Health and Well-Being Matter is the monthly blog of the Director of the Office of Disease Prevention and Health Promotion.
A long-standing narrative suggests that addressing the framework of social determinants of health (SDOH) largely relates to the realm of the health care and public health sectors. Yet, as defined, SDOH exist outside these sectors, with the exception of access to quality health care. SDOH represent all the facets of our lives that we occupy every day. But people engage in the institutions and services of health sectors on a much more limited basis than they engage in those other myriad aspects of living.
Healthy People 2030 defines SDOH as “the conditions in the environments where people are born, live, learn, work, play, worship, and age that affect a wide range of health, functioning, and quality-of-life outcomes and risks.” SDOH form the dynamic context for what we experience in our everyday lives. They are not abstract concepts — they are our life circumstances.
These circumstances have a major impact on people’s health, well-being, quality of life, resilience, and opportunity to thrive. Inequities in SDOH across this nation lead to marked health and well-being disparities. We can also frame this in a more positive way: favorable social determinants can serve as profound drivers for positive outcomes in health and well-being. These “upstream” factors — unrelated to health care delivery though often referred to in relation to people’s need for health care due to illness — can dramatically increase or lower risk for diseases and injuries and have a major effect on someone’s overall well-being.
As a nation, we continue to hold on to outdated precepts, operating under the myth that the health care and public health sectors can and should hold domain over health and well-being. By extension, we propagate the misconception that these sectors have the ultimate responsibility for addressing SDOH and the outcomes they produce. This narrative is grounded in a disease-centric model — one that assumes the reference point for understanding health is in the prevention of disease. It also assumes that the traditional health sector is well-suited to effect favorable change in SDOH, leading to better health outcomes.
Yet while the United States had more than $4.1 trillion (roughly $12,530 per person or 19.7 percent of the gross domestic product) in health care expenditures in 2020 (16.9 percent of GDP in 2018, before the COVID-19 pandemic) and far outspent other high-income countries, our extraordinary investment isn't yielding a healthier nation with better outcomes. The United States continues to have an extremely high burden of chronic disease, the lowest life expectancy, an obesity rate that is 2 times higher than the average for Organisation for Economic Co-operation and Development (OECD) nations, and an American public that logged fewer physician visits then people in most wealthy countries. What’s more, life expectancy in the U.S. was on the decline prior to the pandemic and has continued to worsen throughout the pandemic. These statistics, and many other data, suggest that the U.S. health care system — one almost entirely focused on disease care — already fails to ensure a healthier nation. Which begs the question of how strained health care and public health systems can contribute meaningful leadership in addressing SDOH.
The need for quality health care is undeniable, and every effort should be made to expand equitable access to such care, particularly primary care. Also, the importance of a sound public health system has never been clearer. But the narrative that health care and public health systems can and should lead efforts to address SDOH is simply misguided.
For example, public health institutions certainly should be structured to warn about how pollutants or certain other exposures affect health and, in some circumstances, to provide guidance for avoiding such exposures. However, on their own, such institutions cannot control the root causes of pollutants. Those root causes exist far outside the sphere of public health and health care systems.
The fact that SDOH encompass the environments and conditions of our daily lives, largely removed from the direct influence of our enormous health care system, raises the question that a colleague of mine suggested last year at a conference: if health is principally contingent on our life circumstances, who then owns “life”? I interpreted that question to mean: what sector of government and society owns responsibility for improving those life circumstances?
In my view, the answer is rather simple: we all do. Beyond the clinical environment, medical science, and the institutions and reach of public health are our workplaces, our schools, the places where we sleep and play, the stores where we shop for food, and the social context of our lives – the everyday places that influence our health, well-being, and quality of life.
