She is blind. Cataracts, or maybe glaucoma. Maybe diabetic retinopathy or some other word she will never be able to pronounce or even see. Her prescriptions are filled by a relative, at a pharmacy that only provides half the medication she needs, and brought home to her fumbling fingers. She makes her way to clinic unaccompanied, navigating footpaths and public transportation by memory if not sight. Arrives to hear that her blood pressure is elevated, and her sugar is out of control. Insulin, the doctor says. Never mind that she has not been able to get her Metformin pills for weeks and weeks. Never mind that she has no refrigerator. Never mind that she cannot see. Your sugar is too high and there are no more pills we can prescribe for you. Insulin.
He has HIV. Contracted from some faceless sexual contact long ago; he rages at the diagnosis, a short-sighted anger that settles on his most recent partner. But CD4 cells are warriors, and do not drop to 50 overnight. How could this happen to him? He disappears for months. Changes his number. Skips town. Grows a beard to hide the tattoos. Loses himself in alcohol and cannabis. Cannot forget. He returns on a hospital gurney, face drawn, spiking fevers. Newly diagnosed, the internist says. Never linked to care, the social worker corrects him. If he lives, he will join the clinic. Fire spent, bitter and resigned. If he lives.
What are the social determinants of health?
According to the World Health Organization, these are the conditions into which people are born, grow, work, live and age and the wider set of forces and systems that shape daily life.
In other words, everything. Your world as you know it determines how healthy you can or cannot be. If we were fish, social determinants would be our fish tank and everything in it. Which would be great, because we could just upgrade to a bigger tank with better water and a more efficient pump/filtration system and most of our problems would be solved. Except for food, I guess. I don’t know, I’m getting out of my depth.
Social determinants of health can be thought of as any feature of life that supports people being well or makes it more likely for them to get sick. Things like employment, finances, food supply, housing, education, clean air and water, transportation, and access to healthcare. The list goes on. If we take a curative approach and think of health as treating disease then the social determinants are all the things that get in the way of someone reaching the doctor, getting an accurate diagnosis, getting the right treatment and recuperating successfully. If you stop to think about it, there are a million ways this process can be thwarted.
As a field of significance, social determinants have been on the health agenda for decades, since the 1940s. But they were relegated to the back burner in favour of alternative (read: neo-liberal) approaches to public health. Finally in the early 2000s they were revived and examined more closely, giving us hard science on health inequalities across the globe. This is a prime example of the gap between people who make health policies and the people who live with them. I’m sure the man or woman walking into a doctor’s office could easily have easily told you that the reason they ignored that suspicious lump for so long was that they couldn’t get time off work to visit the doctor and they were trying to save up money to buy the medication but the children had to go to school. Social determinants impact health in real time.
When we think about our roles as medical practitioners (and here I can only speak for doctors) we imagine waving a stethoscope and pen to make people healthy. With the right investigations and the right remedies blood pressures will be controlled, diabetic feet will heal and that infection will clear up in no time. But the reality is that our ten-minute consultation is merely a blip in the busy lives of the people who access healthcare. Our brief contact can only do so much and no more. In medical school we are told in not so many words that you can lead a horse to water, but you can’t make him drink. But our patients are nowhere near the pond. They are on the other side of the hill, separated by hot coals, barbed wire and quicksand.
There just isn’t much exposure to the social determinants in medical school. Public health and primary care docs try to explain this complex and layered concept on two short Community Health rotations to students who care more about cramming for exams than pondering the barriers to care for Miss Ivy in rural St. Mary. But this feels like a failure of the medical education system. I’ve mentioned before that we can’t all be paediatric neuro-oncologists, yet medical schools consistently emphasize the rote memorization of esoterica as the most important part of being a doctor. We graduate into hospitals that perpetuate this idea of health as a binary: either you are ill (in the hospital) or well (not in the hospital), failing to recognize that health exists on a continuum that is constantly shifting in relation to the environment.
We have to shift our thinking to come up with new and better ways to preserve and promote wellness. We have to train new generations of physicians and allied health workers to look beyond the confines of their facilities to the communities where people live and work. Meaning the places where health actually happens (or doesn’t). We have to ask hard questions and be open to the answers. Until we are ready to grapple with the consequences of our societal systems and structures, we will never be able to reach our vision of “Health People, Healthy Environment”, not in 2030 or ever at all.