The Social Determinants of Health
Via Ezra Klein, Gail R. Wilensky and David Satcher ask the new administration not to forget the social determinants of health. Abstract:
The Obama administration faces daunting challenges to reform healthcare. The authors,commissioners on the World Health Organization’s Commission on the Social Determinants of Health, believe that strategies to improve health by affecting the social determinants may gain bipartisan support. These determinants—including the effects of poverty, education, the treatment of women, employment opportunities, and limited access to medical care for some—areas important in promoting health, if not more so, than the direct medical determinants of health. Focusing on these determinants makes more sense than waiting until people become sick and seek care, and it often costs much less.
For fairly obvious reasons, debates about health care policy tend to be dominated by those who either make a living providing health care services (insurance companies, doctors, pharmaceutical firms, hospitals, nurses) or those whose financial interests are badly hurt by the need to pay for health insurance. This has an odd tendency to leave health a bit out of the picture even though it’s fairly uncontroversial to observe that both lifestyle issues and social issues are are more important determinants of health outcomes.
A chart:
As you can see, once genetics—about which we can’t do anything until the brave new world of Gattaca arrives—is also put in the picture, health care services start to look like a pretty small slice of the health picture. Health care services are such a large part of the economy that one can’t ignore the issue, but it is important to put the health impacts of health care in perspective.
33 Responses to “The Social Determinants of Health”
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January 22nd, 2009 at 8:45 am
Insurance companies don’t make a living providing health care services. They make a living (a) collecting premiums, and (b) *not* paying for health care services. These goals are in some conflict, and insurance companies will sometimes, grudgingly, provide some health care services in order to keep their premiums flowing. But that doesn’t change the direction of their overall interest in the system: health care is the problem, for them, not the solution.
I assume that “Behavioral patterns” consists largely of smoking, alcohol and other drug use, eating too much, and exercising too little? I’m not convinced we can do much more about them than we can about genetics, although I suppose it couldn’t hurt to try a nudge or two.
January 22nd, 2009 at 8:49 am
Good luck changing behavioral patterns. Sorry, but I have never seen a study showing that interventions on a mass scale can change adverse behavior and impact public health outcomes. Maybe taxes on cigarettes?
Still this analysis seems overly simplistic – to a large degree, behavior is determined by genetics so separating them as competing causes of health outcomes may not make sense.
January 22nd, 2009 at 8:56 am
I’m proud to live in a country where “Health Care” accounts for a tenth of all premature deaths.
January 22nd, 2009 at 9:00 am
Look, things will be different once our mandatory morning exercise / yoga drills get underway and we all get used to our weekly check-in with our vegan meal planning officers.
January 22nd, 2009 at 9:07 am
Public programs have significantly reduced tobacco deaths and traffic deaths. In Sweden alcoholism has been reduced. In some parts of the country obesity has been reduced, partly because of various sorts of public programs. These programs aren’t futile. Some people don’t like them in principle, and some people find them annoying, and some people want to keep their bad habits, so they misrepresent the success rate.
Besides “premature deaths” there are “post-mature deaths”. In other words, if the normal (”mature”) life expectancy is 80, someone who dies at 75 is 5 years premature, whereas someone who dies at 85 is postmature. I’m wondering whether halth care doesn’t have something to do with people living longer than average.
January 22nd, 2009 at 9:12 am
Jeebus H. Frakkin’ CHRIST! Matthew, try clicking through to the original article the chart is taken from (”The Case For More Active Policy Attention To Health Promotion”,
J. Michael McGinnis, Pamela Williams-Russo and James R. Knickman, http://content.healthaffairs.org/cgi/content/full/21/2/78?ijkey=1657a2b776a41134c689e2e488833b5cfc8078f8 ), and you can see that it is just a bunch of the authors’ assumptions glued together with wishful thinking.