From this perspective, we need to expand the circles where conversations about improving SDOH take place. The policy discussions, the decision-making on which government resources ought to be leveraged, and the systems thinking related to social determinants all need to be more inclusive so that all sectors of government and society are at the table, have an empowered voice, and are invested in the plan for action that will make us a healthier nation. Education, industry, transportation, city planning, religious and spiritual organizations, recreation, and the arts — to name but a few — must be included and work together with a common understanding toward this end. In contrast to the concept of “Health in All Policies,” which implies that health outcomes should drive all policymaking, this perspective suggests that such outcomes are a factor of many diverse sectors and that, therefore, improvement in health and well-being is contingent on those sectors’ roles.
Most important — and key to effective decision-making toward meaningful change in social determinants of health — are community members themselves. People with lived experience in local communities best understand the determinants that influence community members’ lives. In this vein, we cannot address SDOH predominantly at a national level but rather primarily with an appreciation for the hyperlocal inputs of community and with needed sensitivities toward the diversity and inequity that exist throughout the nation.
This framing is meant to emphasize the point that this is an all-hands-on-deck challenge. It requires enormous amounts of cooperation among numerous traditionally diverse entities. And it demands that everyone be present at the table with a shared purpose.
Such an inclusive approach also necessitates a common language for and perspective on SDOH. This, in part, means moving past the legacy viewpoint of the SDOH framework as a means of describing the problem — speaking to what’s wrong with the determinants and the resulting negative health outcomes. It’s understandable that we’ve historically framed SDOH in such pessimistic terms. The inordinate inequity and resultant disparities in our nation — our world — have existed for so long and require so much work and so many resources to overcome that it was completely reasonable to discuss SDOH in this negative way. However, this negative, judgment-oriented framing is in some respects reinforcing and counterproductive.
An alternative construct is a narrative in which the SDOH framework doesn’t define the problem but speaks to the conditions that will enable health, well-being, resilience, and thriving. SDOH can also be what’s right. Social determinants can be what’s affecting health in profoundly beneficial ways. Just as unsafe neighborhoods, unemployment, work absent a livable wage, lack of access to healthy foods and opportunities for physical activity, and limited access to quality health care negatively impact health and well-being; there are also those determinants that positively influence health, well-being, and quality of life for certain communities such as favorable economic conditions, access to quality education, equitably safe and nurturing built environments, and just social contexts.
A roadmap for this approach already exists. The Healthy People initiative sets measurable objectives to improve the health and well-being of people nationwide. The fifth iteration, Healthy People 2030, addresses the latest public health priorities and challenges and espouses a strategy for leveraging the framework of SDOH. One of Healthy People 2030’s 5 overarching goals is specifically related to SDOH: “Create social, physical, and economic environments that promote attaining the full potential for health and well-being for all.”
To address the challenges historically defined through SDOH, the soon-to-be-released Federal Plan for Equitable Long-Term Recovery and Resilience (Federal Plan for ELTRR) provides a framework and strategic set of recommendations for long-term action to improve individual and community resilience on a whole-of-government scale and — in harmony with civil society — on a national scale. The Plan employs a more affirmative, expansive, and inclusive model to create transformative change in the area of SDOH using the Vital Conditions for Health and Well-Being Framework. This model goes beyond acknowledging what makes us sick and unwell and pivots to all the facets of our lives that favor health and well-being, enhance resilience, and enable thriving for all.
Admittedly, it takes a great deal of conscious effort to move from honoring the problem of what makes us unwell to focusing on what — across all dimensions of living — enables well-being and favors health. But the shift toward a positive and proactive approach to social determinants of health is one we can make. It’s one we must make — for the concepts of health, wellness, resilience, and thriving cannot remain couched in terms of preventing disease and mitigating problems.
Consider this approach an opportunity to have a positive outlook, to be more forward-thinking and proactive, and to collaborate broadly toward better outcomes for people and communities. Let’s open communication with one another — far beyond the familiar. Let’s honor the call to equitably create conditions that make us all healthier and enhance resilience. And most important, let’s work together toward greater well-being for every person and every community.
Yours in health,
Paul Reed, MD
Rear Admiral, U.S. Public Health Service
Deputy Assistant Secretary for Health
Director, Office of Disease Prevention and Health Promotion
In Officio Salutis