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."
Scientists use new methods to discover what's inside drug containers used by ancient Mayan people.
- Archaeologists used new methods to identify contents of Mayan drug containers.
- They were able to discover a non-tobacco plant that was mixed in by the smoking Mayans.
- The approach promises to open up new frontiers in the knowledge of substances ancient people consumed.
PARME staff archaeologists excavating a burial site at the Tamanache site, Mérida, Yucatan.
A new study looks at why mysterious voices are sometimes taken as spirits and other times as symptoms of mental health issues.
- Both spiritualist mediums and schizophrenics hear voices.
- For the former, this constitutes a gift; for the latter, mental illness.
- A study explores what the two phenomena have in common.
The study<img type="lazy-image" data-runner-src="https://assets.rebelmouse.io/eyJhbGciOiJIUzI1NiIsInR5cCI6IkpXVCJ9.eyJpbWFnZSI6Imh0dHBzOi8vYXNzZXRzLnJibC5tcy8yNTQ5Nzc1OS9vcmlnaW4uanBnIiwiZXhwaXJlc19hdCI6MTYxOTU1ODQwOX0.wlQLO9cjh2hFAz9BXwf2DpaqwepAlybru_OH6J4ZwzI/img.jpg?width=980" id="d04f9" class="rm-shortcode" data-rm-shortcode-id="f0534bcc03c74a09cc45445de779df40" data-rm-shortcode-name="rebelmouse-image" data-width="1440" data-height="1373" />
Credit: Camila Quintero Franco/Unsplash<p>The researchers, led by <a href="https://www.dur.ac.uk/research/directory/staff/?mode=staff&id=15156" target="_blank">Adam Powell</a> of Durham University's Hearing the Voice project and Department of Theology and Religion interviewed conducted online surveys of 65 clairaudient mediums they found through contact with spiritualist communities. The survey also included 143 people from the general population who responded in the affirmative to the question "Have you ever had an experience you would describe as 'clairaudient?'" posed through an online study recruitment tool.</p><p>All participants spoke English and were aged 18-75. 84.4% were from the U.K.with the rest mostly from the North Americas, Europe, or Australasia.</p><p>Of the spiritualists surveyed, 79% said hearing voices was a normal part of their lives at church and at home, while 44.6% said that they heard voices every day. Most respondents reported the voices as being inside their heads, though 31.7% said they came from outside their bodies.</p><p>Not surprisingly, more spiritualists reported believing in the paranormal than did the general population participants. They also cared less about what others thought of them.</p><p>Both groups were prone to visual hallucinations as well.</p>
Youth and absorption<img type="lazy-image" data-runner-src="https://assets.rebelmouse.io/eyJhbGciOiJIUzI1NiIsInR5cCI6IkpXVCJ9.eyJpbWFnZSI6Imh0dHBzOi8vYXNzZXRzLnJibC5tcy8yNTQ5Nzc2NS9vcmlnaW4uanBnIiwiZXhwaXJlc19hdCI6MTYzNzE3MTUyNn0.BsqsYO4KFNF9RX9O6TXYE14RysJgiwXua7FegMBf8Ss/img.jpg?width=980" id="5fe11" class="rm-shortcode" data-rm-shortcode-id="6fb24471c94f7e69617c763927c1dc0e" data-rm-shortcode-name="rebelmouse-image" data-width="1440" data-height="1080" />
Credit: Tanner Boriack/Unsplash<p>Spiritualist clairaudients reported their first experiences with other voices early in life. Of these participants, 18% said they had heard voices for as long as they remembered. The average age, however, for first hearing voices was 21.7 years. Schizophrenia typically presents when a person is somewhat older than this, in the <a href="https://www.mayoclinic.org/diseases-conditions/childhood-schizophrenia/symptoms-causes/syc-20354483" target="_blank">late 20s</a>.</p><p>Significantly, 71% said their experience with voices pre-dated their awareness of spiritualism. Rather than religion prompting the hearing of voices, it seems that it's more like the other way around — voices led them to religion.</p><p>Says Powell, "Our findings say a lot about 'learning and yearning.' For our participants, the tenets of spiritualism seem to make sense of both extraordinary childhood experiences as well as the frequent auditory phenomena they experience as practicing mediums."</p><p>Still, the voices came first he says, so "all of those experiences may result more from having certain tendencies or early abilities than from simply believing in the possibility of contacting the dead if one tries hard enough."</p><p>The more likely factor is spiritualist clairaudients' relationship with absorption. Responses to questions based on the 34-point <a href="https://www.ocf.berkeley.edu/~jfkihlstrom/TAS.htm" target="_blank">Tellegen Absorption Scale</a> revealed that these people tended toward absorptive personality characteristics. These are described by the study's authors as "being readily captured by entrancing stimuli, reporting vivid mental imagery, becoming immersed in one's own thoughts."</p><p>Some, though not all, voice-hearing individuals from the general population were found to exhibit high levels of absorption — those that did were more likely to believe in the paranormal than others.</p>
Implications<p>The study's finding regarding the relative young ages at which spiritualist clairaudients begin hearing voices suggests that these individuals' more welcoming attitude toward the phenomenon may have to do with malleability of youth — a belief in the fantastical is part of being young.</p><p>Says co-author <a href="https://www.northumbria.ac.uk/about-us/our-staff/m/peter-moseley/" target="_blank">Peter Moseley</a> of Northumbria University, "Spiritualists tend to report unusual auditory experiences which are positive, start early in life and which they are often then able to control. Understanding how these develop is important because it could help us understand more about distressing or non-controllable experiences of hearing voices too."</p><p>The authors of the study do note, however, that their findings leave two big unanswered questions: Does a tendency toward absorption reveal "a predisposition to having RSEs or a belief in the plausibility of having RSEs?"</p><p>The other obvious big question? It's beyond the scope of this survey, but are those really the voices of the dead?</p>
Dr. Eric Lander is a pioneer in genomics. What role will he play in the new administration?
