The social determinants of health, explained
Want to tell someone's future in the US? You don't need a crystal ball, just their zip code.
Kevin Dickinson has been an independent writing consultant since 2011. During that time, he's worked as an educator, editor, journalist, and researcher, and written on subjects ranging from religion to Dr. Seuss, film history to Mars' surplus of iron oxide.
- Social determinants of health, such as income and access to healthy food, affect well-being long before people may enter medical facilities.
- They're one reason neighborhoods in the same city can maintain life expectancy gaps larger than a decade.
- With growing awareness of how societal ills determine health, medical professionals and their partners are devising more holistic approaches to health.
New York City is a vibrant, vivacious city. No one knows this better than the people who live on its Upper East Side. Residents of this Manhattan neighborhood enjoy easy access to Central Park, a panoply of top-tier restaurants and markets, and some of the country's most renowned museums and cultural venues. But the real perk to calling the Upper East Side home is measured in years.
Upper East Side residents maintain an average life expectancy of 86.4 years, a number on par with the most peaceful, prosperous countries in the world. For a population to enjoy so many precious years represents historic achievements in education, infrastructure, and health care. Yet these hard-won achievements have not been distributed equally. A mere 15 miles away, in the Brooklyn neighborhood of Brownsville, the average life expectancy is a full decade shorter.
Just 15 miles from Brownsville, Brooklyn, residents of the Upper East Side in Manhattan have an average life expectancy of 86.4 years.
Source: NYC DOHMH; Bureau of Vital Statistics, 2006-2015
Such life-expectancy gaps are common across the United States. Residents of Chicago's Streeterville neighborhood can rest easy knowing they will live to be, on average, 90 years old. Chicago's Englewood neighborhood, however, maintains a life expectancy of around 60 years. That's ten years lower than the world average—in the world's most affluent country. The phenomenon is not just an urban affliction. On the whole, rural community members have lower life expectancies as they become more likely to die from these five leading causes than their city-dwelling peers.
While it may be tempting to write off these life gaps as the result of lifestyle choices or bad luck, they aren't. They are the consequences of a complex intersection between social, environmental, and cultural conditions that fall under 'social determinants of health.'
You can have the best treatments, the best physicians, the best facilities, but unless a patient's non-clinical needs are addressed, none of it will make a difference.
The 80/20 rule of health
Social determinants of health are those conditions in a person's life and environment that can either aid or degrade their health. They include employment, education, food availability, living conditions, communal support, neighborhood quality, socioeconomic status, and the wider systems that surround these conditions. When such determinants aren't wholesome, they erode health long before someone enters a hospital—at which point, health professionals may have only minutes to turn the tide of years of eroded health.
As Udai Tambar, vice president for community health at Northwell Health, said, "You can't medicate for social issues, and that's, in a way, the system we have developed. We're trying to medicate for social risks and social factors. You can have the best treatments, the best physicians, the best facilities, but unless a patient's non-clinical needs are addressed, none of it will make a difference."
Today, experts generally agree that 20 percent of health outcomes are derived from the care received at medical facilities, 80 percent from the non-clinical care attributed to one's lifestyle, environment, and social circumstances.
The data bear this out. U.S. health-care spending has nearly quadrupled since 1980, and the country has invested that bankroll heavily in hospitals, nursing facilities, prescription drug development, and medical specialist training. Each is valuable in its own right, yet as a systematic whole, this massive, decades-long investment has not netted proportionate health dividends. In addition to country-wide life gaps, the U.S. has one of the lowest life expectancies, the highest suicide rate, the highest chronic disease burden, and the highest obesity rate when compared to other major OECD nations.
These other OECD countries don't spend more on health than the United States. In terms of absolute dollars, the U.S. handily outspends these countries. Instead, these countries spend a larger portion of their GDP on social services, helping to mitigate deleterious social determinants long before a hospital visit. By one estimate, other major OECD countries allot, on average, $1.70 for social spending for every dollar on health. The U.S. system is almost the inverse, spending .56 cents on social services for every dollar on health.
"You need social equity to get health equity," Tambar added.
There’s no pill to cure poverty
This pattern of spending is one reason for the U.S. health-wealth divide, a pernicious and destructive social determinant of health. We've seen this divide's handiwork in the life expectancy differences between the Upper East Side and Brownsville, but those are samples of a whole. According to a 2017 paper in The Lancet, the "life expectancy of the wealthiest Americans now exceeds that of the poorest by 10-15 years." And these life-gap metrics signal the end consequences of a myriad of unmet social needs.
