Health maintenance, disease prevention, and health outcomes once disease develops are all critically influenced by factors outside the scope of medical care as traditionally taught and practiced. Medical care is estimated to contribute only 10% to 20% to a person’s health, while nonmedical factors (such as health-related behaviors and socioeconomic and environmental factors) account for 80% to 90% of overall health. Medical care alone also plays a relatively minor role in health outcomes, again estimated to be between 10% and 20%. (Am J Prev Med. 2016; 50:129-135).
Explore This IssueJune 2021
These nonmedical factors are collectively referred to as the social determinants of health, defined by the World Health Organization as the conditions—shaped by political, social, and economic forces—in which people are born, grow, live, work, and age. These factors are called determinants because they determine access, or lack of access, to the crucial elements needed for health and for improving health once disease sets in—from basic living requirements (e.g., housing, food, safe drinking water, and transportation) to economic opportunities (e.g., education), to environmental security (e.g., safe homes and neighborhoods and clean air), as well as the larger structural issues within which these factors play out, notably with regard to issues of equity and justice based on race and gender.
Many of these determinants have long been incorporated into public health planning and initiatives. The more recent move into population-based health programs recognizes that improving health outcomes for and reducing costs of many of the most prevalent chronic diseases, such as diabetes and heart disease, rely on going “upstream” to address the context within which these diseases are seeded and take root before they head “downstream” as chronic illnesses seen in clinical care.
Even downstream, however, once a person develops an illness or needs medical care, it’s important to pay attention to social determinants to improve patient outcomes. Primary care is leading the way, but specialty care is also participating, as providers and healthcare systems become increasingly aware of the impediments to healthcare delivery and the high cost of not addressing factors, such as a lack of access to transportation, that can limit a patient’s ability to reach clinical care or adhere to treatment.
We want patients to show up for appointments, so we want to make sure they have adequate transportation. We want them to have great postoperative care, so we want them to have food security as well as clean and safe housing. I don’t think our field knows enough about how to assess our patients’ social determinants of health and then address their social needs. —David J. Brown, MD
None of this is new. Fundamentally, recognizing social determinants of health and incorporating them into healthcare delivery is about health equity. It’s about acknowledging and addressing all of the factors that determine the health, or illness, of a person. If COVID-19 did nothing else, it raised considerably the awareness that health equity is far from being achieved in this country, as illuminated by the disproportionate effect of the virus on minority populations (JAMA Otolaryngol Head Neck Surg. 2020;146:995-996).
“The COVID-19 pandemic raised people’s awareness that health disparities exist, and that these disparities are connected to the social determinants of health,” said David J. Brown, MD, associate vice president and associate dean for health equity and inclusion, and associate professor of otolaryngology–head and neck surgery at the University of Michigan Medical School in Ann Arbor.
Regan Bergmark, MD, a sinus and endoscopic skull base surgeon in the department of otolaryngology–head and neck surgery in the Center for Surgery and Public Health at Brigham and Women’s Hospital, Harvard Medical School in Boston, underscored the idea that the disparities associated with COVID-19 highlight the need for equity to be central to clinical care. Currently, she emphasized, the U.S. does not have a healthcare system based on the concept of a universal design in which the system works the same for everyone, but rather, it’s based on a system in which segments of the population have poor access to care, low quality of care, and often catastrophic costs associated with their care. “Health equity and attention to the social determinants of health need to be baked into routine practice,” she said.