health Project which grew from a small community health program in Jamkhed, India, have been able to address “upstream” factors in the three ways that the RWJF recognized at the completion of its survey of physicians: (a) Recognizing that social needs are connected to health; (b) Equipping providers with the resources they need to allow patients to realize their health potential; (c) Rethinking the system to address unmet social needs.
Including Society in Medicine
As outlined previously, numerous studies show that social needs are connected to our potential health. As the social determinants of health may play a role five times more important than access to medical care, projects and programs that can divert health care’s attention “upstream” become increasingly necessary. In their call for reframing the system, Wong, LaVeist, and Sharfstein suggest, “It is time to broaden the expectation for what a health care system can do to include redesigning services to achieve health equity.” However, redesigning services must include addressing power, money, resources, and the complicated structural context of such in a way that provides what Engel describes in his seminal work on the bio-psycho-social model as “a design for action in the real world of health care.”
In the process of rethinking the system, care must be exercised in bringing participants such as physicians and support staff into the planning process. Further, as community members represent a significant contribution to achievable health, they too should be considered in the planning and executing of a novel system, insomuch that sustainability will be maximized in what Briggs and Mantini- Briggs call the “horizontal approach” to community engagement. Similar to the RWJF physician study, Lawrence suggests that when physicians have an answer or resource to provide, they are more likely to provide such. He continues that in order to focus the lens upstream, systems should, “develop the appropriate combination of education, training, modification of practice setting, and reward system to bring about the desired change.” Essentially, options must be available to those on the front line.
Rethinking the System
Finally, the RWJF physician study suggests that the current system of health delivery requires fundamental change in a way that will allow it to properly address the social determinants of health (SDH). Garg, Jack, and Zuckerman recommend that making the SDH more relevant within the context of a medical visit requires at a minimum, screening for social factors, indexing community-based resources, and developing multidisciplinary interventions such as medical-legal partnerships. Such models have proven to empower communities in ways that may have otherwise been impossible.
Baltimore’s ‘Family Help Desk’ has successfully applied such requirements insomuch that it has improved connections to available services such as childcare, housing, and job training. Further, Anderson et al.’s community guide suggests resources that may be important at the community-level include adult learning services, recreation programs, voter registration events, and neighborhood festivals, to name a few. By providing for more equitable access to community resources, health and wellness can be realized, and the ensuing empowerment may improve quality of life for generations.
Refocusing efforts upstream, as Rishi Manchanda discusses, will afford patients and community members comprehensive care that is community-based and patient-centered. Programs such as Baltimore’s ‘Family Help Desk’ partner with key community entities that have a similar appreciation for community health, such as local universities. Similarly, HealthPartners has established and cultivated a relationship with the local university, Northern Arizona University (NAU), and considers this relationship a pivotal partnership within the community. Additionally, Highland Health Advocates in California and Global2Local in Washington have partnered with local undergraduate universities to help staff their resource desks. Although these programs specifically recruited undergraduate students in the health sciences such as pre-medical students, HealthPartners’ founded its relationship with the university through the anthropology department, stressing the importance of a multidisciplinary approach. This strategy proved beneficial in the first semester of the course in 2015, as students possessed a relative comfort in the recognition of structural determinants of health, and interviewing/analytical skills that go beyond the typical undergraduate student in the health sciences.
Lavis et al. describe the change that is requisite of programs attempting to cultivate richer healing events, stating, “Most fundamentally, change involves a renegotiation of the traditional subject positions within the health care interaction and the patient-practitioner relationship, and a deconstruction of the power dynamics inherent within them.’
Such renegotiation requires reframing health in a broader context, suggesting that equity is more important for healing than traditional paternalistic approaches. As iterated above, partnerships fuel equity, which empowers individuals and communities to be active and equitable participants in their health. Additionally, partnerships permit opportunities to improve neighborhood living conditions, learning and developing capacity, community development and employment opportunities, social cohesion, civic engagement, health promotion, and collective efficacy.
Finally, as programs similar to HealthPartners are becoming more prevalent, better outcome measures should be developed that would afford more meaningful data on efficacy. Of note, provider confidence and empowerment would be particularly useful to measure, as a lack of physician and provider involvement may undermine the utility of similar programs. Additionally, further-defined outcome measures may be helpful in securing funding for similar programs.