Consider the health barriers common in impoverished areas, where residents lack access to healthy, affordable food. Limited funds make it impossible to update or maintain safe housing without mold or lead-contaminated paint or water pipes. Narrow or nonexistent transportation options cut off residents from employment opportunities or health-care access. And being surrounded by street crime, unsafe public spaces or no greenways generates sustained high stress, which research shows grinds away at our physical health as fiercely as it does our mental wellbeing.
Each of these conditions is bitter in and of itself, but these social determinants often come packaged as part of a social circuit that magnifies the effects of each.
Unfortunately, dietary fads and the U.S.'s rugged individualism have loudly espoused health to be the culmination of lifestyle choices (for some, even moral rectitude). While lifestyle and choice certainly have their role, an understanding of these social determinants shows how inextricably tied our choices are to our social conditions. As Tambar points out, a person can be well-versed in nutrition, but if their neighborhood is a food desert, their choices are constrained. Social circumstances can limit or adversely influence health in inimical ways.
As Dr. Mary Travis Bassett, Director of the FXB Center for Health and Human Rights at Harvard University, told Big Think: "Nobody picks a substandard building to live in with terrible issues of rodent infestation and indoor allergens that trigger asthma. That's not a lifestyle choice. […] It's not about choice; it's about the fact that people don't have enough choice."
Going to the source
Credit: Getty Images
Negative social determinants of health provide a massive challenge to the health-care community, but experts and medical professionals aren't powerless to meet it. As Michael Dowling, CEO of Northwell Health, writes in his book "Health Care Reboot":
This trend toward greater awareness of the social determinants of health is one of the most encouraging developments in health care, for it creates greater awareness among providers of the whole patient, including all of the various elements—most of them outside what might be considered strictly medical issues—that affect an individual's overall health and wellbeing.
An outgrowth of this growing trend goes by the name "upstreamism." Upstreamist practitioners don't only focus on the patient's downstream symptoms; instead, they also turn their attention upstream to incorporate the patient's social determinants of health in their diagnosis. Dowling illustrates this paradigm with an example of a patient with chronic, life-interrupting headaches. Her upstreamist doctor provided her the usual medication but added the unusual prescription of a visit by a community health worker. The health worker found the patient's apartment walls to be infested with high levels of mold. The doctor and health worker told the patient to have her landlord fix the problem and provided the number for a public-interest attorney should the landlord fail to comply.
Dowling's story shows the holistic approach of upstreamism: to take into account all the determinants of health, not only those found within hospital walls. Sometimes, Dowling notes, that will require medical professionals to take the lead. But other times, when there are extra-symptomatic drivers of health, it will mean partnering with or supporting social service workers, law enforcement, or legal minds to secure a combination of services to heal the whole person.
It's for these reasons that many health-care organizations are spearheading initiatives and outreach programs to directly target social determinants of health before they become medical issues. Examples include Northwell's first-of-its-kind gun-violence screening program and the American Academy of Pediatrics' fight for food security for U.S. children.
As Tambar points out, this holistic outlook means changing our approach to more than just medicine. It will require many aspects of our society to adopt a multi-lens approach, one that adds an interdisciplinary depth to social problems beyond a solitary profession's expertise. He concluded, "What people are realizing is to holistically serve someone, it's not about you doing it all. It's about partnering with the best person who can do something you can't do."
There's a lot to love about the innovations of Scrivener 3 for the Mac.
- Most word processors are not suitable for long-form writing projects.
- Scrivener 3 for Mac addresses specifically what is lacking in its competitors.
- At an affordable price, Scrivener 3 is the best option on the market for writers.
During a quarantine in the 17th century, Shakespeare wrote what many consider to be his greatest masterpiece, King Lear. There’s a certain inspiration that comes from isolation. In fact, even today, a great number of people have been inspired to write in their time alone. But sooner or later, it becomes apparent that attempting to write seriously on platforms like Microsoft Word and Google Docs is a futile endeavor.
