POLICY OPTIONS BRIEF
TO:
Mary Travis Bassett, MD, MPH, commissioner of the New York City
Department of Health and Mental Hygiene
Maria Torres-Springer, commissioner of Small Business Services
Carmen Farina, chancellor of the Department of Education
FROM: Tesaen Chavis
RE:
Social and Nonmedical Determinants of Health vs. Individual Medical
Care Interventions
DATE: December 2, 2014
THE PROBLEM:
It is well understood that lack of access to health care is not the fundamental cause
of health vulnerability or social disparities in health. (Lantz, 2007) However, it can
be argued that most federal policies introduced within the health spectrum are
usually in regards to access, or more recently, cost. In response, there has been a
recent confluence of interest from public health advocates in addressing the
inequities alongside the inequalities behind health and healthcare within the United
States.
Irving Zola presented the concept of medicalization, which is defined as the “the
expansion of medicine as an institution and the use of a medical lens to view human
processes and behavior.” (Lantz, 2007) This highlights a burgeoning societal norm
in correlating health issues to individualistic biological, hygienic, and behavioral
failures, with biomedical treatment given to combat these health problems through
providers and physicians. By viewing medicine under these conditions, we are not
addressing the roots of health vulnerability, where epigenetic changes brought
about through stressful years earlier in life can prove to be negatively fruitful for
“these [stressful] exposures can influence adult health through multiple
mechanisms and pathways, including hormonal, neurological, and immune system
dysfunction.” (Lantz, 2007)
To put this in context, during the nineteenth and early twentieth centuries, it was
beginning to be understood that there was a correlation between health status
vulnerability and socioeconomic vulnerability. As such, there was much attention
paid to the “upstream” causes behind health vulnerability, including sanitation,
housing conditions, work environments, food insufficiency, and nutritional habits.
This acknowledgement proved to be highly important as shown in the sharp decline
in mortality rates across the U.S. (Lantz, 2007)
However, during recent years, U.S. health policy has held a focus on access to
medical care and improved medical care as the primary policy amendments to
address. As aforementioned, this is due to a medicalized view of population health
and health vulnerability, and increasingly, a view that health is rendered and
addressed from the individual level. (Lantz, 2007) But if there were such of a focus
given to the inequities behind health vulnerability, namely the socioeconomic and
racial disparities that give rise to it, we would potentially be in a position where we
would already be addressing the root causes behind this vulnerability. With the
amount of evidence pointing towards a need to address this issue, we are obliged to
act upon this information and work towards correcting it.
Issues exaggerating medicalization include an American history of ambivalence
towards disadvantaged groups and individuals. This ambivalence made it easy to
designate a status for those that are “deserving of assistance” vs. those that aren’t.
These concurrent views of ambivalence along side a booming scientific and medical
industry introduced a hyperactive tendency to medicalize health, illness, and
ultimately, wellness. In response, a separatist approach emerged, granting a two-tier
“safety net” system, where disadvantaged groups were given access to piecemeal
and separate institutions and physicians. It also rendered “facilities, systems,
providers, financing arrangements, and bureaucracies that exist outside the
mainstream health care delivery system and operate specifically for vulnerable
populations”. (Lantz, 2007) These institutions are typically not well funded, serve a
larger population than intended, and operate under financial stress. An issue arises
in the rendering of inadequate services to those in need of the most help.
Another issue of medicalization lies in the concept of there being a difference
between health status disparities and health care disparities. It encourages the view
that one can “solve socioeconomic and racial/ethnic health status disparities
through initiatives and policies that reduce disparities in health care access, use, and
quality.” (Lantz, 2007) This convolutes the health inequity problem and makes it
seem as though an easier path to “closing the gap” can be achieved through
addressing health care access. As stated by Lantz, this path is much easier to
conceive than a path that would encompass complete social and economic reform.
Making matters worse, it is estimated that 95 percent of U.S. health services
spending goes toward direct medical services, and only 5 percent is invested in
prevention services and health status improvement. (Lantz, 2007; Mays and Smith,
2011) This can later be seen in the form of disability income support and benefits,
with these provisions only being made available to the disadvantaged after they
have been diagnosed with a condition. An ideal mode of addressing health should be
to help prevent preventable illness from occurring in the first place as opposed to
providing compensation to live with it later in life.
