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" . . . there are social determinants of health care, social determinants of health, and social determinants of health equity."
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Making Sense of the Social Determinants of Health

By Susannah Berlowe Binder | Thursday, January 17, 2019

Rishi Manchanda, MD, MPH, Founder and President of HealthBegins, is passionate about health care’s role in addressing the social and environmental factors that influence health. In the following interview, he links that role with pursuit of the Triple Aim and joy in work.

How do you explain the social determinants of health to people unfamiliar with the concept?

It’s a new concept for a lot of folks and it’s a mouthful. It can be hard to wrap one’s head around how to address the social factors that influence health. The reality, though, is that this body of work — including community-oriented primary care and the origins of the community health center movement — has been around a long time.

One way to understand the social determinants of health is to think about upstream and downstream parables. The story of American health care has largely been defined by “rescuers” and “raft builders” in specialty and primary care who save people from “drowning.” What they do is crucial, but it’s only two thirds of the story — two thirds of what it means to provide good health care. We also need to support a third, often unrecognized part of the health care team. We can call them the “upstreamists” — those who redesign care and bridge the work of health care providers with partners in the community to address what’s happening upstream. They help address the nonmedical root causes of major health problems — like a lack of housing, food insecurity, or social isolation.

What are some common misunderstandings about the social determinants of health?

The challenge is that we’re now like the six blind men and the elephant when we talk about the social determinants of health. It’s not uncommon to have a kind of Tower of Babel phenomenon happening, where everybody’s trying to say the same thing, but using different languages.

You have health care folks talking about social determinants of health because — more than ever — value is what they’re being held accountable for, and they know this means they need to address non-medical social factors. You have organizations with deep community expertise and relationships. You also have public health departments, policy makers, and academics talking about the social determinants of health. The problem is that we don’t have definitional agreement about this term. I use the example of transportation to illustrate this point.

From one perspective, transportation is seen as a social determinant of whether you can get a ride to the doctor. Folks with that frame of reference ask, “Can you get a ride to my office or to the hospital for the reimbursable visit?” That’s valid. It’s important to recognize that that’s largely where health care interests are currently being expressed.

But that’s distinct from transportation as a social determinant of health. This means asking, “Do you have a ride not just to the doctor, but to a job, or to get healthy food, or to keep you connected to your network of social support?” That’s a social determinants of health frame of reference rather than a social determinants of health care frame of reference.

Questions about transportation may lead to asking about equity. If a patient has trouble getting rides to her doctor, you might wonder why there are no bus lines in her community. In other words, there are social determinants of health care, social determinants of health, and social determinants of health equity. You could also say there are political determinants of health.

How can an improvement lens inform how we see the social determinants of health?

There are so many elements of good continuous improvement that compel us to ask, “Why does the problem exist in the first place? Why is there no transportation in that community? Why is that person having difficulty adhering to their treatment plan for diabetes? Why can’t we bend the cost curve for a whole population?” It’s like Root Cause Analysis or asking the 5 Whys. When we ask these kinds of questions, we immediately start encountering the social determinants of health.

How do you see the role of primary care in addressing social determinants of health?

The current conventional wisdom is that primary care physicians don’t understand the importance of addressing upstream issues. As a primary care physician, I can attest that the exact opposite is true, and there’s more and more research to demonstrate this. Ask anybody who’s spent just a minute providing care to a patient who has any degree of unmet social needs. It’s not that primary care physicians don’t understand the importance of upstream issues. It’s that they often don’t have the sense of efficacy to do something about it.

There are a lot of folks who understandably ask, “Is it my job to address social determinants of health?” But I think the framing of the question is incorrect because it implies that the burden of addressing large, historic, generational, social, political, and environmental factors is on the shoulders of one person in a fifteen-minute encounter, or one encounter in a hospital. It’s not possible for any single person to take that on.

So, let’s reframe the questions: “Have you ever modified a care plan because you knew your patient couldn’t afford a medication? Have you counseled a patient about what to do when they’re skipping meals so they don’t take an overdose of blood sugar lowering medication and have a hypoglycemic event?”

In other words, many primary care physicians are already addressing social determinants of health, but they’re doing so one person at a time. The issue isn’t, “Is it my job to address social determinants of health?” You’re already doing it. As part of your care, you’re already factoring in your understanding of how upstream issues matter for your patients. The issue is, “How can we help you do that job better?”

The answer is to do it as part of a team. It's not your job, it's our job. It's not your job as a doctor to become a social worker; it's our job as a system to provide a social worker so you can work with them as a team. It’s not your job to become a community health worker; if that’s required for your patients, it’s our job as advocates together — both in the system and outside — to create that role.

It sounds like you’re saying that the goal is not to add to the primary care physician role, but to better support it.

Some of what’s necessary in figuring out how to move upstream is about role clarification. Just like any good care team, it’s about understanding what role you’re going to play. For clinicians, this means knowing where they can lead, where they can partner, and where they can support.

For instance, in the exam room, a clinician may take the lead on working with a patient to adjust their care plan based on information on what’s going on in his or her life. If they’re worried about getting evicted, for example, you may partner with a lawyer. There are increasing numbers of medical/legal partnerships that do a lot of great work.

Support means not only supporting your patient or supporting your care team, but also supporting initiatives that build bridges between the health care system and social sectors. For example, if you’re a food bank, your success is my success because you’re taking care of my patients who experience food insecurity. I need to be your ally and support your work.

How does addressing social determinants of health link to joy in work?

There’s been some research now demonstrating that there’s a link between provider burnout — physician burnout included — and the lack of a system to address social determinants of health. The research is telling us what I think many of us know — you can’t be a happy clinician working in a system that doesn’t allow you to address what’s causing or contributing to your patient’s illness. The more we treat the social determinants of health as something extra or outside our scope of work, the more we miss an opportunity to advance the Triple Aim and joy in work.

Editor’s note: This interview has been edited for length and clarity.

(Having difficulty watching this video? Watch on YouTube.)

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Learn more about HealthBegins

Don Berwick's 2018 IHI Forum keynote address: "Start Here: Getting Real About Social Determinants of Health"

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