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A Reintroduction to social determinants of health

SEMINAL STUDY

1.2

1.3 // Integration of social Drivers

1 INTRODUCTION

1.2 // introduction to Social Emergency Medicine

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WHO’S DRIVING?

AN INTRO TO

SOCIAL DETERMINANTS (DRIVERS) OF HEALTH

&

SOCIAL EM

JOHN LEWIS, MD, MS FACEP�ASSISTANT PROFESSOR �DEPARTMENT OF EMERGENCY MEDICINE�EMORY UNIVERSITY�ATLANTA, GA

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Disclosures: None

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Objectives

Explain the difference between Determinants and Drivers
Learn the all-encompassing role of SDH
Describe why addressing health disparities is essential
Commit to integrating a SDH paradigm into ALL clinical and academic efforts
Embrace Social Emergency Medicine as inextricable from ALL of Emergency Medicine

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NEW TERMINOLOGY (Language)

Determinants = Finality
Drivers = Dynamic (modifiable)
Preferred by patients/communities

Social Drivers of health

Define SDH as the conditions in environments that impact health outcomes.
Mention the ancient origins of the concept and its relevance in modern healthcare.
Stress that SDH can be positive or negative and often overlap across various domains.

DEFINITION:

SDH are the conditions in the environments where people are born, live, learn, work, play, worship, and age that affect a wide range of health, functioning, and quality-of-life outcomes and risks. The concept is ancient, 4 BC, if not earlier (Physiocratic school of thought)

SDH play a pivotal role in health inequities/disparities, serving as the primary driver. It's important to understand that they can be

Both positive and negative, further emphasizing their complex nature and impact on health outcomes.

These domains can be expanded and almost always overlap.

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Chapter 1: Where are we going?

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Stop 1: Where are we going?

Wonderland

Down the rabbit hole

The Promised Land

Freedom and Equality

Uptown/Downtown

Equity and Access

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WONDERLAND

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Down The Rabbit Hole

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It’s getting dark. Can you see where we’re going?

- Population Reference Bureau

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Rabbit Hole…

A Deeper Dive “Drive”

Source: The Equality of Opportunity Project

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Economic Stability

Inheritance

Education

Military

Employment

Home Ownership

None/Outlawed

Anti-Literacy

US Policy Defaults

Unfair Wage/Hiring

Unfair Housing & Lending

Wealth

Poverty

Discuss how race-based policies have influenced the racial wealth gap and its implications for health.
Highlight the connection between economic stability, wealth, and poverty in shaping health outcomes.

Responsible for the Racial Wealth Gap (which does not exist to the same degree for West African Immigrants. While similar persons in origin, No prolonged exposure to the legacy of US race-based policies and practices:

Historical Examples of each of the above categories. Each of the below is a governmental policy that was repealed, unfulfilled, or restrictive concerning African Americans:

40 Acres & Mule – promised wealth and inheritance of wealth never received for the majority of freed slaves

Reconstruction –the end of this period politically disenfranchised African Americans in the South and ushered in the Jim Crow Era.

GI Bill –helped to rapidly expand the middle class in America. African American soldiers were not afforded the benefits of this bill despite their service. economic stability

Redlining –successfully defunded quality public works, infrastructure, and wealth through home ownership in African American communities.

Gerrymandering –removed political power and thus the ability to shape law and policy beneficial to African American communities

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Economic Stability

Inheritance

Education

Military

Employment

Home Ownership

None/Outlawed

Anti-Literacy

US Policy Defaults

Unfair Wage/Hiring

Unfair Housing & Lending

Health

Disease

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THE PROMISED LAND

The light at the end of the tunnel

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Half of the Story…

Marcozzi et al (2018)

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The Right Medicine?

NAM & HHS -2022

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UPTOWN�MIDTOWN�DOWNTOWN

This Photo by Unknown Author is licensed under CC BY-SA

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Chapter 2: How to we get there?

Trip Planning

Passengers
Navigation
Vehicles
Access

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TRIP PLANNING

This Photo by Unknown Author is licensed under CC BY-SA

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Passengers

Who?
Needs

Special
Specific

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Navigation

Starting Point?

Distance (Disparity)
Cost*

Time
Fuel

Landscape

Risk
Determines Mode

This Photo by Unknown Author is licensed under CC BY-SA-NC

* The price of inequity financial and human –APHA Policy Statement 2018

Highlight the business case for health equity and the financial implications of health disparities.
Discuss how the landscape, including structural barriers like transportation, legal issues, and economic disparities, influences access to healthcare and health outcomes.
Encourage participants to consider the risks, costs, and efficiency of addressing social drivers of health in healthcare practice.

