Over the last year the consideration of the social determinants of health has become my greatest professional interest. This shift in my thinking has not been because I have lost interest in or am less committed to the noble ideals and objectives of the Triple Aim, but rather because I have come to believe that the Triple Aim can never be achieved, or even much lasting progress made toward those lofty objectives, until we realistically deal with the social determinants of health. Once that reality is accepted then the world looks different and the next question must be why is there so much variation in the management of the social determinants of health from place to place in a country that has the economic resources that our country has. One possibility that explains why other advanced economies are closer to the concepts of the Triple Aim than we are is that they more effectively address the social determinants of health.
In 2007 Steven Schroeder was asked to present the Shattuck Lecture, an annual tradition of the Massachusetts Medical Society. His speech “We Can Do Better—Improving the Health of the American People” was published in the NEJM in 2007 and suggested that behavioral and social issues were the most important contributors to the overall health of the nation. It is disappointing to admit that in the decade since Schroeder’s speech we have not been very effective in acting on his insights and addressing the challenges of behavioral health and the intimately associated social determinants of health that spring from poverty and economic inequity. Below is a pertinent section of his speech with bolding to emphasize his points:
…people with lower socioeconomic status die earlier and have more disability than those with higher socioeconomic status, and this pattern holds true in a stepwise fashion from the lowest to the highest classes. In this context, class is a composite construct of income, total wealth, education, employment, and residential neighborhood. One reason for the class gradient in health is that people in lower classes are more likely to have unhealthy behaviors, in part because of inadequate local food choices and recreational opportunities. Yet even when behavior is held constant, people in lower classes are less healthy and die earlier than others. It is likely that the deleterious influence of class on health reflects both absolute and relative material deprivation at the lower end of the spectrum and psychosocial stress along the entire continuum. Unlike the factors of health care and behavior, class has been an “ignored determinant” of the nation’s health. Disparities in health care are of concern to some policymakers and researchers, but because the United States uses race and ethnic group rather than class as the filter through which social differences are analyzed, studies often highlight disparities in the receipt of health care that are based on race and ethnic group rather than on class.
If looking back a decade does not convince you that we in healthcare are ignoring both a moral responsibility as well as the opportunity to do a better job, let me refer you to a speech given in October 1967 by Robert Ebert, Dean of Harvard Medical School, about a month after I enrolled. [You really should click on the link and read the speech] Here are a series of quotes that make my point that we have been talking about these problems for a long time:
There is no lack of problems to preoccupy the physicians who wish satisfaction from personal involvement in the health field. In my opinion the social problems are of greater magnitude than those which are strictly medical. Not only is there a place for the physician in the approach to these problems but he must be involved if they are to be solved….
Closely linked to the evolution of the modern hospital is the problem of the distribution of medical care. There are two groups who have suffered from the changing pattern of medical practice: the rural population and the urban population occupying the central city. Both groups present special problems, and both require new approaches to solutions…
…the health problems of the urban poor are intimately linked with their socio-economic problems, and they cannot be solved by imitating the care given in the suburbs.
The social, emotional and economic impacts of chronic disease must be understood and intelligently dealt with…
Dr. Ebert ended his speech on a high note and with an expression of hope.
He [the medical student] must be made as aware of the social problems of medicine as he is of the biological problems.
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..students come to medical school dissatisfied with the manner in which society has handled the problems of the poor and of the Negro. … above all they wish to become actively involved in seeking solutions. I predict that they will provide the necessary prod to a conservative profession and to a conservative educational process.
I was among those medical students to whom he referred who came to medical school with a sense of social responsibility. Considering that we were his primary source of optimism, I feel guilty. He described the problem and issued a challenge and now looking back fifty years at the lack of real progress we have made I am left with the sense that we could have done better. We still have the opportunity to translate the wisdom of Ebert and Schroeder into progress toward the ideals of the Triple Aim.
One of the strategic advantages of conceptualizing shifting our central vision from the end objective of the Triple Aim to the barriers between us and that objective is that “next steps” become more efficient. Another derivative benefit from a change in focus is that I have discovered a community of others who are drawn to the very proximate issues of the poor, racial minorities, the underserved, and the disadvantaged. Others are contacting me as they come to understand that I share their concerns about inequality. One such articulate activist is Joe Knowles. Beyond being an “Interested Reader” Joe is the CEO of the Institute for Health Metrics, and a serial social entrepreneur. Joe and I met at his request several weeks ago to discuss a fabulous idea that he has been developing.