That’s why writing professionals around the world use Scrivener. Scrivener is a word processor and project management tool that is there for writers from the first idea to the final draft. It has all the features you’ve come to expect from other word processors and new features, such as allowing you to compose your text in any order and then combine it later on in sections as large or small as you desire. In addition, the split view and corkboard settings allow you to take a step back and look at the bigger picture of your project, which means the ability to rearrange your manuscript quickly and efficiently. And the outliner feature makes it easy to outline your work throughout the writing process, an essential part of any long-form project which must be accounted for.
To get serious about writing, one must make sure they're writing on a proper platform, which accounts for the unique necessities and requirements of taking on any kind of extensive written project. Scrivener is the ideal word processor because it looks after everything one could desire as a writer, and for an affordable price.
You can get Scrivener 3 for Mac on sale for just $29.99 (regularly $49) and begin investing in your writing like you never have before.
Prices subject to change.
When you buy something through a link in this article or from our shop, Big Think earns a small commission. Thank you for supporting our team's work.
This spring, a U.S. and Chinese team announced that it had successfully grown, for the first time, embryos that included both human and monkey cells.
In the novel, technicians in charge of the hatcheries manipulate the nutrients they give the fetuses to make the newborns fit the desires of society. Two recent scientific developments suggest that Huxley's imagined world of functionally manufactured people is no longer far-fetched.
On March 17, 2021, an Israeli team announced that it had grown mouse embryos for 11 days – about half of the gestation period – in artificial wombs that were essentially bottles. Until this experiment, no one had grown a mammal embryo outside a womb this far into pregnancy. Then, on April 15, 2021, a U.S. and Chinese team announced that it had successfully grown, for the first time, embryos that included both human and monkey cells in plates to a stage where organs began to form.
As both a philosopher and a biologist I cannot help but ask how far researchers should take this work. While creating chimeras – the name for creatures that are a mix of organisms – might seem like the more ethically fraught of these two advances, ethicists think the medical benefits far outweigh the ethical risks. However, ectogenesis could have far-reaching impacts on individuals and society, and the prospect of babies grown in a lab has not been put under nearly the same scrutiny as chimeras.
Mouse embryos were grown in an artificial womb for 11 days, and organs had begun to develop.
Growing in an artificial womb
When in vitro fertilization first emerged in the late 1970s, the press called IVF embryos “test-tube babies," though they are nothing of the sort. These embryos are implanted into the uterus within a day or two after doctors fertilize an egg in a petri dish.
Before the Israeli experiment, researchers had not been able to grow mouse embryos outside the womb for more than four days – providing the embryos with enough oxygen had been too hard. The team spent seven years creating a system of slowly spinning glass bottles and controlled atmospheric pressure that simulates the placenta and provides oxygen.
This development is a major step toward ectogenesis, and scientists expect that it will be possible to extend mouse development further, possibly to full term outside the womb. This will likely require new techniques, but at this point it is a problem of scale – being able to accommodate a larger fetus. This appears to be a simpler challenge to overcome than figuring out something totally new like supporting organ formation.
The Israeli team plans to deploy its techniques on human embryos. Since mice and humans have similar developmental processes, it is likely that the team will succeed in growing human embryos in artificial wombs.
To do so, though, members of the team need permission from their ethics board.
CRISPR – a technology that can cut and paste genes – already allows scientists to manipulate an embryo's genes after fertilization. Once fetuses can be grown outside the womb, as in Huxley's world, researchers will also be able to modify their growing environments to further influence what physical and behavioral qualities these parentless babies exhibit. Science still has a way to go before fetus development and births outside of a uterus become a reality, but researchers are getting closer. The question now is how far humanity should go down this path.
Chimeras evoke images of mythological creatures of multiple species – like this 15th-century drawing of a griffin – but the medical reality is much more sober. (Martin Schongauer/WikimediaCommons)
Human–monkey hybrids might seem to be a much scarier prospect than babies born from artificial wombs. But in fact, the recent research is more a step toward an important medical development than an ethical minefield.
If scientists can grow human cells in monkeys or other animals, it should be possible to grow human organs too. This would solve the problem of organ shortages around the world for people needing transplants.
But keeping human cells alive in the embryos of other animals for any length of time has proved to be extremely difficult. In the human-monkey chimera experiment, a team of researchers implanted 25 human stem cells into embryos of crab-eating macaques – a type of monkey. The researchers then grew these embryos for 20 days in petri dishes.
