September 27, 2024
Dear Interested Readers,
Exploring The Structural Determinants of Health
When I became a healthcare CEO in February 2008, I was more focused on what happened within our organization and our relationships with our affiliated hospitals and insurers than I was on the social factors of the external environment. I was committed to the quality movement, the principles of a “healthcare system for the twenty-first century” advocated in Crossing the Quality Chasm (2001), expanding access to the care we provided, and reducing the cost of care by eliminating waste. I was a foot soldier in the effort to achieve the recently articulated Triple Aim as described by Don Berwick, Tom Nolan, and John Whittington.
It was my feeling that we were the perfect “organization (an “integrator”) that accepts responsibility for all three aims” for a population. We had the culture, the experience, and the remnants of the tools necessary to prove that the Triple Aim was possible. I was hoping that we could use our ability to introduce innovations in care delivery to prove that a focus on quality, process improvement, and waste elimination could improve patient and employee satisfaction while lowering the cost of care. My job was primarily internal.
The first step toward the Triple Aim was for us to repair the infrastructure that was damaged by our losses associated with the receivership of Harvard Pilgrim. To rebuild what we had lost we implemented Lean as our management platform. We believed that we could live up to Dr, Ebert’s purpose in launching us in 1969 and show the world that the Triple Aim could be achieved by a motivated medical group.
We were fortunate to have one vice president, Dr. Zeev Neuwirth, who was always scanning the outside world for ideas and transferable innovations. It was Zeev who introduced me to Lean. It was also Zeev who introduced me to Dr. Steven Schroeder’s 2007 Shattuck Lecture entitled “We Can Do Better — Improving the Health of the American People” which was published in The New England Journal of Medicine.
Dr. Schroeder begins his lecture with a statement that is as true today as it was seventeen years ago:
The United States spends more on health care than any other nation in the world, yet it ranks poorly on nearly every measure of health status. How can this be? What explains this apparent paradox?
The two-part answer is deceptively simple — first, the pathways to better health do not generally depend on better health care, and second, even in those instances in which health care is important, too many Americans do not receive it, receive it too late, or receive poor-quality care.
It was Zeev that underlined “reason one” for me, “the pathways to better health do not generally depend on better health care.” Schroeder’s startling estimation was that a lack of access to care contributed to only about 10% of “premature deaths.” He positions premature death as an indicator of our healthcare deficiencies. I was flummoxed because the social issues that compromised the health of our patients seemed to be beyond our reach as a medical group. We did make efforts to mitigate social problems one patient at a time, but improving the deficiencies that compromised the health of a population seemed to be the job of someone else. Zeev, like Schroeder, contended that all of healthcare was neglecting some of the most significant causes of poor health. If questioned, most physicians shared my feeling that social issues were not our responsibility and were beyond our independent capacity to address.
In his speech and paper, Dr. Schroeder identified factors such as smoking and obesity as “non-healthcare” causes of premature death before he moved on to “Non-Behavioral Causes of Premature Death.” I have bolded important points in that section. He writes:
Improving population health will also require addressing the nonbehavioral determinants of health that we can influence: social, health care, and environmental factors. (To date, we lack tools to change our genes, although behavioral and environmental factors can modify the expression of genetic risks such as obesity.) With respect to social factors, 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…
Schroeder continues:
…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…
Schroeder’s conclusion:
More investment could be made in research efforts designed to improve our understanding of the connection between class and health. More fundamental, however, is the recognition that social policies involving basic aspects of life and well-being (e.g., education, taxation, transportation, and housing) have important health consequences.
The analysis sounds a bit tentative given the explosion of literature about the Social Determinants of Health and the connection to race, class, and poverty over the last decade and a half. At the time of the speech, few physicians and healthcare professionals were talking about the social determinants of health. I was among those giving the subject little attention. We were not social workers. We provided care to patients in the office and hospital.
