Is the concept of ‘social determinants of health’ inhibiting progress toward equity?

The time has come to refer to social determinants with more realistic, less euphemistic, nomenclature. Make no mistake: Social determinants are real but they also get cast aside by those thinking the problems are too large and difficult to solve or that there’s little health care leaders can do to adequately address them.  

Social determinants are factors that influence the health of individuals and populations, such as socioeconomic status, housing,  zip code, transportation, education levels, employment and health insurance, food insecurity and others. But the name itself is in some ways inhibiting the advancement of work to advance equity among the very groups that need it most.

“I don’t even like to use the term social determinants of health because it gives a sense that these are immutable or as unchangeable as your genetic code. I cannot accept that. Now, in the 21st Century, we’re seeing our genetic code is quite mutable through CRISPR and other means,” said Carrie Byington, MD, Executive Vice President, University of California Health. “So if we can change our genetic code, we can change poverty and racism. And we can’t just have this defeatist attitude that blames the victims.”  

With so many systemic and longstanding problems, including a lack of mental and public health infrastructure and widespread disparities, health care executives “should not misuse the concept of social determinants of health as an easy button for the status quo,” added Patrice Harris, MD, immediate past president of the American Medical Association. 

What’s more, Sachin Jain, MD, President & CEO, SCAN Group and Health Plan, called for putting a stop to the phrase social determinants of health altogether. “I think our industry has created a wonderful excuse for lower performance in certain groups by saying, ‘well, it’s the social determinants of health,’” Jain said.

The impact of such lower performance is a widening of already deep health disparities. Scratching the surface of what has led people to not have fair or equal opportunities to achieve their best health reveals structural discrimination and racism, according to J. Nwando Olayiwola, MD, SVP & Chief Health Equity Officer, Humana.

“Health equity really requires that you get people to a place where they have the opportunity to have the best health possible, but also that you’re addressing the structural determinants of health that have led to inequities that exist in the first place,” Olayiwola said.  

Janice Nevin, MD, President & CEO, ChristianaCare, also said that it’s critical to understand the root causes of vulnerability and stress that make resilience so challenging.

“We need courageous conversations. We’re going to have to talk about racism and poverty,” Nevin said. “We must do more to make specific changes and create accountability among our leaders.”

Advancing health equity also necessitates broad transformation throughout the health care industry and new ways of thinking that begin with recognizing that the role health care leaders play does not end with care delivery services and understanding the value of care relative to what the system pays for, said Carladenise Edwards, PhD, EVP & Chief Strategy Officer, Henry Ford Health System.

“How do we design a system where we actually promote health?” Edwards said. “If you look at our current health care system, we’re really heavy on the sickness and the treatment. We’re not as heavy on health and wellness and prevention. Ultimately, I want it to be 80, 20 with health and wellness at 80 percent and sickness at 20 percent. But if we get to 50-50, where the amount of money we spend on sickness equals the amount we’re spending on health and wellness, I think I’d be satisfied.”

So, in the meantime, about the phrase social determinants of health?

“We have to call social determinants of health what it is — poverty and racism — and speak in plain English as opposed to creating these terms of art,” Jain said. “Then we also have to do the hard work to develop new strategies for communicating with and improving how we serve these populations. That’s the work we have to do and we have to measure ourselves from a clinical performance perspective and stop giving ourselves easy excuses about why things are a certain way.”

Edwards, Jain and Olayiwola participated in the Health Evolution Virtual Confab 2021, which Harris and Nevin co-hosted. The Health Evolution Confab 2022 is scheduled for September 15-16 in Nashville.