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The Social Determinants of Health: Critique and Implications

Of all the healthcare topics in vogue these days, the phrase “social determinants of health” (SDOH) has enjoyed an increasingly prominent place in both practice and policy. First inspired by Geoffrey Rose’s 1992 book, The Strategy for Preventative Medicine, and then mainstreamed by the WHO in the early 2000s, the term is now ubiquitous in public health literature. The CDC has defined SDOH as “conditions in the places where people live, learn, work, and play that affect a wide range of health and quality-of-life risks and outcomes.” Under such a broad definition, it is difficult to disentangle the difference between SDOH and the mere happenstance of life, or to grasp why this is an area in which public health officials should be so heavily involved. While such factors undoubtedly matter for health outcomes, the slanted narrative in this brand of literature omits some important social influences on health. This is particularly puzzling given the widening net experts have cast around these problems. Without assessing such issues in SDOH literature, it is impossible to know if this is a desirable paradigm for health models to continue adopting.

“Social determinants”–omissions and overreach

The CDC has a laundry list of programs and initiatives to address SDOH, and while some of these address real issues with prominent downstream health effects (the Childhood Lead Poisoning Prevention Program is a good example), others leave out essential health factors. These omissions and biases make them less effective at promoting wellness than they are at encouraging increased spending on Federal and State programs. For instance, the “Essentials for Childhood” program claims to provide a framework for promoting “relationships and environments that help children grow up to be healthy and productive members of their communities.”1 This is quite the daunting task to begin with, but nowhere in the document can the promotion of the two-parent household be found. It includes many allusions to community support of children (and states that we are “all” responsible for their well-being), but the promotion of a two-parent norm gets nary a mention.

Reading through the policy section of the “Essentials for Childhood” document, it is noticeable that nearly all the legislative areas mentioned would be better strengthened by sustained parenting commitments and traditional two-parent marriage. For instance, the approaches proposed to reduce child physical abuse mainly create new (or expand existing) government programs, but none promotes children remaining with the birth parents in a stable household. This is particularly odd since one of the single greatest risk factors for physical child abuse is the presence of a stepparent, and children living with married biological parents have the lowest risk.2 The CDC lists many risk factors and protective factors related to child abuse, but the greatest risk factor and protective factor—a stepparent and married biological parents, respectively—are suspiciously absent. Even the preventative strategies section strays from promoting the traditional household and instead claims it is better to focus on “changing social norms” by adopting “legislative approaches to reduce corporal punishment.”

Despite this omission, SDOH literature rarely misses an opportunity to comment on socioeconomic status and its effect on healthcare access and outcomes. There is little room for disagreement here: greater wealth has an unsurprising correlation with healthy aging and healthcare access. The recommended solutions proposed by these reviews invariably involve some form of insurance expansion and income supplementation. But, whatever the merits or demerits of such proposals, it is again notable that the traditional two-parent household has a stronger correlation with rising wealth and childhood health outcomes than alternative household models.3 Many articles on SDOH are also quick to mention racial health and wealth disparities. Ian Rowe, an AEI resident fellow who studies economic upward mobility for American youth, has argued that poverty is lowered across the board for two-parent households regardless of race or ethnicity:

Perhaps if there wasn’t such a narrative insisting that the breakdown of the family is a “black problem,” more agreement might be reached around the idea that the decline in family structure is an existential challenge facing communities of all backgrounds and one that all should tackle together.

One might have assumed that promoting family unity would be among the top priorities of those concerned with upstream social health influences. But public health institutions do not seem to be interested in finding a policy or promotional campaign intended to increase the prevalence of traditional households. This cognitive dissonance is exemplified by southern California’s Healthy Places Index, which posted an article that details the plethora of economic and educational benefits of two-parent households, and then recommends policy proposals like minimum wage increases, early childhood outreach organizations, and job training programs. Again, such proposals may have their merits, but it is odd for public health officials to confirm the immense benefits of a traditional family and then recommend public programs that have little or no positive influence on this social factor.

It is possible that public health groups have determined the promotion of the traditional family to be outside the realm of bureaucratic influence and it may be that there is no obvious strategy to mitigate dissolving families. Nevertheless, it is considered a public service to assist those without the baseline benefit of a traditional family unit. If there is merit to this claim, it is undercut by the eagerness with which this sector of public health comments on so many other influential social factors.

The Healthy Places Index advocates raising the minimum wage, and the American Public Health Association (APHA) added that this should specifically benefit “historically underserved populations represented among minimum wage earners, predominantly women and people of color.”4 The APHA paper also recommends increasing funding to the CDC and other federal agencies while adjusting eligibility for social safety net programs since the higher wage would “create a discrepancy between [recipients’] benefit eligibility and their ability to maintain their previous standard of living.” In other words, even if people can graduate from a public program after adjusted wages, the program must be expanded to keep as many individuals on board as possible.

