A Brief History of Social Determinants of Health

Posted on Thursday, July 22, 2021

Social determinants of health (SDOH) – this term and many derivatives are used today to discuss the broadly non-clinical factors that impact a person’s health. It’s the environment in which they live, the world they know, the foods they eat, the careers and education they pursue, the people they engage with, and much more. Although it is easy to grasp how certain factors and living conditions can affect a person’s health, others are less obvious and may go unnoticed and unaddressed by trained medical professionals.

The groundwork for how we approach SDOH today can be traced to the early 19th century as a response to the Industrial Revolution when society saw significant increases in disease and poverty. At that point, the scientific community began to explore the roots of disease not in just the biological realm, but the social as well.

Rudolf Virchow, a German physician known for his work in pathology, social medicine, and forensics, wrote one day following an 1840s typhus epidemic: “If medicine is to fulfill her great task, then she must enter the political and social life. Do we not always find the diseases of the populace traceable to defects in society?” Thinking like Virchow’s and others soon laid the groundwork for social medicine, a scientific field that is closely associated with the efforts of public health.

Ideas in the arena of social medicine began to emerge and evolve over time, and became a global focus in 1948 when the World Health Organization (WHO) – newly formed in response to public health and humanitarian challenges following World War II – finalized a constitution that defined health as “a state of complete physical, mental and social well-being.” Note the use of “social”.

However, the Cold War soon followed, and a number of political challenges occurred that, while not outright rejecting the WHO’s vision, at least slowed down the widespread adoption of public health measures focused on social determinants. As the Soviet Union withdrew from the United Nations in 1949, so too did its involvement in the WHO diminish, giving the U.S. more influence over the emerging organization.

The U.S., wary of the ideological implications of a “social” approach to health in the age of the Red Scare, did not appear to embrace the role of community in the healthcare continuum until several decades later, and instead focused more on technological advancements and innovations in a clinical setting.

Despite resistance from the U.S., stories of successful community-based initiatives began to emerge from developing nations in East Asia and Latin America, where hi-tech resources and infrastructure were not as readily available to large portions of the population. For example, 1960s China saw the rise of “Barefoot Doctors”, which were village-level health workers who brought healthcare to a more rural setting instead of urbanized population centers. They stressed self-reliance and prevention and helped demonstrate how a social approach in medicine – where all of the patients’ needs are identified and met instead of treating a select few symptoms – could be not only advantageous but also cost-effective.

This approach became more clearly defined following the International Conference on Primary Health Care, sponsored by WHO and UNICEF at Alma-Ata, Kazakhstan, in September 1978, when WHO Director-General Halfdan Mahler famously declared “Health for All by the Year 2000,” with a focus on primary health care (PHC) at the heart of that goal. This new philosophy reinforced the idea that PHC applied not just to immediate health needs but also required the coordination of other sections such as food, education, housing, public works, and others.

However, many global leaders found the Alma-Ata declaration “too vague and all-embracing to yield concrete results”, one author writes, and found resistance especially from those who believe in a market-based approach to health. Some began to propose an alternative called “selective PHC”, which adopts the same community-level philosophy but focuses more on a small handful of key interventions linked to specific and timely public health goals (like vaccination or maternal health campaign) rather than the broad, holistic view of health and its determinants adopted at Alma-Ata.

The two schools of thought continued with no clear “leader” until macroeconomic policies once again shifted the course of public health. By the 1990s, the WHO’s political and financial capital waned in comparison to that of the World Bank – an organization which, at the time, lent to the health sector a figure greater than the WHO’s entire budget.

Under new leadership, the WHO established in 2002 the Commission on Macroeconomics and Health (CMH), which used insight from economics experts to help quantify the impact of SDOH in terms of dollars and cents. It helped more or less tether the previously lofty ideals of “Health for All by the Year 2000” to a more grounded set of goals and objectives, making it easier for policymakers to entertain the idea that SDOH can and should be part of any public health discussion.

Ever since the healthcare community in the United States has steadily incorporated the spirit of SDOH-centered care into their strategic philosophy. For example, as of 2014, at least 53% of all Medicaid long-term care spending was on home & community-based services. Unfortunately, health outcomes do not always keep pace with health spending, and an area of contention in the United States over the past two decades is the rapidly rising cost of medical care, despite initiatives like the Affordable Care Act.

Political disagreements over the nature and future of publicly-funded healthcare had somewhat stalled healthcare policy innovation in the 2010s until the onset of the COVID-19 pandemic in 2020. Lockdowns, high healthcare resource demand, and social distancing introduced a ‘perfect storm' of challenges that rocked the healthcare community to its core.

For example, the U.S. saw a rapid increase in the number of people struggling with food insecurity during COVID-19 – a truly unfortunate development considering the food insecurity rate in 2019 was at a 20-year low. After the World Health Organization (WHO) declared a global pandemic on March 11, 2020, and cities and states issued stay-at-home mandates and the closure of non-essential businesses, food insecurity skyrocketed. Feeding America estimates 45 million adults (1 in 7) and 15 million children (1 in 5) experienced food insecurity in 2020. Read more about how health plans responded to food insecurity during the pandemic.

SDOH became such a focus area during the pandemic that the Centers for Medicare & Medicaid Services (CMS) issued a “roadmap” designed to help States address SDOH in order to “improve outcomes, lower costs, and support state value-based care strategies.”

“The evidence is clear: social determinants of health, such as access to stable housing or gainful employment, may not be strictly medical, but they nevertheless have a profound impact on people’s wellbeing,” said CMS Administrator Seema Verma.

Today, SDOH is often brought up in discussions related to health equity, or the goal of equal access to health resources for all, thanks in large part to a renewed focus on social issues and historic inequities. The public and private sectors are increasingly focusing on finding concrete, measurable objectives for SDOH as part of many policies and campaigns. For example, as of June 2021 there are at least 58 bills before Congress that mention SDOH, and major health plans like Humana are implementing campaigns like “Bold Goal” that focus resources on initiatives that address SDOH like food insecurity for vulnerable populations with chronic illnesses.

As health plans, State and Federal agencies, and community organizations learn more about the link between SDOH and health equity, we’re likely to enter an unprecedented period of innovation and collaboration where action on healthcare outcomes starts not in the doctor’s office, but in the household. It’s like we always say: home is where the health is.

At Mom’s Meals, we are committed to learning everything we can about food insecurity and SDOH. Click here to find out more about how we use home-delivered meals to support unique nutritional needs and enable independence at home.

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