Between Social Determinants of Health and Health Care

We are socialized to think that to achieve physical and mental health is more of an individual effort and has to do with the quality of health care the person has. Growing up, I was lectured time and again that the rules of thumb for a healthier life are eating healthy and staying active, steering away from smoking and binge drinking, getting regular health exams and tests, etc. However, I never learned that health is tied to the distribution of resources and that the single strongest predictor of our health is our position on the class pyramid (aka the social ladder).

Whether measured by income, schooling, or occupation, those at the top of the social ladder have the most power and resources to live longer and healthier, whilst those at the bottom rung are most disempowered and thus get sicker and die younger.

Factors that significantly affect health are called social determinants of health (SDOH). They are conditions in the environments in which people are born, live, learn, work, play, worship and age that affect a wide range of health, functioning and quality-of-life outcomes and risks. Downstream SDOH are often used broadly to refer to any nonmedical factors influencing health, including health-related knowledge, attitudes, beliefs or behaviors, whereas upstream SDOH are the factors that play a more fundamental, causal role and represent the most important opportunities for improving health and reducing health disparities. With important direct or indirect effects on health, SDOH framework is more inclusive than health care alone.

A health care approach is an approach that addresses the treatment and prevention of disease with the help of licensed professionals in order to maintain and restore health. An SDOH approach is an approach that addresses the five key areas of SDOH, including economic stability, education, social and community context, health and health care, as well as neighborhood and built environment. Each of these five key areas reflects a number of critical components that constitute the underlying factors in the arena of SDOH. As we can see, SDOH approach consists of health care as one determinant area, along with four others.

Dr. Laura Gottlieb argues that Americans will not be able to pay for medical care unless we address the avoidable causes of disease. Problems of medical quality and access account for only about 10% of all avoidable deaths in the Unites States. Epidemiologist Ichiro Kawachi also contends that Health care can deal with diseases and illnesses, but lack of health care is not the cause of either. Personal behaviors themselves are in part determined by economic status, so our ability to avoid smoking and to eat healthy diet depends, in turn, on our access to income, education, and, what we call, social determinants of health.

To solve different problems, we must strike at the common roots. Differences in the quality of medical care have less impact on people’s life expectancy than social differences in their risks of getting life-threatening disease in the first place. Therefore, only addressing health care that fixates on causes of disease and treatment plans would result in less optimal outcomes than does addressing SDOH, which manages the avoidable social factors that make people either sick or sicker than they should be.

The typical health care approach we are all exposed to has a confined connotation of health policy. It fails to encompass the broader significance of health policy—everything we can do to improve the quality of life of individuals in our society that has an impact on their health is a health policy. As Sociologist David Williams said, “When we improve economic circumstances and narrow the economic gap, we improve health.”

To improve community health by addressing SDOH, the government should first of all direct millions of dollars from the health care force toward community programs that adopt the SDOH framework and center on the avoidable social conditions. Furthermore, professionals and advocates in both medical and public health fields must be able to recognize, treat and help change­—through collaboration or direct advocacy—the social issues that lead to disproportionate amount of sickness in people at the bottom rung of the social ladder.

In conclusion, policy makers may use Health Impact Assessment as a tool to help them understand health beyond health care, and researchers may use it to review needed, proposed and existing social policies for their likely impact on health. Government agencies may apply the European Health in All Policies strategy that introduces improved health for all and set the closing of health gaps as a mutual goal for all parties involved.

This article was written by Mildred D. Li, a writer for dusk magazine. 

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