From Determinants to Determination

2020 has been both a painful and insightful year. Never have we been more aware of the unease in society. Discord and disparities go hand in hand, and they both influence health and negatively impact health outcomes.  

Social determinants of health (SDOH) is a hot topic these days. And rightfully so! You cannot separate people from their environment, and research tells us that 80% of health outcomes are due to SDOH. It is no wonder that COVID-19 infection and death rates are so much higher in the communities and neighborhoods that have less. Less safety, less access to good food, less access to preventative measures, and less access to financial resources and economic opportunity.

As a society, we are at a crossroads. Substantial, sustainable change requires a change in attitude: a commitment to transparent, collective, and cooperative action. We have many elements in place: grassroots engagement, demand for corporate social responsibility, and corporate recognition that economic disparities lead to health disparities. 

But are we determined to work together to advance the health of people and communities? Or will we default to a transactional top-down approach that makes checking the box easier but does not move the needle?

At SHI, we talk about this collective approach as taking care of the fish, the water, and the bowl. Health challenges are chronic and persistent because they are rooted in human and corporate/community behavior. 

As a society, we have a lot of expectations about fish behavior.  We measure their biometrics, we manage their pharmacy benefits, we narrow provider networks they can access, and we cost-shift to high-risk individuals. But, we don’t understand the water that they are swimming in (grassroots behaviors, community beliefs) or the bowl they live in (environmental/structural barriers e.g., shift work that leads to insufficient sleep and poor eating that leads to cardiometabolic disease).

You can’t fix what you don’t measure. Moving from recognizing social determinants of health to determining a different outcome requires something new. We must gather new information. We must better understand our communities’ behaviors, beliefs, and barriers. And we must be willing to work collectively and cooperatively to address these fundamental drivers. 

We don’t need a top-down approach to act on the fish, but we DO need a top-down approach to improve the water and the bowl they are swimming in. And we need the fish to help us understand what improvements are needed.

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