Health as the means, not the end
The following is an interview with Sandro Galea, PhD, physician, epidemiologist, author, and dean and Robert A. Knox Professor at Boston University School of Public Health.
Austin Frakt: Among health care systems, plans, and programs, there has been increasing discussion of, if not investment in, approaches to addressing social needs. What is driving this phenomenon? Why is it happening now (as opposed to, say, 10 years ago)?
Sandro Galea: I agree that there has been a sea change on this in the past five years; the widespread adoption of “SDOH” as a concept has been remarkable to watch. My sense is that this has been driven by three factors.
A. The field has been building, communicating, for the past two decades. At some point the ideas penetrate and are being taken up.
B. The futility of medical interventions, as evidenced by the ever worsening state of American health, at some point becomes impossible to ignore, and health systems are looking for solutions.
C. The election of a president who is openly hostile to the concerns of social needs has resulted in an embrace of these concerns by many who previously were not centrally focusing on them but realize that they are important.
All of this has conspired to result in a surge in interest in social needs, which is to the good.
To what extent should the health system be involved in addressing social needs? After all, these are not traditionally in the purview of health care. Are the boundaries of health care shifting? Should they?
This is an excellent question. I am not sure that the boundaries of health care should shift, even if it is tempting to say that they should. Ultimately health care is about curative care; it is about restoring people who are sick to health. Can the boundaries of the health care system shift so as to include the full scope of social and economic forces that keep people healthy to begin with? Does the suggestion that this is the case let the rest of society off the hook from dealing with the social needs that are inseparable from the production of health? In some respects, the progress in accepting social needs as a part of the health conversation creates a tremendous opportunity. The question though is both how health care can adapt to embrace some of this, and also how we can collectively change the public conversation so that the relevant sectors can take up these issues to complement the work done by health systems.
Are we making progress in addressing social needs and/or social determinants of health? How would we know if we are? What would constitute “success”? How should we measure it?
This is a complicated question. In the past few years we have seen a disinvestment in many of the forces that shape health, in equitable incomes, environmental regulation, investment in urban spaces, etc. So, that is clearly several steps backwards. But we also have seen a galvanizing of public attention around these social needs, as noted above. In the long term, that stands to serve us well, with more people recognizing the importance of investment in social factors to generate a better and healthier world. Success to my mind is the opportunity for all to live life to their full potential, to flourish and thrive. Insofar as social determinants create health, health is the means, not the end. But it is an important and measurable means. So we will “know” when we see progress on health, when our health achievement improves rather than retracts, when we are creating equitable opportunity for all to live a rich and satisfying life.