By Dr. Jeremy Morrison, Grace Cottage Family Health
“Do you smoke?”
“Any family history of high blood pressure, strokes, or heart attacks?”
“If something happened, how long would it take you to get $500 together?”
You probably haven’t been asked that last one at a medical visit, but maybe it’s time you were. In the last thirty years, more and more evidence has piled up showing that some aspects of social and economic status are risk factors as important to illness and mortality as traditional villains like smoking or genetics. The common terminology for these is “social determinants of health.”
For doctors, the evidence is disquieting: medical care turns out to be only a fraction of health care. We have done our best to work harder and try to reach everyone equally, and we’ve done a lot to increase access to medical care. Unfortunately, this may not have as much effect as we would like.
There is a saying: “Your zip code is a bigger predictor of health than your genetic code.” This holds more true in some places than others. For example, life expectancy in urban Washington, D.C., is 17 years less than in the surrounding suburbs of Maryland. In a big metropolitan area like that, all of the social factors that affect health – wealth, race, education, housing, grocery opportunities, your power to influence your circumstances – can all be inferred from your zip code.
How do we look at this in a more rural state like Vermont? We all live together, rich and poor, minutes apart, sometimes almost next door. How do we measure differences here?
The differences are both visible and invisible. The reason we don’t get asked about socioeconomic status in medical encounters is that medical people, like everyone, are probably making assumptions based on how we dress, what our teeth are like, and how we speak. This is what humans do. However, visible differences aren’t necessarily measurable. Stable and safe housing, dependable access to a car, and money in your bank account are things that impact health and might be measured by questionnaires. Teeth, accent, clothing, haircut? Not so much.
Invisible differences like self-esteem, feeling empowered, behavioral norms, and interpersonal connection are more subtle because the soil they are grown in is more mysterious and multifactorial. Some of these can be indirectly quantified by educational level or household income during childhood. In medicine, one way we have tried to quantify these is by counting “adverse childhood events”: abuse, exposure to the abuse of someone else, separation from a parent, exposure to addiction or mental illness, etc., but it’s like measuring the barn door after the horse has escaped. We try to chase things down with case management and care coordination; unfortunately, without primary resources that doesn’t go very far.
Ideally, we as a society can intervene earlier to avoid or soften these factors, but meaningful interventions and education are expensive and difficult. That is social determinants of health in a nutshell: measuring is difficult, and intervention is expensive and requires systemic change. It would be easy to throw up our hands, except that we spend so much money already on medical care! Perhaps there are other places to invest that money that might yield better health outcomes.
One certain difference between socioeconomic classes is how many layers of protection you have. When you are poor, even the smallest of setbacks can spell disaster. There are systems we might invest in that would add buffers to poverty from both directions. For example, meaningful and fare-free public transportation would mean that all of our kids might have a chance to get a job after high school, that our elders might not find their lives so diminished when they give up their licenses, or that the “check engine” light going on might not threaten homelessness. There are investments in health we can make that can also improve equity. For example, if Medicare and Medicaid covered dental work, the benefits would be directly medical (for example, by decreasing the incidence of heart disease), but also indirect – no more “welfare teeth” to be judged by, which could lead to opportunities for better jobs and greater perceived status by oneself and others.
Considering the social determinants of health is one key to understanding the disparity we see between what we are putting into medical care and what we are getting out in terms of health outcomes. Our challenges are different in a rural state like Vermont, both more difficult to quantify and more expensive per capita to address. However, if we are going to continue to invest in health on such a large scale, we should make our interventions as meaningful and robust as we can manage.