Joe has had a deep concern for impoverished families and children. He recognizes that poverty is the repugnant foundation upon which the negative aspects of the social determinants rest. He also realizes that poverty is a self perpetuating manifestation of economic inequity that is so poisonous to the future of individuals, communities, and the nation that it must be called “toxic inequality.” At the time Joe and I first met to discuss his idea about how to mitigate the toxic effects of inequality and poverty on children and families I was finishing Thomas Shapiro’s 2017 book, Toxic Inequality: How America’s Wealth Gap Destroys Mobility, Deepens The Racial Divide, and Threatens Our Future. Shapiro reinforces the idea that we can’t really improve the health of the nation until we fix the social determinants of health which result from “toxic inequality.” Shapiro emphasizes that as bad as “toxic inequality” is for all of our poor, it has been and remains most devastating for African Americans.
Perhaps one of the best books to read as an introduction to the matrix of issues that create and sustain toxic inequality is Matthew Desmond’s 2017 Pulitzer Prize winning beautiful example of narrative nonfiction, Evicted: Poverty and Profit in the American City. Recently Desmond was interviewed by Terry Gross on “Fresh Air,” her NPR show. Desmond’s view of our housing policy and practices allows us to see how poor housing reinforces poverty and leads to poor health in ways that perhaps Ebert and Schroder could only sense but did not have a searchable database to prove. Few Americans understand that even though the Fair Housing Act was passed in 1968, many of the outcomes and practices of discriminatory markets to “protect” white neighborhoods and the lending practices of banks that unnecessarily block home ownership by African Americans such as “redlining” still exist or their impact still exists long after they were technically “against the law.” A New York Times editorial, “Blacks Still Face a Red Line on Housing,” outlines this shameful reality and supports the ideas of Desmond, Shapiro and so many other social scientists. As a result of these policies many African Americans are doomed to spend their lives in “public housing.” Even on a nice spring day, as seen in the header for this post, public housing is stark and the residents are denied the advantages of wealth building through home ownership.
Joe Knowles knows that desired outcomes require an effective PDSA (Plan, Do, Study, Act) cycle that leads to scalable solutions. He presented me a fabulous 10,000 word white paper with 93 references documenting the life long toxic effects on children of growing up in poverty. Living in a daily bath of excessive catecholamines that are driven by the continuous stress of poverty on their families and neighborhoods, many children are literally doomed before birth. That fact has been emphasized in an opinion piece in the NYT, “The Cost of Keeping Children Poor” by Mark Rank, a professor of sociology at Washington University.
Professor Rank brings big data analysis and economics to support many of the points Joe Knowles makes. The conclusion that we must draw from the facts is that in many many ways none of us are shielded from the damage that the poor suffer. Rank puts it in economic terms. There is a huge ROI in addressing poverty. It is easy to define the benefit in terms of public safety because no one doubts the idea that poverty breeds crime just as it breeds disease and disability.
The poverty of anyone should be a concern for all of us, but not everyone realizes that the poverty experienced by our neighbor is a threat to all of us, but Joe Knowles does. I love the way his paper begins. It is right out of Lean thinking. It has a straightforward “reason for action” that calls us to focus our attention on what we can begin do today even as we are swimming against a very strong current coming from Washington.
Children living in poverty have lower scores on standardized tests of academic achievement, poorer grades in school, and lower educational attainment overall, a situation referred to as the “income-achievement gap” in the United States.
This gap, better understood in the context of the developing brain’s response to stress, has significant economic and societal costs if not addressed through active intervention, ideally beginning before birth. While there are existing programs to effect this valuable intervention, they suffer from a dated service model, heavy personnel expense associated with high-skill professional staffing, and constrained ability to scale for a variety of reasons. This paper reviews current thinking on the causality and amelioration of the income-achievement gap phenomenon and the effectiveness of current programs to address it. We propose a new, more cost-effective, and scalable approach to this intractable issue that harnesses existing technology to lower the skills and education threshold required of field personnel to deliver timely service in conjunction with a data-rich collection process to manage service and track outcomes.
The paper is a beautiful piece of work that leads to plausible action now that is not a jump to conclusion; but rather after considering the “current state,” and the “ideal or improved state,” and the “barriers to improvement,” it offers a model of care to test that contains an innovation that involves and strengthens communities. If you would like to know more let me know.
