It’s becoming increasingly obvious that health status is not just about medical care. Nationwide health initiatives, such as Healthy People 2030, have recognized and incorporated social needs as an integral part of health status. Likewise, “social determinants of health” have become a popular talking point, in everything from healthcare press conferences to political debates.
But what exactly are the social determinants of health, and why are they suddenly on everyone’s mind?
Social determinants of health are the conditions in which people are born, grow, live, work and age, and they play a large role in determining health status and disparities. They include such seemingly obvious factors as income and education level, access to healthy food and clean water, and availability of safe and secure housing. There are also social determinants that, while less obvious, play just as large of a role in health status. For example, language and culture, which impact communication between patients and providers, play a significant role in accessing and adhering to medical care.
Social determinants of health do not act in isolation. In reality, they interact with each other in complex ways. To highlight this, let’s look at the example of three important determinants: nutrition, environment, and socioeconomic status.
It’s universally acknowledged that good health demands proper nutrition. Proper nutrition, in turn, depends on a person’s ability to access healthy food. And what enables access? A person’s environment and socioeconomic status.
Specifically, to gain access to healthy food, a person must live near stores that regularly stock sufficient supplies of healthy food. Further, one must have adequate income to afford transportation to the stores and pay for the groceries. But income, and by extension socioeconomic status, depend in part on the ability to work, which depends on health and therefore access to healthy food. Thus, significant, unmet needs related to any one social determinant of health can drastically affect a person’s ability to fulfill needs related to others, and trap that person in a vicious, health-detracting cycle.
While providers have long recognized the role that social determinants play, it’s only recently that they’ve captured the nation’s attention. COVID, in particular, brought social determinants into harsh light as the media highlighted disparities among different communities with regards to how they were impacted by the pandemic. Low-income communities, for instance, proved particularly vulnerable throughout the pandemic. Because they already face myriad social challenges, adhering to best practices regarding social distancing couldn’t always be a top priority—not when it came at the expense of putting food on the table.
The increased focus on racism and racial inequity in the country also brought social determinants into the forefront. In healthcare, it’s impossible to ignore the jarring racial inequities that exist. Structural racism—the “policies, institutional practices, cultural representations, and other norms” that perpetuate inequities—impacts access to a number of social supports and needs, as well as negatively affects interactions with existing social services. For BIPOC (Black, Indigenous, and People of Color) populations, job loss, homelessness, and financial and food insecurity are more frequent. Structural racism also restricts access to higher quality schools and non-polluted neighborhoods, and increases the likelihood of negative interactions with public safety. All of these are social determinants of health.
In spite of determinants’ obvious prominence in the health equation and significant research on their interconnectedness, the healthcare system still isn’t well organized to take them on. Too often, providers are judged by their ability to treat health issues, rather than prevent them. Unfortunately, this means that more funding goes towards developing new medical procedures and innovations that, while needed, fail to fully address factors causing adverse health problems. Meanwhile, there are other countries that both understand and address the impact of social needs on health status. In fact, other countries with comparable GDP to the US spend significantly more on social services per healthcare dollar—an average of $1.70 versus $0.56 in the US.
Since passage of the Affordable Care Act, the US healthcare system has focused mainly on decreasing costs and increasing a very generic definition of quality, relying on metrics like infant mortality and readmission rates to judge the effectiveness of care. While useful, in isolation these metrics fail to account for the broader range of social determinants like education, housing, and transportation that feed into lower health outcomes, particularly those impacting Black, Latinx, and other underinvested communities.
In the wake of the past year, healthcare providers and insurers are working to better acknowledge and address the social influences impacting their patients’ health. Despite the US healthcare system focusing primarily on treatment innovations, a focus on social determinants is gaining more and more traction; hopefully we will continue to see work in this area grow.