This is the second of what will be 4 parts comprising the Henry A. Withers lecture I gave at the University of Texas-Houston Department of Family and Community Medicine. When they have all been posted, I will attach them as a "GoogleDoc".
The Social
Determinants of Health
A key measure of
Social Justice are the Social Determinants of Health, and manifests, in
the negative, as health disparities. Some of the most important work on disparities
was done by the British physician, Julian Tudor Hart. Practicing in the Welsh
coal-mining town of Glyncorrwg, Tudor Hart was able to identify who got sick from
what, and as the physician for this community, he could identify how it related
to their economic and social standing. As an epidemiologist he gathered this
data in the pre-computer era, and then expanded it by looking at access to health
care across Britain. The result was a 1971 article in Lancet called “The Inverse Care Law”,[1] in
which he demonstrated with empiric data that “the availability of health
care services is inversely proportional to the need for it.”
A corollary of this
law is that the “higher” the level of medical involvement, in terms of both
complexity and cost, the lower the overall impact on the health of the
population, as demonstrated in this graphic from Dr. Steven Woolf. The greatest
determinants of health of the populations are those that come before medical
care. This incontrovertible truth is integrally tied to the concept of social
justice. The role of social determinants in the health of the population and
the production of health disparities was developed as an outstanding cartoon by
Camara Phyllis Jones and colleagues, “Addressing the social determinants of
children’s health: a cliff analogy.”[2]
A link to a
powerpoint presentation of these, developed by Neal Palafox and colleagues at
the University of Hawai’i Department of Family Medicine, can be found here, and
is definitely worth reviewing. In brief, it pictorially demonstrates that all
people are at risk for injury or illness, but some live a little closer to the
“edge,” which puts them at greater risk of falling off. The same is obviously
true for populations who live “closer to the edge”, who are at higher risk for
disease – because of genetic risks, environmental risks, and behavioral risks –
but also because they have less money, or social support, or greater stress in
their lives. Things that, at the best of times, mean they are just able to get
by and keep from falling off.
So, what can we do?
· We can pick up the
person, or people, who “fall off the cliff”, who get sick. This is known as “tertiary prevention”, because the bad thing has
already happened and we are hoping to prevent complications, prevent it from
getting worse. This is
where we spend almost all of our “healthcare” dollars.
· Or maybe we can put up a safety net. You’ve heard
of “safety net clinics” and “safety net hospitals”. This can be thought of as a
form of secondary prevention – they have already fallen, their high blood
pressure or diabetes has become uncontrolled and they are at risk for something
really bad, but we intervene. In the nick of time.
· Or we could actually put a fence up on
the edge of the cliff, preventing people from falling off. This is a kind of
“primary prevention”.
But there is something else that might
even be more effective. We can move these people further from the edge. This
“pre-primary” prevention actually involves intervening on the core risk factors
for health – addressing the social determinants of health. It is not a major
component of our current medical model.
This is what health disparities are
about. They are about differences that we could control. About some people
living closer to the edge. And maybe the ambulance doesn’t come as quickly;
that is, high tech medical care is less available. Or there is no
safety net. And not even a fence, primary prevention. All these three are
characteristics of access to medical care. Social determinants address health
disparities by asking the questions that Dr. Jones asks: why are there differences in who is found at
different parts of the cliff, and why there are differences in resources along
the cliff face?
Earlier I mentioned the work of John
Rawls, and tried to distinguish between the concepts of intrinsic equality (as
in the Declaration of Independence, “All men [sic] are created equal”), and people actually being
equal in all things (including intelligence, wealth, physical ability,
genetics, etc.) I noted Rawls speaks of distributing societal goods equally,
which is a different thing. I also noted that the principle of “justice” in
medical ethics, which I said implies that people with the same conditions be
treated the same. This concept is equity. What is the difference between
equality and equity? Which should we strive for?
The Declaration of Independence, for
example, also states that all men [sic, again] are entitled to “life,
liberty and the pursuit of happiness”. It doesn’t guarantee happiness,
but suggests some degree of equity, of equality of opportunity. What about when
people start, as the folks on the cliff do, from such different places? What
are the implications? For example, we have all heard politicians rail against
inheritance taxes as “death taxes”, but what does it say about someone who is raised
with all the advantages of money – good food, education, support, tutoring – but
still cannot compete with a person raised with nothing? Are inheritance taxes
good or bad? For myself, I’d say it depends on what we are going to spend the
money on. Bombs? Feeding people? Bailing out banks? Housing people?
A key concept, going back to Rawls, is
that the exception to the general rule of distributing all social goods equally
is when not doing so is to the benefit of the least advantaged. This is also
the basis for why for it is a different thing for the underprivileged or oppressed
to band together to relieve that oppression or lack of privilege than it is for
the privileged or oppressors to band together to maintain it. This is the flaw
of the concept of “reverse discrimination”. Is it discrimination if we take
away all of the advantages that one group had that another did not? I suppose
that it is still a matter of perspective. While I do not know the source of
this quotation, I believe it speaks very well to the issue of perspective: “If
you’ve spent your whole life with the wind at your back, a calm day seems
unfair!”
(to be continued)
