News October 25, 2018

What Really Creates Health? Embracing the Social Determinants as Our Health Imperative

Guest blog by Terry Allan, Cuyahoga County’s Health Commissioner and SLF Trustee

Clevelanders have a strong reputation for supporting those most in need in our community. There are a wide range of public and private health and human services agencies and a very engaged philanthropic community working together to address unmet needs. Despite these collective efforts, disparities in health outcomes by factors like race, gender and income remain. How can we work together to turn the tide?

The Health Impact Pyramid from the Centers for Disease Control and Prevention (CDC) is instructive in understanding the relative impact of the types of programs, services and interventions offered in a community.

What Really Creates Health? Embracing the Social Determinants as Our Health Imperative

The Pyramid demonstrates that the most impactful and sustainable interventions can be found closer to the bottom of the pyramid. As we think about what creates health, we’re learning that the socioeconomic factors, often referred to as Social Determinants, can have the most substantial impact in our collective efforts to improve the health of our community. Income, the quality of housing and education as well as access to transportation and good jobs can all have profound effects on our health status.

In discussing the social determinants, it’s useful to pause for a “literacy moment” to assure that everyone has a common understanding of terminology.

What Really Creates Health? Embracing the Social Determinants as Our Health Imperative

The CDC defines the social determinants as the complex, integrated, and overlapping social structures and economic systems that are responsible for most health inequities, which include the social environment, physical environment, health services, and structural and societal factors. Social determinants of health are shaped by the distribution of money, power, and resources throughout local communities, nations, and the world.

These data are further supported by the Robert Wood Johnson County Health Rankings, which demonstrates that healthcare is responsible for 20% of health outcomes while the social determinants while health behaviors and the environment in which we live collectively account for 80% of what drives health. Given the clear value of focusing on high impact investment in improving health, it’s also instructive to understand how we currently spend money toward that end.

So how are we doing? To answer that question, we turn to the Kaiser Family Foundation which notes that, relative to the size of its wealth, the U.S. spends a disproportionate amount on health care compared with other countries. The Network for Excellence in Health Innovation (NEHI) found that the US spends 88% of national health expenditures on medical services while spending only 4 cents on the dollar for prevention. How we spend our money matters, as the Brookings Institute research tells us that states with a higher ratio of social to health spending (calculated as the sum of social service spending and public health spending divided by the sum of Medicare spending and Medicaid spending) had significantly better health outcomes.

What Really Creates Health? Embracing the Social Determinants as Our Health Imperative

Ultimately, our goal is to achieve health equity, where everyone has a fair shot at being healthy. Changing how we spend our money to remove obstacles to good health.

Children exposed who lack safe places to exercise, neighborhoods without healthy food choices and lead based paint in low income housing all represent barriers to health equity, to that fair shot at meeting ones full potential. The burden of these obstacles is disproportionately faced by low income communities of color, who have limited opportunities and access to the benefits available in more advantaged neighborhoods.

Changing how we invest our resources to tilt the balance toward prevention and equity makes good economic sense. A healthy community, where everyone has access to the resources that create health, is a prosperous community and this vision, after all, is one that can be shared by all of us.

For more information from Terry Allan on the Social Determinants of Health, please view his slidedeck on our resources page.


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