After 15 days, the human stem cells had disappeared from most of the embryos. But at the end of the 20-day experiment, three embryos still contained human cells that had grown as part of the region of the embryo where they were embedded. For scientists, the challenge now is to figure out how to maintain human cells in chimeric embryos for longer.
Regulating these technologies
Some ethicists have begun to worry that researchers are rushing into a future of chimeras without adequate preparation. Their main concern is the ethical status of chimeras that contain human and nonhuman cells – especially if the human cells integrate into sensitive regions such as a monkey's brain. What rights would such creatures have?
However, there seems to be an emerging consensus that the potential medical benefits justify a step-by-step extension of this research. Many ethicists are urging public discussion of appropriate regulation to determine how close to viability these embryos should be grown. One proposed solution is to limit growth of these embryos to the first trimester of pregnancy. Given that researchers don't plan to grow these embryos beyond the stage when they can harvest rudimentary organs, I don't believe chimeras are ethically problematic compared with the true test–tube babies of Huxley's world.
Few ethicists have broached the problems posed by the ability to use ectogenesis to engineer human beings to fit societal desires. Researchers have yet to conduct experiments on human ectogenesis, and for now, scientists lack the techniques to bring the embryos to full term. However, without regulation, I believe researchers are likely to try these techniques on human embryos – just as the now-infamous He Jiankui used CRISPR to edit human babies without properly assessing safety and desirability. Technologically, it is a matter of time before mammal embryos can be brought to term outside the body.
While people may be uncomfortable with ectogenesis today, this discomfort could pass into familiarity as happened with IVF. But scientists and regulators would do well to reflect on the wisdom of permitting a process that could allow someone to engineer human beings without parents. As critics have warned in the context of CRISPR-based genetic enhancement, pressure to change future generations to meet societal desires will be unavoidable and dangerous, regardless of whether that pressure comes from an authoritative state or cultural expectations. In Huxley's imagination, hatcheries run by the state grew a large numbers of identical individuals as needed. That would be a very different world from today.
Sahotra Sarkar, Professor of Philosophy and Integrative Biology, The University of Texas at Austin College of Liberal Arts
Scientists should be cautious when expressing an opinion based on little more than speculation.
- In October 2017, a strange celestial object was detected, soon to be declared our first recognized interstellar visitor.
- The press exploded when a leading Harvard astronomer suggested the object to have been engineered by an alien civilization.
- This is an extraordinary conclusion that was based on a faulty line of scientific reasoning. Ruling out competing hypotheses doesn't make your hypothesis right.
Sometimes, when you are looking for something ordinary, you find the unexpected. This is definitely the case with the strange 'Oumuamua, which made international headlines as a potential interstellar visitor. Its true identity remained obscure for a while, as scientists proposed different explanations for its puzzling behavior. This is the usual scientific approach of testing hypotheses to make sense of a new discovery.
What captured the popular imagination was the claim that the object was no piece of rock or comet, but an alien artifact, designed by a superior intelligence.
Do you remember the black monolith tumbling through space in the classic Stanley Kubrick movie 2001: A Space Odyssey? The one that "inspired" our ape-like ancestors to develop technology and followed humanity and its development since then? What made this claim amazing is that it wasn't coming from the usual UFO enthusiasts but from a respected astrophysicist from Harvard University, Avi Loeb, and his collaborator Shmuel Bialy. Does their claim really hold water? Were we really visited by an alien artifact? How would we know?
A mystery at 200,000 miles per hour
Before we dive into the controversy, let's examine some history. 'Oumuamua was discovered accidentally by Canadian astronomer Robert Weryk while he was routinely reviewing images captured by the telescope Pan-STARRS1 (Panoramic Survey and Rapid Response System 1), situated atop the ten-thousand-foot Haleakala volcanic peak on the Hawaiian island of Maui. The telescope scans the skies in search of near-Earth objects, mostly asteroids and possibly comets that come close to Earth. The idea is to monitor the solar system to learn more about such objects and their orbits and, of course, to sound the alarm in case of a potential collision course with Earth. Contrary to the objects Weryk was used to seeing, mostly moving at about 40,000 miles per hour, this one was moving almost five times as fast — nearly 200,000 miles per hour, definitely an anomaly.