It is interesting to me that after the successful passage of the Civil Rights Act of 1964 and the Voting Rights Act of 1965, Dr. Martin Luther King, Jr. tried to shift the focus of his movement from the issue of full rights for black Americans to alleviating poverty across all races. From the link to the National Civil Rights Museum, we read:
By 1967, King was repeatedly condemning the “triple evils” of racism, militarism, and poverty. He began defining true integration as a society in which all people – regardless of race or background – would “share equally” not only power but also wealth. Poverty could be abolished completely given that America was one of the richest nations in the world, he held. By reallocating money spent on the Vietnam War to poor people, every citizen finally could afford decent housing and good educations, economic assurances that would literally transform their lives.
The most obvious manifestation of this shift in Dr. King’s focus was the Poor People’s March on Washington which was planned before he was killed and occurred after his death. It is interesting to me that in his last book, Where Do We Go From Here: Chaos or Community?, published in 1967, Dr. King pointed out the need for political power if the problems of racism and poverty were to be effectively addressed. King asserted that demonstrations and marches needed to give way to the exercise of political power through elections if the public policies that could improve poverty for everyone were ever to be passed.
There are many King quotes about poverty. Some are quite “raw” and reveal his passion for the changes necessary to end poverty. He knew that the effort to end poverty would be resisted more vigorously than the effort to gain civil rights or voting rights. One quote aptly uses a reference to cannibalism:
“The curse of poverty has no justification in our age. It is socially as cruel and blind as the practice of cannibalism at the dawn of civilization, when men ate each other because they had not yet learned to take food from the soil or to consume the abundant animal life around them. The time has come for us to civilize ourselves by the total, direct and immediate abolition of poverty.”
It is interesting to note that President Johnson’s call for a Great Society that would eliminate poverty came in concert with the progression of King’s focus from civil rights and voting rights to his demand for policymakers to address the overwhelming social problems created by poverty.
In retrospect, Schroeder’s analysis, more than forty years after Dr. King, may seem somewhat quaint and I am sure that he was not the first clinician to point out the connection between social status and healthcare challenges, but it was his presentation delivered to me through Zeev that broadened my field of vision. With retirement, my ability to engage in the internal improvements of a medical group has declined as more and more years come between me and my leadership responsibilities. It is interesting for me to observe that as I have had less to say about day to day operations of a group practice, I have had more and more to say about the Social Determinants of Health and the highly associated subjects of poverty and healthcare inequities.
As I have explored the Social Determinants of Health I have come across the reality that improvement in the health of the nation will require increasing our understanding of “the Political Determinants of Health.” I first introduced the Political Determinants of Health in these letters on December 2, 2022. At the time, I was referencing an article by Dr. Eric Reinhardt who had written:
Although they treat the sequelae of poverty every day, doctors in the United States have historically failed to use their collective influence to address political etiologies of disease. Now, for the last year, the pandemic has preyed on America’s racial and economic inequalities. This reality has awakened many more doctors to the political determinants of health—the fact that health is not just about health care and is inseparable from power and political struggle. It has also fractured the traditional medical objectivity that records politics as biological misfortune. During the pandemic, calls for equity, justice, and decolonization have grown louder within health care, echoing traditions of social medicine that have long been relegated to the fringes of American medicine.
Since then, especially as the issues for the presidential election have emerged, I have called for the election of a president and a Congress that understands that one of the most effective ways to improve our dismal healthcare outcomes, which are achieved at enormous expense, is to use public policy to address the root cause problems that drive healthcare inequities. I have felt that we need to elect those who understand the need for improvement in the Social Determinants of Health. We need to use our knowledge of the Political Determinants of Health to improve the Social Determinants of Health.
Several recent articles in the Millbank Quarterly have pointed out what should have been more obvious to me long ago, which is that the current problems are the product of long-standing “Structural Determinants of Health.” In an article entitled “Keeping It Political and Powerful: Defining the Structural Determinants of Health” published in the February 2024 issue of the Millbank Quarterly, we read: [As is usually true, the bolding is my addition for emphasis.]
