Background on Social Determinants of Health

Leveraging Data on the Social Determinants of Health

Here is the Foreward:

Foreword

HHS Assistant Secretary for Health Admiral Brett Giroir

America yearns for a new approach to healthcare, and addressing the social determinants of health must be a foundational principle of that approach. America’s healthcare spending is unprecedented and unequalled, accounting for almost 18 percent of our Gross National Product (GNP), potentially topping $6 trillion by 2027. But sadly, we are not getting our money's worth for those expenditures - no matter how you look at the data. Of our 36 peer high-income OECD nations, the United States is 28th in life expectancy, and our life expectancy decreased even more in 2015 and 2017. If this trend continues, my two-year-old granddaughter will live a shorter life and with less quality than my generation. None of us believe that's acceptable.

While sophisticated immunotherapies and genetic manipulations are always welcomed by those already suffering, the key to our successes is much less esoteric – but equally challenging. Our nation must transform our “sick care system” into a “health promoting system.” And the key to that transformation is meaningfully and sustainably addressing the social determinants of health. Social determinants impact every aspect of disease risk – nutrition, exercise, stress, and the environment; access to primary healthcare and early detection; and adequacy of treatment and recovery support. A few examples based on current HHS priorities are as follows:

The drug overdose crisis. This is the most complex and daunting public health issue of our time, with almost 70,000 Americans dying a year, often at the prime of their lives. The underlying factors are frequently found in social determinants, including unemployment and lack of economic opportunity; housing insecurity; arduous labor that predisposes to traumatic injury and chronic pain; lack of access to treatment or alternatives; and the significant impact, especially on risk of methamphetamine abuse, of adverse childhood experiences, including sexual or physical abuse.

Infant mortality. A recent study by researchers at the National Center for Health Statistics documented the high rate of infant mortality in the poorest regions of our country, the Mississippi Delta and Appalachia.i Obesity, teenage pregnancy, smoking, and malnutrition all contribute to infant mortality in these areas. We will never solve infant mortality or maternal mortality if we don't work on these socially related problems.

The obesity epidemic. A 2017 study of trends among today’s two-year-olds projected that nearly 60 percent of them will be clinically obese by the time they’re 35.ii We’re already seeing that three-quarters of our 17- to-24 year-olds would not qualify for the military if they tried to join, many of them because of obesity. For obesity, social determinants are everywhere: food deserts and food insecurity; lack of access to safe sidewalks and parks; lack of affordable youth sports; and lack of access to preventative and treatment services. From my former work in Texas, in the border counties, people generally knew what they should eat and how they should change their lifestyle, but were prevented from doing so by social, economic, and demographic roadblocks.

i Thakrar, Ashish P., Alexandra D. Forrest, Mitchell G. Maltenfort, and Christopher B. Forrest. “Child Mortality In The US And 19 OECD Comparator Nations: A 50-Year Time-Trend Analysis.” Health Affairs 37, no. 1 (January 2018): 140–49. https://doi.org/10.1377/hlthaff.2017.0767.
ii ScienceDaily. “More than Half of US Children Will Have Obesity as Adults If Current Trends Continue.” Accessed November 25, 2019. https://www.sciencedaily.com/releases/2017/11/171130085733.htm.

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Dementia. Social engagement and cognitive activities can decrease the risk of Alzheimer’s and other diseases, but isolation and loneliness are rampant in our society. Together with proper nutrition and exercise – themselves dependent on social determinants – we have a real opportunity to impact the upcoming “silver tsunami.”

HIV/AIDS. Despite the “medical miracle” of modern anti-retroviral therapy and pre-exposure prophylaxis, there are still approximately 40,000 new HIV cases a year in America. We believe, and programs such as Ryan White have proven, that the social determinants are inexorably linked to new infections – beginning with social stigma preventing early diagnosis and linkage to care. But even then, lack of transportation, housing, adequate food, or a home, the expense and time associated with getting medical therapy, often keeps treatment out of reach.

Truly, in America, your ZIP code is still more important than your genetic code. And as a society, we must “change the map” and finally address health disparities stagnant for generations. While the emphasis on access to clinical care and the quality of that care is important, they account for only about 20 percent of health outcomes. Everything else is wrapped up in air and water, housing and transit, faith, family and social support, community and safety. We will never solve our healthcare spending addiction, or our progressive degradation of health, unless we focus on what causes 80 percent of the poor health outcomes in this country.

