Social determinants of health & the

clinical setting: opportunities for action

Miriam Herzfeld

Tasmanian Health Conference 27 July 2014

Gaza

Image: International State Crime Initiative

1. Background

Most preventable disease and poor health arises from the social determinants of health

Historical recognition of the fundamental conditions and resources for health (WHO 1948+) & the importance of health promotion

“The circumstances in which people are born, grow up, live,work and age, and the systems put in place to deal with illness...shaped by power, money & resources” (WHO, 2008). USA

Image: BA Kenneally

2. Social gradients

Around the world, the poorest of the poor tend to have the worst health.

Evidence shows that health and social status are intimatelylinked, such that those with higher social status tend to have better health, while those with lower social status tend to have worse health outcomes.

This pattern happens at every stage up the social ladder and is called the social gradient.

Little Jessie, 2006. Little Jessie has been drinking coffee in his bottle since he was a baby. He is 12 now and he still drinks coffee. He says it helps him sleep. Image: BA Keanneally.

USA

Social gradients: around the world

Social gradients: here at home

DHHS, 2013, State of Public Health Report

A limited approach

See the work of Prof Michael Marmot on Proportionate Universalism; Images: Few-Meng Khaw, 2011

Proportionate universalism

See the work of Prof Michael Marmot on Proportionate Universalism; Images: Few-Meng Khaw, 2011

3. Do we recognise SDOH?“I recently completed a death certificate for Marie. She was 42 years old. I listed the cause of death as cancer of the cervix, metastatic. But I think I erred in completing the certificate. I really believe Marie died of her poverty.

Marie was a single mom of 2 children, raising them alone after separating from her abusive male partner following the birth of her second child. She struggled on social assistance, then later at cleaning and dishwashing jobs for minimum wage, trying to support her young family as her grade 8 education limited her vocational options. Her long work hours and child care responsibilities made visiting a family doctor a rare, episodic occurrence. Nor did she understand the importance of a Papanicolaou smear.

So although she technically died of cancer, her poverty and social circumstances were more than just a risk factor for cervical cancer, a preventable and treatable disease when caught early. Why didn’t I write poverty as a cause of her death? What is it about my attitude and training that told me poverty wasn’t an acceptable reason or important contributing factor to her demise?....”

S. Buchman MD, Canadian Family Physician

4. A word about language

“It is striking that anyone who uses the term “social determinants of health” is not likely to be someone who is at risk from them ... Knowing about is not the same as knowing.”

(T. Senior MD, 2014; Image: BA Kenneally, 2007)

USA

Social compassion

“In considering the badly off, if we as a community are to assist them, we need to listen to their voices, the voices of the poor... Giving voice to the voiceless is the way to achieve a better distribution of power, to support our democratic institutions, to build social capital and to address not just inequalities in health and income but those that exist at a more structural level in our society. That is the road to a decent caring society” (Gavin Mooney, 2005).

Mooney G, 2005, ‘Addiction and social compassion’, Drug and Alcohol Reviews, 24: 137-141. Image: Utopia

Australia

5. Opportunities in the clinical setting & beyond

Image: Raw Story

Nigeria

Holistic medicine

Holistic medicine is a system of health care thinking which considers the patient as a person within their community, family and workplace. It includes consideration of factors that include the physical, emotional, environmental, social and lifestyle.

Image: Capital Campus

India

It brings together concepts of wellbeing and wellness, including social functioning, ability to work, to form and sustain relationships, to learn, to enjoy social and other interactions as well as being free of avoidable illness, and to have unavoidable illnesses managed in ways which are acceptable to the individual (BMA, 2011).

Act on the findings of the CSDH – Healthy early child development

“Investment in the early years provides one of the greatest potentials to reduce health inequities within a generation. Experiences in early childhood (defined as prenatal development to eight years of age), and in early and later education, lay critical foundations for the entire lifecourse” (Commission on Social Determinants of Health, WHO 2008).

Image: Liberal America

“We can do better.We will do better.

”Jeremy RockliffDeputy PremierABC, 25 July 2014

Social screening & prescribing

Social prescribing is a means of enabling primary care services to refer patients with social, emotional or practical needs to a range of local, non-clinical services (Age UK).

Friedli and Watson (2004): Improving mental health outcomes; Improving community wellbeing; and Reducing social exclusion.

Cawston (2011): Awareness of the disabling impact of government

policies; and Aspiration to emphasise the strengths of patients

themselves to tackle their own problems.

Social screening & prescribing

Challenging our dependency on hospital-based health care

8% patient admissions could not be justified on medical grounds

24% patient admissions had at least one day hospital day that could not be justified on medical grounds

Of the 1438 total bed days, 33% were for nonmedical reasons

The estimated cost of those non-medical bed days for this cohort was $764 800

Image: Alamy, The Guardian

UK

Utilisation of beds on the general medical unit by ‘non-acute medical’ patients: a retrospective study of incidence and cost in two Tasmanian regional medical hospital units (Buist et al 2013).

Advocacy

Act not only as a clinician but as a community leader

Develop understanding of the social determinants of health and develop innovative approaches for action

Advocate in partnership with others

Image: Wisdom Quarterly

Ukraine

Plenty of opportunities

“GP co-payment would increase emergency department wait times” says Mark Mackay et al (2014)

Image: Health Services Union

The purpose of the Network is to work together to leverage action on the Social Determinants of Health so as to improve health and wellbeing outcomes for all Tasmanians. Vision of the NetworkAll Tasmanians have the opportunity to live a long, healthy life regardless of their income, education, employment, gender, sexuality, capabilities, cultural background, who they are or where they live. 

Key Focus Areas• Advocacy• Information sharing• Cross-sector participation

How to joinMembership is open to all and free.

Contact Miriam Herzfeld at miriam_herzfeld@internode.on.net

Social Determinants of Health Advocacy Network