When the World Health Organization (WHO)’s Commission on the Social Determinants of Health (CSDH) published their framework for the social determinants of health (SDOH) in 2010, they intentionally included two distinct concepts in their definition, “distinguishing between the mechanisms by which social hierarchies are created, and the conditions of daily life which then result.” The WHO continues to include both “the conditions in which people are born, grow, live, and age” and “the wider set of forces and systems shaping the conditions of daily life” in their definition. Perhaps responding to prior criticism, the CSDH explicitly called out changing the distribution of power as central to addressing the forces and systems that maintain inequity and was clear that engaging in this work is a political endeavor.
The article includes several key points that define the Structural Determinants of Health that the WHO Commission included in their report with the indication that the Social Determinants of Health were derivative of these factors.
Policy Points [from the World Health Organization (WHO)’s Commission on the Social Determinants of Health (CSDH) published in their framework for the social determinants of health (SDOH) in 2010]
- The structural determinants of health are 1) the written and unwritten rules that create, maintain, or eliminate durable and hierarchical patterns of advantage among socially constructed groups in the conditions that affect health, and 2) the manifestation of power relations in that people and groups with more power based on current social structures work—implicitly and explicitly—to maintain their advantage by reinforcing or modifying these rules.
- This theoretically grounded definition of structural determinants can support a shared analysis of the root causes of health inequities and an embrace of public health’s role in shifting power relations and engaging politically, especially in its policy work.
- Shifting the balance of power relations between socially constructed groups differentiates interventions in the structural determinants of health from those in the social determinants of health.
If the “policy speak” is hard for you to follow, I would summarize the ideas by saying that a combination of historical factors, biases, persistent deleterious public policies that disadvantage the poor, and the power of those self-interests that control the status quo constitute the Structural Determinants of Health that create health inequities and outcomes that we lump together as the Social Determinants of Health. Outcomes decline and healthcare inequality increases as you descend the economic ladder. It will take acknowledgment of and the modification of the Structural Determinants of Health if we are to improve the Social Determinants of Health.
Many public policies will need to be redesigned if we are to overcome our long history of poor decisions and structural disadvantages for the poor if we hope to improve the Social Determinants of Health. The creation of a political environment and the political power necessary to achieve improvement in the Social Determinants of Health will be a challenge to our expertise in using the Political Determinants of Health.
Even more cryptically, I would say we have a cascade of Structural Determinants of Health that determine the Social Determinants of Health. An improvement in the Social Determinants of Health will be dependent upon the Political Determinants of Health which will require the election of policy makers who believe that everyone deserves health equity. That will be good for you to consider when you go to the polls this fall.
On Wednesday, I received another email edition of the Millbank Quarterly which contained an editorial entitled “Sick and Tired of Being Sick and Tired”: Inequality, Disease, and Death in American History. The editorial is excerpted from a new book that is coming out on October 8 entitled Building the Worlds that Kills Us: Disease, Death and Inequality in American History (Columbia University Press). [I have ordered the book. The delivery is scheduled to be in November.]
The phrase “Sick and tired of being sick and tired” is lifted from a 1964 speech by Fanny Lou Hamer. Within the editorial, we read:
To a surprising extent…disease, suffering, and premature death are a function of the worlds that we as a society have constructed for ourselves and for others over time. They are, more particularly, often a function of specific people and groups of people making decisions that create or maintain conditions in which ill-health and suffering can flourish.
The editorial ends with a statement of fact with an implied challenge:
If there is one historical truth that emerges from our history it is that disease is not “caused” by bacteria or viruses or accidents. Rather, it is the conditions we as humans create that provide the nurturing conditions within which they can prosper. As the renowned epidemiologist Rene Dubos once cogently pointed out: Bacteria, he suggested, were only “opportunistic invaders of tissues already weakened by crumbling defenses.”
The challenge that I think is implied is that we don’t have to accept the status quo created by the Structural Determinants of Health. Coordinated political will could lead to new policies that could dramatically improve the Social Determinants of Health and create a more equitable healthcare future.