Value-based care means meeting patients where they are, and freeing up doctors and nurses and pharmacists and health systems to attack the core of the problem. That could translate into temporary housing, or transportation, or medically tailored meals. Or it could be an exercise coach, or sponsored farmers’ markets, or just extra love and attention by a visiting paraprofessional. Value-based transformation means that social determinants are no longer an afterthought, but for many people are truly the “main event.”

Our office emphasized in Healthy People 2020 that the social determinants are an essential ingredient for a healthful nation. But we can only focus on social determinants that we can reliably and accurately measure – so much foundational work still needs to be accomplished. As we begin work on Healthy People 2030, we have reliable data on employment, college enrollment, poverty, and housing insecurity, among other indicators. We need more indicators, and ones which more closely correlate with the health outcomes we desire; by 2025, it is my hope that we have new levers to pull, and more tools in our social determinants toolbox.

Our office is dedicated to catalyzing a health-promoting culture, moving people from treatment towards prevention, with a focus on integrating social determinants into sustainable healthcare systems and platforms. And by doing that, we will decrease costs, and increase longevity and quality of life – not for some, or most, but all.

Admiral Brett Giroir
Assistant Secretary for Health
U.S. Department of Health and Human Services

Janice T. Booher

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Dear FL Disaster Resilience Initiative  and Resilient American Communities Initiative colleagues, 

This past week, Rear Admiral Felicia Collins (Director of the U.S. Department of Health and Human Services, Office of Minority Health), kicked off a Roundtable organized and facilitated by the Center for Open Source Enterprise (CODE).  This meeting focused on creating a nation-wide effort to advance our abilities to prevent and manage COVID-19 by better understanding the social determinants of health (SDOH) in our most vulnerable communities that deeply suffer from adverse social determinants of health.  In September, the Resilient American Communities (RAC) Initiative will be facilitating a collaboratory in conjunction with CODE to examine how RAC pilots can deepen our abilities to reduce COVID-19 infections, hospitalizations, ICU visits, and premature deaths through improving the social determinants of health.  

We are seeking your input as to how the participation of your community in this RAC / CODE SDOH Pilots Collaboratory might help your community improve its health status and human security during and following the COVID-19 pandemic.  We will be examining the community data systems, tools, methods, and organizing approaches that historically disenfranchised communities have been able to use to lower their climate change and COVID-19 risks by advancing pandemic and global change resilience and regeneration.  We are particularly interested in what you plan to do during the next several months of the combined threats of extreme heat, hurricanes, and waves of cascading pandemic impacts.  

We understand that several of the Florida Disaster Resilience Initiative (FL DRI) communities have begun to move into their Phase II FL DRI activities to build deeper levels of mission critical function management, social cohesion, and social equity as they advance their Phase II activities to elevate their states of resilience and regeneration through FL DRI community-driven unity of effort.  We welcome FL DRI communities into this broader Resilient American Communities collaborative discourse.  We hope that you will share your advances and struggles regarding elevating your community’s mission critical functions in the face of the unprecedented challenges of these times.  We are also hoping that this RAC SDOH Pilots Collaboratory will allow you to hear from other community voices striving to emerge from this troubling period with improving resilience and regenerative practices while elevating social equity in New York, California, North Carolina, Tennessee, Indiana, Michigan, New Mexico, Louisiana, Mississippi, Ohio, Minnesota, Washington, the National Capital Region, Colorado, …, as well as in Florida.  We look forward to hearing from you about your community’s needs for greater capacity and resources essential to advancing as a resilient American community with greater social equity and improving social determinants of health.

Mike

Michael D. McDonald, Dr.P.H. 

Coordinator

Resilient American Communities COVID-19 Initiative

Global Health Response and Resilience Initiative 

Alliance for Global Resilience and Regeneration 

Executive Director 

Health Initiatives Foundation, Inc.

Chairman 

Oviar Global Resilience Systems, Inc. 

Cell: 202-468-7899

Michael.D.McDonald@mac.com