They based their behavioral conclusions on the Framingham study–which is widely accepted, but problematic along several dimensions. See http://www.proteinpower.com/drmike/cardiovascular-disease/framingham-follies/
Matthew, along with your admiral insight and profligacy, you have an unfortunate tendency to accept authoritative-sounding or intriguing statements in domains where you are fundamentally uninformed. If you want to be more than a dilettante, you need to do something about this.
January 22nd, 2009 at 9:28 am
That lifestyle and social patterns are important to health is a fair point, but it’s a mistake to conflate “health” with “not dying prematurely”; long life isn’t everything there is to health. Even if it were, the chart is fairly ambiguous: is it really that someone has a a “genetic predisposition” to premature death, or do they have a predisposition to illness that results in premature death? And in the meantime, is there nothing to be done for the illness? By focusing on death, this chart misses the importance of health care for the living.
January 22nd, 2009 at 9:37 am
By what metric?
By the most generous estimates, medical errors account for around 100,000 deaths/year.
Heart disease kills 650,000, cancer 560,000. Right there you’ve got 1.2 million premature deaths. Add in stroke, COPD, trauma, and you’re comment is completely meaningless.
January 22nd, 2009 at 9:43 am
social circumstances and behavioral patterns are not easily teased apart and probably should not be shown seperately.
January 22nd, 2009 at 9:58 am
“Heart disease kills 650,000, cancer 560,000. Right there you’ve got 1.2 million premature deaths. Add in stroke, COPD, trauma, and you’re comment is completely meaningless.”
I’m pretty sure a large part of the 10% of premature deaths caused by inadequate health care is because of a lack of preventative care. Many cancers can be treated just fine if they’re caught early enough; same with high blood pressure, high cholesterol, etc. The issue is that people can’t afford to get this preventative treatment so they die years earlier than they should have.
January 22nd, 2009 at 10:35 am
This is a bit off topic. Does Obama’s health plan as is include comprehensive dental coverage?
January 22nd, 2009 at 11:13 am
Matt,
Am in agreement with vorkosigan1. The central point of the argument you presented here relies on misleading statistics.
The J. Michael McGinnis, Pamela Williams-Russo and James R. Knickman article relies on behavioral data from 1993!!!
“However, some 40 percent of deaths are caused by behavior patterns that could be modified by preventive interventions.2″
2. J.M. McGinnis and W.H. Foege, “Actual Causes of Death in the United States,” Journal of the American Medical Association 270, no. 18 (1993): 2207–2212.
Wow data that almost a decade old even before it was cited in the McGinnis study in 2002!!
Mortality figures should not be hard to come by – even historical ones in the new everything is online Obama administration. This data should not be hidden beneath the conclusions but front and center to the report!!
JAMA apparently followed up from 1993 and had several reports done in 2000, with corrections to the 2000 data as late as 2005. Why isn’t this type of information tabulated nearly constantly? Burrowing into these statistics is really where the low hanging fruit in health care policy becomes available.
Matt why don’t you guys and ezra get some more accurate data and make this data and it’s publicly verifiable conclusions central to the Health Care policy remedies proposed by the Obama administration?
It’s all about the numbers now. Make the numbers front and center. And take some responsibility to make sure they are accurate.
January 22nd, 2009 at 11:31 am
shah8, I’ll go one step further. Social circumstances, behavioral patterns and health care are not easily teased apart and probably shouldn’t be shown separately.
January 22nd, 2009 at 12:01 pm
nolo- Good point, but I think you can do a decent job separating health care from the other variables. the key is to distinguish ‘treatments offered at reasonable accessibility’ from ‘treatments used’. Separating the direct effects of social circumstances from their indirect effects via behaviors (and vice versa) is very hard even as a research project on other primates. Still, there are some data which can be used to estimate the net effects of inequality, for example, and those estimates are more important than the subsequent categorization.
January 22nd, 2009 at 12:11 pm
I’m a former nurse who has viewed healthcare from the point of view of a patient and spectator for the past eight years. It ain’t a pretty sight. In fact, the American healthcare industry is so puke-worthy I decided to become a ‘former’ nurse rather than continue to take part in it.