Acting Locally To Mitigate The Structural Determinants of Health And Improve the Social Determinants of Health
I have never liked the phrase “Compassionate Conservatism” which George Bush popularized during his 2000 presidential campaign against Al Gore. As you remember, President Bush won the election 5 to 4 in the Supreme Court although he lost the popular vote by half a million votes. I have much preferred the phrase, “Think globally, act locally!” which I learned from Don Berwick.
Today’s header pictures my friend Carol in the “pantry” of the Kearsarge Sunapee Food Pantry. Carol is a neighbor who volunteers two days a week at the pantry. I see Carol every other Tuesday morning when I pick up a supply of fresh veggies, frozen foods, milk, eggs, and other items to deliver to a home-bound man. I am proud of the fact that the KLS Food Pantry is housed without charge at the First Baptist Church of New London where I have been a member for almost ten years and the church moderator for almost six years. The church is also the site for the Boys and Girls Club, alcoholics anonymous, the Scouts, and many other community organizations and events. The motto of the church is “Grow, Love, Serve.”
There are other local entities that seek to address the social determinants of health and combat the unavoidable stresses of poverty in our community. Most notable are the Kearsarge Neighborhood Partners (KNP), Kearsarge Regional Ecumenical Ministries (KREM), and Loaves and Fishes which is also a source of financial help located at the local Catholic church, Our Lady of Fatima. I frequently complain that these organizations are necessary in the “Live Free or Die” state where a reluctance to raise taxes has created a very porous social services safety net.
I am proud of the evidence of commitment to the health and welfare of others that I see every day in our community. I encourage you to explore where you might make a difference in your community. We don’t know what sort of political philosophy will be empowered either to improve or ignore the Social Determinants of Health following the election in November which we are told is “too close to call.” What I do believe is that for years to come, there will be a need for caring people to support their neighbors. Take a look around your community and see where your talents might make a difference.
Be well,
Gene
Addendum:
Dear Persistent Reader,
As you may have noted, unlike some other recent letters, I wrote this week without input from ChatGPT! When I finished I could not contain my curiosity about how ChatGPT would have approached the subject or whether it would have even understood its potential significance. I decided to ask.
I fear AI is going to be a humbling experience that will intensify as ChatGPT gets even better, and as I move further into my dotage. In my defense, I did make the subject a little more personal and used some redundancy to emphasize some points.
For those of you old enough to remember the TV show Dragnet, I would say that ChatGPT is a disciple of Sargeant Joe Friday who would cut off a loquacious answer with a curt, “Just the facts Mam.” You might notice that ChatGPT delivered as much information in a thousand words as I did in three thousand words.
So, I asked ChatGPT, “What is the relationship of the Social Determinants of Health to the Structural Determinants of Health and the Political Determinants of Health?” The answer appeared in a couple of seconds:
The Social Determinants of Health (SDOH), Structural Determinants of Health, and Political Determinants of Health (PDOH) are interconnected concepts that together shape the health and well-being of individuals and populations. Each determinant plays a unique but overlapping role in influencing health outcomes, primarily through creating or mitigating health inequities.
1. Social Determinants of Health (SDOH)
Social Determinants of Health refer to the non-medical factors that influence health outcomes. These include the conditions in which people are born, grow, live, work, and age. Common examples of SDOH include:
- Education: Access to quality education impacts health literacy and employment opportunities.
- Income and Social Status: Higher income and social status often result in better health outcomes.
- Access to Healthcare: Availability of and access to medical services directly impact health outcomes.
- Neighborhood and Built Environment: Safe, clean living environments and access to healthy food are critical for physical and mental well-being.
The World Health Organization (WHO) emphasizes that SDOH are largely responsible for health inequities, or the unfair and avoidable differences in health status seen within and between countries.