Beyond this contradictory statement, mandated wage adjustments are not clearly beneficial to the general public. Author and journalist Jason L. Riley notes that more than 90 percent of professional economists agree that minimum wage laws ultimately lower employment for minimum wage workers and that these laws affect the “least-educated and least-skilled workers—the same group that minimum-wage advocates are trying to help.”5 A report from Seattle and a study in New York6 both indicate that hours for low-skilled workers decline and unemployment rises for younger workers after raising the minimum wage. In this manner, efforts to attenuate a SDOH can end up exacerbating existing issues. A writer from the Journal of the American Medical Association noted this when evaluating the possible positive minimum wage effects that could take place, stating, “it would be unwise to assume that all populations will experience the effects the same way.”

This overreach of public health also bleeds into the educational sector, where schooling is yet another SDOH requiring intervention. While no one can reasonably deny the correlation between higher education and overall better health outcomes, some of the vague and platitudinous recommendations offered by public health institutions lack empirical support. The APHA recommends community agencies “promote high-quality schooling as a means to reduce health disparities by supporting the equitable allocation of educational resources communitywide,” while also urging “local health departments to collaborate with local education agencies and other community agencies to improve high school graduation rates as a means to reduce health disparities.” This may be a worthy goal, but the Coleman Report published in the 1960s found that the quality of schools has little to do with eventual academic achievement, and that family background was far more important. These findings were upheld when they were reanalyzed in the 1970s.7,8 This pattern holds true in contemporary studies outside the US.9 Furthermore, innate academic ability matters greatly for population differences in educational achievement.10 Quality education may matter, but it is hardly a deterministic factor by itself.

Suggested methods of improving educational quality and graduation rates can also cut against other, already successful academic models. Some Charter School programs along with expanded school choice have resulted in improved educational outcomes for disadvantaged students (often racial minorities). But public health authors who claim that “education is the most important modifiable social determinant of health” have instead lavished praise on the recent Global Education and Monitoring (GEM) report. While the report conveys great improvements in developing countries (universal disability access being one example), it is also filled with statements like “too much decision-making autonomy can undermine inclusion, as can incentives if parents push for less inclusion” and “in the United States, a range of school choice policies contribute to growing segregation by income and race.” This section concludes:

…a key question is whether a voluntary and affirmative parental decision to educate children separately is a legitimate response for minorities and, if so, what conditions and criteria allow the avoidance of school ghettoization to the detriment of inclusion.

Those who subscribe to the SDOH vision are undermining school choice if it collides with the goal of racial equity or lowers the probability that governments, not individuals, will be making decisions about a child’s education. Meanwhile, organizations like the APHA continue to recommend questionable education strategies such as “group therapy” during the day, ongoing cultural-specific training for staff, and reviews of allegedly discriminatory school policies. There is little doubt that many students and families find such initiatives comforting or important, but whether they lead to improved educational outcomes and population health is dubious.

Nowhere is the vacuous nature of the SDOH vision clearer than in the recommendations related to policing in the US published during 2020. Soon after the George Floyd protests and riots began, the American Medical Association (AMA) issued a statement promoting their Center for Equity. Dr. Aletha Maybank, the chief officer of the new center, believes police brutality is an issue needing redress through public health: “People are dying. That’s our business, whether they are dying through a slow violence, such as structural racism or COVID-19, or direct violence, like police brutality.” While Maybank goes on to claim it is the responsibility of medical providers to “act” on such an issue, a review of the Center for Health Equity’s promotional resource materials is likely to leave clinicians perplexed as to how they are to respond to this social determinant. For instance, the recommendations offered to medical faculty in March 2021 to address police brutality offer a myriad of vagaries like “recognize students’ struggle” and “be flexible with teaching plans.” Given real-world data showing the disastrous effect that defunding the police has on racial minorities, one would think Maybank would be pleading with medical school attendees to write to their state and local governments to refund the police immediately. Instead, the focus is guided towards coddling the egos of medical students—already some of the luckiest people on the planet.