If you don’t have an emergent problem for which the treatment is obvious, your involvement with our ’system’ is probably doing you more harm than good.
Want to maximize your health? Look at what killed your parents and grandparents, and then change your behaviors to minimize the chances you will die the same way. Look both ways before crossing the street and don’t work for employers who demand that you rush across without looking because their task is so urgent.
And for gods sake get on the internet and learn about any health problem you’re told that you have. Keep your own medical records. The chances are better than 50-50 that your doctor doesn’t know what has happened to you and doesn’t know (or care) what is the currently best accepted practice.
Most of what you see in our healthcare is about as meaningful and up-to-date as the ceremony of a witch doctor. If you enjoy that kind of thing, well, that’s your own look-out, but don’t confuse it with actually improving your health.
January 22nd, 2009 at 12:30 pm
While I did not look into the specifics of the chart numbers it does seem like reasonable ratios.
Social circumstance – if you don’t have access to clean water you are much more likely to get sick. Clean water, sewage systems, restaurant sanitation standards, and food and drug standards, are the government mandates that keep social circumstances at some baseline level. Improving them improves every body’s health.
Behavioral patterns – wash your hands, cook your food, use condoms, don’t share needles-, or drive drunk, wear seat belts. Promoting these practices really really helps people live longer.
Environmental health, and behavioral health are bigger bang for the buck than pretty much any medical intervention except maybe vaccination. We have most of the low hanging fruit taken care of, but no reason to think there aren’t some big gains in health still out there.
January 22nd, 2009 at 1:04 pm
I’m a physician involved with HIV/AIDS care. At the international AIDS conference in Toronto a few years ago, what blew me away were the talks about how addressing property and inheritance rights for women in African would improve AIDS related survival and decrease transmission.
I’m used to thinking about viruses and medications, but globally, other issues trump these==such as: the fact that if the husband gets sick and the wife sells the cow to buy him meds, and then he dies, and his family gets the farm and kicks her into the street, and she now has kids to feed, and no income potential except sex work and then she infects other people, gets sicker can’t afford meds, and dies and her children are destitute and uneducated……compared to she sells the cow to buy him meds, but when he dies she keeps the farm and is able to feed herself and her children and sell produce to get her meds, and she stays healthy and the kids have a mom etc.
This is what I think of when I hear the phrase “social determinants of health”.
January 22nd, 2009 at 3:47 pm
Social determinants of health can be reduced to 2 things:
1. Laziness
2. Stupidity
Don’t confuse ignorance with stupidity, it more closely associates with laziness.
January 22nd, 2009 at 5:41 pm
We don’t need to wait for Gattaca because we’re already there. Selective abortion and pre-implantation screening have been used for years. The incidence of Tay-Sachs disease, e.g., has dropped 90% from a few decades ago. See this article and this page. The absolute numbers are fairly small, so far, but it’s happening.
January 22nd, 2009 at 6:24 pm
Why would you include genetics in this comparison? We’ve all 100 percent genetically predisposed to die, since none of us are immortal–if you don’t count all of those deaths as “premature,” it’s hard to see on what basis you’d count any of them. Because you die more prematurely than half the population? That’s bogus.
And all the other things are stuff you could do something about, at least theoretically. One suspects that genetics were included because healthcare is something the authors don’t *want* to do something about.
January 22nd, 2009 at 7:46 pm
40% from behavioral patterns. Well the British are trying to tackle this problem. In fact the policy that they are testing would create 36,000 jobs in the U.S. Hopefully Obama is paying attention. Although, if this ever gets implemented and one of these guys comes to my door they will get punched in the face…
http://www.telegraph.co.uk/earth/environment/4214024/Dont-throw-away-leftovers-warn-food-police.html
January 22nd, 2009 at 8:02 pm
How about if we subsidize HEALTHY school lunches, offer free healthy snacks and breakfasts to kids in public schools and get rid of those candy machines? They’ll start off better and develop better habits. It seems like really low hanging fruit.
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