2. Structural Determinants of Health
Structural determinants of health refer to the broad, systemic conditions that shape social hierarchies and inequities, which in turn affect SDOH. These structural determinants include societal organization, policies, and governance systems that influence the distribution of resources and power. Structural determinants impact health by determining:
- Economic Systems: How wealth and resources are distributed impacts income inequality, which in turn affects access to housing, healthcare, and education.
- Social Policies: Policies related to labor, welfare, housing, and healthcare shape the environments in which people live and work.
- Cultural and Social Norms: Cultural attitudes and institutional biases (e.g., racism, sexism, xenophobia) can systematically disadvantage certain groups and affect their access to SDOH.
The structural determinants help explain how power imbalances and systemic inequities shape the more immediate social determinants of health. For instance, institutional racism can lead to poorer housing, education, and employment opportunities for marginalized communities, which are critical SDOH.
3. Political Determinants of Health (PDOH)
The Political Determinants of Health are the decisions, policies, and governance actions that directly or indirectly impact health outcomes and create health disparities. The political determinants often drive structural and social determinants. Some examples of political determinants include:
- Healthcare Policy: Decisions about who gets access to healthcare, how it is funded, and what services are covered have profound impacts on population health.
- Immigration Laws: Policies that determine access to healthcare for immigrants or undocumented workers can exclude vulnerable populations from necessary health services.
- Economic and Social Welfare Policies: Decisions about minimum wage, social safety nets, and employment protections influence income distribution and access to essential services, thus affecting health outcomes.
The PDOH framework, as articulated by public health scholars like Daniel E. Dawes, emphasizes that political actions shape the structural conditions that either promote or inhibit health equity. Political determinants operate by influencing policies that govern areas such as housing, education, transportation, and healthcare—key components of the social determinants of health.
Relationship Between the Three Determinants
- Interdependency: The three determinants are highly interconnected. Political determinants shape the structural environment, which in turn influences the social determinants of health. For instance, a political decision to cut funding for public housing can create structural inequities (lack of affordable housing), which then negatively impacts social determinants (e.g., increased homelessness or housing insecurity).
- Top-Down Influence: Political Determinants are often at the top of the causal chain. Political decisions (e.g., healthcare policy, tax laws) affect the structural framework (e.g., economic policies, social justice), which then creates the conditions in which social determinants, such as education and employment, operate.
- Health Inequities: Together, the political, structural, and social determinants create a framework that either perpetuates or mitigates health disparities. Health inequities are largely driven by the unequal distribution of power, resources, and opportunities as structured by political and structural forces, which directly impact social conditions like education, income, and housing.
Example: Housing and Health
- Political Determinants: A policy decision to reduce funding for affordable housing programs (a political determinant) creates a structural environment where affordable housing becomes scarce.
- Structural Determinants: The lack of investment in affordable housing exacerbates structural inequities, making it harder for low-income individuals to find stable, affordable living conditions.
- Social Determinants: As a result, people in affected communities experience poorer housing conditions (a social determinant), which may increase exposure to environmental hazards like mold or air pollution, impacting their health.
Improving Health through Addressing Determinants
To improve population health, particularly among disadvantaged groups, policymakers need to address the political and structural drivers of health inequities. This requires:
- Equitable Policy-Making: Enacting policies that promote equal access to education, healthcare, and housing.
- Systemic Reform: Reforming structural systems, such as economic and social policies, to ensure fair distribution of resources.
- Community Empowerment: Engaging marginalized populations in the political process to ensure their needs are met.
Conclusion
In summary, the Social Determinants of Health are the everyday conditions that directly impact health outcomes. The Structural Determinants shape the distribution of these social determinants by creating systems of inequality or equity. Finally, the Political Determinants are the decisions and policies that create the structural framework, making them the foundational drivers of health disparities. To achieve health equity, all three determinants must be addressed, with a particular focus on reforming the political and structural systems that perpetuate inequality.
I am impressed. I have got to believe that AI could be a tool that could help us transform healthcare and take down the centuries of structural barriers to the improvement of the Social Determinants of Health..
Once again,
Be well,
Gene
