Looking beyond medical care to the social determinants of health

Provost Lloyd B. Minor
April 2012
“Leadership Speaks” column in Change, a forum for Johns Hopkins Medicine faculty and senior staff

Only six miles separate the Baltimore neighborhoods of Roland Park and Hollins Market, but they might as well be worlds apart. For one thing, the affluent and educated residents of Roland Park can expect to live 20 years longer on average than their counterparts in Hollins Market.

As clinicians it is easy to equate health with the amount and quality of health care we provide, yet social factors are actually a greater determinant of health than medical care. In fact, many studies have found that health care spending directed at disease intervention addresses only about one quarter of the determinants of health.

The World Health Organization defines the social determinants of health as the conditions in which we are born, grow, live, work and age. These factors—including income, employment, social support, stress, early life and housing—are shaped by the local and global distribution of money, power and resources.

Social factors help explain why the United States still has poor outcomes on broad measures of health despite all of the money we spend on medical care. When it comes to infant mortality and life expectancy, we rank near the bottom of the countries belonging to the Organization for Economic Coordination and Development. There is only so much the medical system can do when neighborhoods lack safe areas for exercise, liquor stores abound, good schools are rare, access to nutritious food is limited, crime rates are high, homes contain dangerous levels of lead and role models are scarce.

According to the Commonwealth Fund, the mortality rate for chronic conditions like coronary disease and diabetes is nearly four times greater for individuals who did not graduate from high school than it is for those who have at least some college education. Low-income individuals are more than twice as likely as those with higher income to smoke if they are adults or to be overweight or obese if they are children.

Health disparities by race and ethnicity are increasingly getting the attention they deserve. But even with this work, few physicians realize the significant disparities that are the result of social factors. In order to improve our nation’s health—not just its health care—we must begin to see social determinants as being within the scope of our roles as clinicians.

By considering social factors, we would acknowledge that independent of health care, life expectancy would still be higher in Bethesda than in Baltimore, higher in Maryland than in Mississippi, and higher in the United States than in Uganda.

To raise awareness about the impact and importance of the social determinants of health, I am hosting a Conference on the Social Determinants of Health on May 8 and 9 on the Homewood campus. All members of the Johns Hopkins community are invited to attend and to hear from experts and deans from around the university and health system about what we can do to reduce health inequities.

Sessions on topics such as early life, race and gender, stress, poverty and education will be led by faculty across departments, from economics and engineering to pediatrics and political science. The keynote address will be delivered by Amartya Sen, a Nobel Laureate for his contributions to welfare economics and a member of the World Health Organization’s Commission on Social Determinants of Health.

With this conference I hope that we might begin to look beyond medical care to address the social determinants of health. In the wise words of famed Johns Hopkins neurosurgeon Harvey Cushing, “A physician is obligated to consider more than a diseased organ, more even than the whole man—he must view the man in his world.”

To learn more about the Provost’s Conference on the Social Determinants of Health, please go to www.jhu.edu/provost/sdh.