Dissenters of the social determinant vision

SDOH authors have waxed philosophical about income, education, discrimination, and many other factors that apparently determine population-level health and disparities (and always with the background noise of a policy that will fix these issues). Throughout the last decade, some of these authors appear to be coming to an understanding of how poor this model has been for shaping the understanding of health outcomes. Some recent quotes from public health literature are revealing:

  • “Perhaps this ambiguity [around social determinants] and a growing list of determinants are two major reasons as to why the content list of most textbooks on social determinants of health vary significantly.”11
  • “By downplaying the role of individual agency, trying very hard not to blame victims, we in fact tend to end up with a world view in which the poor or less educated are stripped of all agency and reduced to ‘puppets on strings.’”12
  • “…there is no evidence that clinicians and care systems can either add this [treating social determinants] to their plates or have much impact on the social determinants of their patients.”13

Despite this growing acknowledgement of the instability of the SDOH model, other writers remain strong advocates for implementing SDOH-oriented health initiatives even when admitting the lack of evidence for their utility. A publication in Academic Medicine for the Journal of the American Association of Medical Colleges reads, “…there is little evidence that teaching the SDOH—even as broadly captured by the various terms and the pedagogical approaches above—does anything to alleviate inequity.”14 But rather than reflect on alternative approaches, the authors recommend a complete “transformation” of medical education while advocating for “equity in admission” through “waiving application fees and considering ‘multiple kinds of excellence’ in the admissions process.”15 In the authors’ eyes, it is more important to achieve a medical and public health sector in line with their own ideological assumptions than something that would measurably improve health markers.

Conclusions

SDOH is not a useful framework for improving population health. It omits consideration of social factors that correlate with improved health (two parent families) while promoting policies that are unlikely to positively influence these outcomes (wage adjustment). Why, then, is there a dogmatic adherence to this model? It is likely that the vague and broad nature of SDOH has been a useful rhetorical shortcut for promoting the ideas and policies of equity through government intervention. It is therefore not surprising that nearly all the collective literature comes pre-packaged with recommendations for expanding existing social programs (even those without a clear track record of success) and the power of those charged with administering them.

If SDOH were really a movement concerned with improving the nation’s health, its advocates would not waste oceans of ink telling us how “inequity” is killing the less fortunate while completely avoiding discussion of obvious standards of living and values that correlate with better health and wellness. SDOH had the potential to be a useful framework, but as it stands, it is just another platform for ideologues to push a specific societal vision further into public health and medical models.

 

Zachary Robert Caverley is a physician assistant specializing in cardiology and working in rural health clinics throughout the north-west coast.

References:

1 Center for Disease Control, National Center for Injury Prevention and Control, Division of Violence Prevention. Essentials for Childhood: Creating Safe, Stable, Nurturing Relationships and Environments. Accessed: 04/19/2021.
2 Sedlak AJ, Mettenburg J, Basena M, et al. Fourth National Incidence Study of Child Abuse and Neglect (NIS-4): Report to Congress, Executive Summary. Washington, DC: US department of Health and Human Services, Administration for Children and Families. 2010. Accessed 04/20/21. URL: https://cap.law.harvard.edu/wp-content/uploads/2015/07/sedlaknis.pdf
3 Parke M. Are Married Parents Really Better for Children? What Research Says about the Effects of Family Structure on Child Well-Being. Center for Law and Social Policy. 2003.
4 American Public Health Association. Increasing Health by Increasing the Minimum Wage. 2016.
5 Riley JL. Please Stop Helping Us: How Liberals Make it Harder for Blacks to Succeed. Encounter Books. 2014. Digital. pp 72–75.
6 Sabia JJ, Burkhauser RV, Hansen B. Are the Effects of Minimum Wage Increases Always Small? New Evidence from a Case Study of New York State. ILR Review. 2012;65(2):350–376. doi:10.1177/001979391206500207
7 Coleman Js, et al. Equality of Educational Opportunity. US Office of Education. Washington DC. 1966.
8 Moynihan DP, Mosteller F. and Harvard University. On equality of educational opportunity / edited by Frederick Mosteller & Daniel P. Moynihan. Random House. New York. 1972
9 Alves AF, Gomes CMA, Martins A, etc. Cognitive performance and academic achievement: How do family and school converge? Eur J Psychol Educ. 2017; 10(2): pp 49–56. doi: 10.1016/j.ejeps.2017.07.001
10 Murray C. Real Education: Four Simple Truths for Bringing America’s Schools Back to Reality. Crown Forum. 2008. Digital. pp 29–31.
11 Islam MM. Social Determinants of Health and Related Inequalities: Confusion and Implications. Front Public Health. 2019;7:11. Published 2019 Feb 8. doi:10.3389/fpubh.2019.00011
12 Lundberg O. Next steps in the development of the social determinants of health approach: the need for a new narrative. Scand J Public Health. 2020;48(5):473–479. doi:10.1177/1403494819894789
13 Solberg LI. Theory vs Practice: Should Primary Care Practice Take on Social Determinants of Health Now? No. Ann Fam Med. 2016;14(2):102–103. doi:10.1370/afm.1918
14 Sharma M, Pinto AD, Kumagai AK. Teaching the Social Determinants of Health: A Path to Equity or a Road to Nowhere? Acad Med. 2018; 93(1):25-30. doi: 10.1097/ACM.0000000000001689
15 ibid

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