The commitment By Hirschel D. McGinnis, MD, FSIR


Countervailing forces Understanding the social determinants of health


D


uring my first month as an intern, our team admitted a middle-aged man with acute onset heart failure. He had


been untethered to regular medical care, and several neglected conditions had finally caught up with him. We did what inpatient medical teams do best and, by the end of the week, he was in a much better-balanced state of health and ready to be discharged home.


But as his nurse was instructing him about his new medications, he flew into a rage. He said he couldn’t afford the medications and would go home just to get sick all over again. While our team had been diligent in addressing his acute cardiac needs and devised an effective treatment plan, we failed to explore other dimensions that had contributed to his illness and long-term outcome. While he had a home and family, clearly economic factors were a significant driver of his recent health event. Care management to the rescue!


All these years later, I remember this incident with compassion and believe his outburst was likely a painful expression of frustration and embarrassment. I’ve tried to let this event remind me of the deeper social context into which medical care is delivered.


The innovative ground-breaking therapies that IR offers advance the possibilities and standards of healthcare. Our efforts can lengthen and improve the quality of life for our patients. However, there are powerful countervailing forces outside of our medical practices that reduce or even block the impact of our work.


22 IRQ | SUMMER 2023


The prevalence of food insecurity


is significantly higher in


Black households (21.7%) and


Hispanic households (17.2%)


compared to the


national average (10.5%)


Social determinants of health Social determinants of health (SDOH) are the economic, social and environmental factors that influence health outcomes, oftentimes before patients are even sick. The lifestyles and conditions in which people grow, live and work directly impact their health and longevity.


These factors are often invisible to care providers but are powerful drivers of individual well-being and broader population healthcare disparities. Surprisingly, research estimates that direct clinical care affects just 20% of county-level differences in health outcomes, while SDOH affect up to 50%.


The socioeconomic factors of poverty, employment and education are the chief drivers of these differences.1


Variation


in the SDOH among populations contributes to healthcare disparities. For instance, in communities with less access to stores with high-quality food, residents are likely to have poorer nutrition that in turn affects rates of diabetes, hypertension, heart disease and renal disease. This in turn negatively impacts life expectancy. Counseling patients on dietary choices may not be enough if their neighborhood infrastructure and personal economic status don’t provide easy access to high- quality food choices.


By understanding the five principal social determinants of health, we can gain a deeper understanding of how they shape individual patient and population health and keep them in mind as we pursue treatment plans for patients.


1. Economic Stability Employment The ability to have a regular and reliable source of income directly allows individuals to purchase access to food, housing and healthcare. Benefits of employment such as health insurance, paid sick leave, parental leave and participation in a retirement plan fortifies the health of the employee and their family. Further, safe workplaces promote employees’ physical and mental health.


Conversely, research has demonstrated negative health consequences related to unemployment such as depression, anxiety, poor self-image and physical pain.2,3,4


Illnesses associated with stress


such as hypertension, stroke and cardiac disease are also found at higher rates in people who are unemployed. Even


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