Intrigued, astronomers tracked the visitor while it was visible, concluding that it indeed must have come from outside our solar system, the first recognized interstellar visitor. Contrary to most known asteroids that move in elliptical orbits around the sun, 'Oumuamua had a bizarre path, mostly straight. Also, its brightness varied by a factor of ten as it tumbled across space, a very unusual property that could be caused either by an elongated cigar shape or by it being flat, like a CD, one side with a different reflectivity than the other. The object, 1I/2017 U1, became popularly known as 'Oumuamua, from the Hawaiian for "scout."
In their paper, Loeb and Bialy argue that the only way the object could be accelerated to the speeds observed was if it were extremely thin and very large, like a sail. They estimated that its thickness had to be between 0.3 to 0.9 millimeters, which is extremely thin. After confirming that such an object is robust enough to withstand the hardships of interstellar travel (e.g., collision with gas particles and dust grains, tensile stresses, rotation, and tidal forces), Loeb and Bialy conclude that it couldn't possibly be a solar system object like an asteroid or comet. Being thus of interstellar origin, the question is whether it is a natural or artificial object. This is where the paper ventures into interesting but far-fetched speculation.
I'm not saying it was aliens, but it was aliens
First, the authors consider that it might be garbage "floating in interstellar space as debris from advanced technological equipment," ejected from its own stellar system due to its non-functionality; essentially, alien space junk. Then, they suggest that a "more exotic scenario is that 'Oumuamua may be a fully operational probe sent intentionally to Earth vicinity by an alien civilization," [italicized as in the original] concluding that a "survey for lightsails as technosignatures in the solar system is warranted, irrespective of whether 'Oumuamua is one of them."
You can shoot down as many hypotheses as you want to vindicate yours, but this doesn't prove yours is the right one.
I have known Avi Loeb for decades and consider him a serious and extremely talented astrophysicist. His 2018 paper includes a suggestive interpretation of strange data that obviously sparks the popular imagination. Theoretical physicists routinely suggest the existence of traversable wormholes, multiverses, and parallel quantum universes. Not surprisingly, Loeb was highly in demand by the press to fill in the details of his idea. A book followed, Extraterrestrial: The First Sign of Intelligent Life Beyond Earth, and its description tells all: "There was only one conceivable explanation: the object was a piece of advanced technology created by a distant alien civilization."
This is where most of the scientific establishment began to cringe. One thing is to discuss the properties of a strange natural phenomenon and rule out more prosaic hypotheses while suggesting a daring one. Another is to declare to the public that the only conceivable explanation is one that is also speculative. An outsider will conclude that a reliable scientist has confirmed not only the existence of extraterrestrial life but of intelligent and technologically sophisticated extraterrestrial life with an interest in our solar system. I wonder if Loeb considered the impact of his words and how they reflect on the scientific community as a whole.
This is why aliens won't talk to us
Earlier this year, in a live public lecture hosted by the Catholic University of Chile, Avi Loeb locked horns with Jill Tarter, the scientist that is perhaps most identifiable as someone who spent her career looking for signs of extraterrestrial intelligence. (Coincidentally, I was the speaker that followed Loeb the next week in the same seminar series and was cautioned — along with the other panelists — to behave myself to avoid another showdown. I smiled, knowing that my topic was pretty tame in comparison. I mean, how can the limits of human knowledge compare with alien surveillance?)
The Loeb-Tarter exchange was awful and, it being a public debate, was picked up by the press. Academics can be rough like anyone else. But the issue goes deeper.
What scientists say matters. When should a scientist make public declarations about a cutting-edge topic with absolute certainty? I'd say never. There is no clear-cut certainty in cutting-edge science. There are hypotheses that should be tested more until there is community consensus. Even then, consensus is not guaranteed proof. The history of science is full of examples where leading scientists were convinced of something, only to be proven wrong later.
The epistemological mistake Loeb committed was to make an assertion that publicly amounted to certainty by using a process of elimination of other competing hypotheses. You can shoot down as many hypotheses as you want to vindicate yours, but this doesn't prove yours is the right one. It only means that the other hypotheses are wrong. I do, however, agree with Loeb when he says that 'Oumuamua should be the trigger for an increase in funding for the search for technosignatures, a way of detecting intelligent extraterrestrial life.
SMARTER FASTER trademarks owned by Freethink Media, Inc. All rights reserved.