Mays’ and Smith’s research highlighted the additional $15 billion funding under the
Affordable Care Act’s Preventational and Public Health Fund that will go directly
towards health prevention services. However, they also explain that while this fund
is “expected to generate substantial improvements in population health over
time...our results suggest that the recent recession-driven reductions in state and
local support for public health activities are likely to have adverse health
consequences over time unless they are offset with new spending.” (Mays and
Smith, 2011)
Policies created to address health inequalities are not intersectional; therefore, they
may only address a very specific part of the problem. It could be proposed that
while we have current programs in place to address declining health within lowerincome communities, we should also be required to have benchmarks – these
benchmarks already set by a higher socio-economic group. While the WHO mandate
is considered vague, “the highest attainable standard of health can be…reflected by
the standard of health enjoyed by the most socially advantaged group within a
society.”(Braveman, 2003)
Beyond the band-aid approach of dealing with health vulnerabilities and disparities,
the overarching need lies in addressing the inequalities and inequities in access to
housing, education, nutrition, amongst other things, in order to fully address health
disparities. (Lantz, 2007)
POLICY RECOMMENDATIONS:
According to Amy B Bernstein of the Centers for Disease Control and Prevention,
“data systems are created by...federally funded national surveys, vital
statistics...regulatory data, and medical records data.” (Bernstein, 2012) This data is
then typically aggregated by geographic location. (PolicyLink, 2013) The data
averages are not calculated to include most social determinants of health, such as:
shelter, education, food, sustainable resources, peace, and equity. (Raphael, 2000)
As such, policies created to address health inequalities often do not acknowledge the
economic or social issues that contribute in keeping these health issues persistent
within communities of color. (PolicyLink, 2013)
I believe, as residents of New York City, we can start piloting programs that can be
replicated across the country to address these health inequities. It could be very
beneficial to allow the public health office to encapsulate the most pressing issues
within our city, work in tangent with the officials of corresponding city agencies, and
propose initiatives to be address and proposed at city council.
As such, I recommend focusing in on 3 areas:
Education:
We need to address childhood educational attainment gaps in order to help
alleviate poverty later in life. As level of education has been tied directly to
income level, access to quality education is a barrier that can be removed to
help forgo later health disparities that are tied to socioeconomic factors.
(Adler, 1994) I propose looking into:
o Summer enrichment programs for disadvantaged groups
o Longer school days and/or longer school years
Social gradients of health:
We need to address the social determinants in health risks (i.e., nutritional
habits, smoking, exercise). By addressing food deserts, food insecurity, and
food educational needs within high-risk populations, we can stem
cardiovascular health problems that arise through the nutritional choices
and nutritional access. We need to create policies that address issues such as
the hunger/obesity paradox, inner-city food deserts, and nutritional
education (such as Michelle Obama’s Let’s Move Program). For NYC, I
propose:
o Making school lunches more nutritional. If NYC at-risk children are
receiving 2 out of 3 meals at school, they should be nutritionally
sound.
o Expanding programs where most disadvantaged children are sent
home with meals.
o Educating the general public on their healthy food options across the
city.
o Addressing complex behavioral choices in any policy introduced that
acknowledges autonomy, free will, and food addiction. Policies where
marginalized communities are “punished” re: taxes and price control,
are not beneficial to the greater community in the long run.
Invest in disadvantaged and marginalized community resources:
We have to address crime and violence in a politically, yet culturally sound
manner.
o Helping to redevelop local economy with small business development
o Providing parks and safe areas
o Addressing educational and employment opportunities within the
community for and by community members.
Bibliography:
GP Mays, SA Smith. Evidence Links Increases In Public Health Spending To Declines
In Preventable Deaths. Health Affairs, 30, no.8 (2011):1585-1593 (published online
July 21, 2011; 10.1377/hlthaff.2011.0196)
PM Lantz, RL Lichtenstein, HA Pollack. Health Policy Approaches To Population
Health: The Limits Of Medicalization. Health Affairs, 26, no.5 (2007):1253-1256;
10.1377/hlthaff.26.5.1253]
Adler, Nancy E., et al. "Socioeconomic status and health: the challenge of the
gradient." American psychologist 49.1 (1994): 15.
Braveman P, Gruskin S. Defining equity in health. J. Epidemiol. Community Health.
2003;57:254–258.
Bernstein AB, Sweeney MH. Public Health Surveillance Data: Legal, Policy, Ethical,
Regulatory, and Practical Issues. Centers for Disease Control and Prevention.
Supplements. 2012;61(03);30-34.
Raphael D. Health inequities in the United States: prospects and solutions. J Public
Health Policy. 2000;21(4):394-427.
PolicyLink. Health Equity: Moving Beyond “Health Disparities”. 2013