- Dr. Lander is a mathematician and geneticist who's best known for his leading role in the Human Genome Project.
- Biden nominated Dr. Lander to head the Office of Science and Technology Policy and also serve as a cabinet-level science adviser, marking the first time the position has been part of the presidential cabinet.
- In an open letter, Biden said it's essential for the U.S. to "refresh and reinvigorate our national science and technology strategy to set us on a strong course for the next 75 years."
Who is Dr. Eric Lander?<p>Born in Brooklyn, New York, Dr. Lander started his academic career as a mathematician, often arriving at high school an hour early to do math. He won multiple awards in mathematics in his teens, including the Mathematical Olympiad in 1974.<br></p><p>Finding mathematics "too monastic" to pursue as a career, he began teaching managerial economics at Harvard Business School. Then, at the <a href="https://www.worldsciencefestival.com/videos/eric-lander-the-genesis-of-genius/" target="_blank">encouragement of his brother</a>, a neurobiologist, Dr. Lander became interested in studying neurobiology and microbiology. This pushed him to his main lifelong pursuit: unraveling the mysteries of the human genome.</p><p>Dr. Lander spent more than a decade as a leader within the Human Genome Project, which provided the world a complete map of all human genes in 2003. In 2004, he founded the Broad Institute, a biomedical and genomic nonprofit research center that partners with M.I.T. and Harvard University.</p>
Pixabay<p>Broad's <a href="https://www.broadinstitute.org/news-multimedia/basic-q-about-broad-institute" target="_blank">mission</a> is to "fulfill the promise of genomics by creating comprehensive tools for biology and medicine, making them broadly available to the world and applying them to the understanding of human biology and the diagnosis, treatment, and cure of human diseases." The institute aims to diminish diseases by better understanding cellular mechanisms, rather than simply treating symptoms.</p><p>Despite some <a href="https://www.statnews.com/2016/01/25/why-eric-lander-morphed/" target="_blank">minor controversies and patent disputes</a>, Dr. Lander remains a monumental figure in American science, and also previously served as co-chairman of former President Barack Obama's science advisory council.</p>
What will Dr. Lander do in the Biden administration?<p>If confirmed by the Senate, it's not exactly clear what Dr. Lander will do in his role as cabinet science adviser and head of the OSTP. But his primary focus likely won't be COVID-19, considering Biden has already established a task force dedicated to shaping policy and recommendations related to the pandemic.<br></p><p>But Biden revealed some of his expectation in an <a href="https://buildbackbetter.gov/wp-content/uploads/2021/01/OSTP-Appointment.pdf" target="_blank">open letter</a> that posed five questions for the Office of Science and Technology Policy to explore:</p><ol><li>What can we learn from the pandemic about what is possible—or what ought to be possible— to address the widest range of needs related to our public health?</li><li>How can breakthroughs in science and technology create powerful new solutions to address climate change—propelling market-driven change, jump-starting economic growth, improving health, and growing jobs, especially in communities that have been left behind?</li><li>How can the United States ensure that it is the world leader in the technologies and industries of the future that will be critical to our economic prosperity and national security, especially in competition with China?</li><li>How can we guarantee that the fruits of science and technology are fully shared across America and among all Americans?</li><li>How can we ensure the long-term health of science and technology in our nation?</li></ol><p>The president-elect wrote that it's essential to "refresh and reinvigorate our national science and technology strategy to set us on a strong course for the next 75 years," concluding:</p><p style="margin-left: 20px;">"I believe that the answers to these questions will be instrumental in helping our nation embark on a new path in the years ahead—a path of dignity and respect, of prosperity and security, of progress and common purpose. They are big questions, to be sure, but not as big as America's capacity to address them. I look forward to receiving your recommendations—and to working with you, your team, and the broader scientific community to turn them into solutions that ease everyday burdens for the American people, spark new jobs and opportunities, and restore American leadership on the world stage."</p>
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