Social determinants pave the way for health equity


Philadelphia has the dubious distinction of being the place where the “social determinants of health” have been identified as such in the United States. The University of Pennsylvania commissioned WEB Du Bois to conduct a sociological study here in the 1890s. The sample was limited to the city’s seventh diverse neighborhood, where the west side was occupied by affluent whites, the middle section was densely populated by “black elites” and the east side was mostly occupied by poor blacks. The study concluded that instead of being linked to racial differences, the “plexus of social problems” (eg, crime, poverty, drug addiction, illiteracy) arose out of the exclusion of blacks from industrial jobs, housing market and educational opportunities in the city.

Fast forward more than a century and, sadly, the same conditions perpetuate racial and ethnic disparities and health inequalities in Philadelphia and across the United States – from our big cities to low-income rural areas. Although most health systems have made efforts to improve the well-being of the communities they serve (e.g., targeted disease management programs), few have made achieving health equity a priority. central strategic objective. The notable exception is Chicago’s Rush University Medical Center (RUMC) – and David Ansell, MD, MPH, is the driving force.

Ansell’s book “The Death Gap: How Inequality Kills” effectively called structural racism, economic deprivation, and neighborhood conditions the afflictions that cause health inequalities and advanced the notion of structural violence. as a root cause of low life expectancy in marginalized communities because it is “designed into” laws, policies and standards. He challenged academic medical centers (CMAs) to address these issues as a first step in identifying ways to address health inequalities.

By shifting to a population-based model of health, RUMC broadened its focus from a narrow focus on the delivery of health care to a panoramic view of improving health in the various communities it dessert. In 2017, RUMC fully embraced Ansell’s Principle that improving health requires a commitment to a community partnership approach with action focused on the complex causes of ill health. Like many CMAs, they had community partnerships, but the initiatives were not designed to get things done on community health outcomes.

Earlier this year, Ansell and his colleagues published an excellent article. In recounting RUMC’s revolutionary journey towards health equity, the authors give us a lot of food for thought. I’ve summarized the article below, but it’s worth reading in its entirety!

After examining data on more than half a million people living in its primary service area, RUMC analysts found that common chronic diseases (e.g., cardiometabolic disease, cancer) made up a significant proportion of premature death. Importantly, they clearly documented the 14-year life expectancy gap between the wealthy and largely white downtown and the racially segregated western neighborhoods with substandard housing, food deserts, dangerous streets, and bad. school results. Based on these findings, they embarked on a multi-year, company-wide culture change strategy and adopted a 5-pillar framework to achieve the monumental goal of health equity. It was not easy to access from all points of view!

Unwrap the 5 pillars, the first – “naming” racism and poverty as the main causes of ill health – seems to me the most courageous. The reasoning is quite simple; it stems naturally from a well-established approach to improving quality and safety known as root cause analysis, a technique that leads to researching why untoward events occur and naming them without bias .

Pillar 2 identifies the business as an “anchor mission” – an understanding that large local nonprofits are often critical economic drivers in their communities. RUMC has committed the company to hire, train, buy, invest and volunteer locally. For example, the company’s total spend on key mission-related initiatives from fiscal year 2019 to the second quarter of 2021 was $ 20.4 million, and the company opened 16 employment hubs. during the same period to support local hiring.

The third pillar focuses on creating wealth-building opportunities for employees, many of whom had experienced extreme financial distress and were not saving for retirement. Initiatives include items such as a pension reform program to dramatically increase retirement savings, a healthcare career path program for existing employees, and wellness training programs. be financial and credit.

Pillar 4 calls for an active fight against inequalities in health care. A multidisciplinary committee contributes to performance improvement projects that address racial, ethnic, gender and age inequalities in health care outcomes. For example, patients are now screened for the social determinants of health: food, shelter, utilities, transportation and access to primary care.

The last pillar is a challenge to address the social and structural determinants of health. RUMC achieves this through a community collaboration on racial health equity that includes all health systems in West City. With a shared long-term vision, collaboration avoids unnecessary duplication of programs, establishes common standards and best practices, coordinates resources, and works to improve health outcomes. The goal is to reduce by 50% the gap in life expectancy between affluent neighborhoods in the city center and the west by 2030.

I salute Ansell and RUMC for their commitment to tackle the thorny issue of health disparities head-on and to work to resolve these disparities. Wouldn’t it be great if America’s 150 AMCs followed their example? It will likely remain a draw for most, but many health systems are starting to nibble at the edges. Here in Philadelphia, for example, Thomas Jefferson University and Novartis recently signed a 3-year, $ 3 million contract to help fill one of the city’s long-standing healthcare gaps. The goal is to reduce cardiovascular health disparities in 5 city zip codes.

Ansell demonstrated that CMAs can change their heavy culture and successfully pivot to tackle the social determinants of health. He gave us a roadmap, and it’s up to us to replicate his milestones.

David Nash, MD, MBA, is Founding Dean Emeritus and Dr Raymond C. and Doris N. Grandon Professor of Health Policy at the Jefferson College of Population Health. He is the special assistant to Bruce Meyer, MD, MBA, president of Jefferson Health. He is also editor-in-chief of American Journal of Medical Grade and of Population health management.

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