�

* The business case for Health equity -Estimated that from 2003 to 2006, the combined costs of health inequities and premature deaths in the United States totaled $1.24 trillion and that elimination of health disparities among racial/ethnic minorities would have reduced these costs, including direct medical care, by $229.4 billion

The landscape also determines the mode of transport = What are the structural barriers (transportation, legal, economic)

Hills Valleys = equal structural barriers. For example, think of hospital closures as roadblocks, falling bridges, potholes (poor infrastructure vs funded infrastructure)

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Home = The Starting Point

Real Estate

Location, Location…
Geospatial

Introduce the concept of the Social Vulnerability Index and other measures used to identify vulnerable communities.
Discuss the 15 domains of social vulnerability and their impact on community health.
Encourage participants to think about syndemics and the interconnectedness of health issues in vulnerable populations.

Major Driver:

Social Vulnerability Index (One of many measures). Others include, Wealth gap, Education Gap, Social Deprivation Index, Social Needs Assessments (all based in geography)

Social vulnerability refers to the potential negative effects on communities caused by external stresses on human health.

15 domains to identify areas that may be more vulnerable to external stressor to human health caused by human mediated or natural disasters or disease outbreaks

Syndemics Think Hati v Fukushima or the effects of the Pandemic in various communities

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Vehicles (Tools & Resources)

Access
Cost

Ticket
Time
Fuel

Efficiency

Speed vs Cost

https://www.storybasedstrategy.org/the4thbox

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Chapter 3: Who’s (What’s) Driving?

Drivers vs Determinants

Visiting vs staying
Migrating vs stranded/imprisoned

Ride Sharing

AKA partnerships

This Photo by Unknown Author is licensed under CC BY-NC

Differentiate between personal drivers (human factors) and programmed drivers (policy, law) in addressing health disparities.
Discuss the importance of partnerships and collaborations in addressing social drivers of health.
Encourage participants to consider the interplay between different drivers and determinants of health in healthcare practice.

Uber and CVS have partnered in Atlanta, GA, to provide free rides from a targeted zip code to the Good Sam Charitable clinic because, when asked, patients listed transportation as their #1 obstacle. This was created as a 5-year initiative https://www.cvshealth.com/impact/healthy-community/health-zones/atlanta.html

2 types of drivers:

1. Personal (human) -think educators, politicians, community members, stakeholders

2. Programmed (automated like Tesla) –think policy, law, the 5 domains of SDH

The 2 types are interdependent, inextricably linked, and not easily changed.

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All in the Same?

Yes and No

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Figure

The Lancet 2022 4002137-2146DOI: (10.1016/S0140-6736(22)01989-4)

Introduce interventions targeting the health effects of racism, xenophobia, and discrimination.
Discuss the levels of society at which interventions operate and the evidence supporting these approaches.
Encourage participants to consider the impact of societal factors on health disparities and the importance of addressing systemic issues.

Interventions targeting the health effects of racism, xenophobia, and discrimination: what, where, and at which level of society?

Visual representation and summary of the interventions identified that aim to reduce the health effects of racism, xenophobia, and discrimination. Interventions are categorised on the basis of the level of society at which they operate, and the circles represent the amount of evidence at each level. The skewing towards individual and community-level interventions is evident (appendix p 6).

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Chapter 4: Are We There Yet?

Garcia et al, NEJM 2022

Present data on disparities evidence and the journey towards closing the gap in healthcare.
Discuss designated drivers and the importance of recognizing individuals making a difference in addressing health disparities.
Encourage participants to consider the role of advocacy, collaboration, and innovation in promoting health equity.

Case studies and Anecdotes.

This slide explains the power of access to quality CPR in Black men. Demar Hamlin –Buffalo Bills on field Cardiac Arrest and Bronny James (LeBron James’ son) cardiac arrest on the USC basketball court. Both made a full recovery.

Data: Disparities Evidenced by decreased likelihood of quality, bystander CPR for Black and Brown persons who suffer a witnessed cardiac arrest outside of a hospital.

Closing the Disparity Gap = The Journey

Support that racial disparities in HTN are geographical not biological (Cooper, R.S., Wolf-Maier, K., Luke, A. et al. An international comparative study of blood pressure in populations of European vs. African descent. BMC Med 3, 2 (2005). https://doi.org/10.1186/1741-7015-3-2) https://bmcmedicine.biomedcentral.com/articles/10.1186/1741-7015-3-2#citeas

KFF closing the GAP of racial health disparities:

https://www.kff.org/racial-equity-and-health-policy/report/key-data-on-health-and-health-care-by-race-and-ethnicity/

Closing the racial disparity gap in resuscitation: CARES data –Garcia et al NEJM https://www.nejm.org/doi/full/10.1056/NEJMoa2200798

One way to close the gap is to Identify Designated Drivers = people you probably know a*

*List persons in your community and institution who are making a difference (e.g. community worker X, or Dr. Y)

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The Social EM Scripts

“HOUSING IS HEALTH”

“FOOD IS MEDICINE* (POISON)”

“RELATIONSHIP IS THERAPY”

(TOXIC)

“VOTING IS A

DISPO”

“COMMUNITY IS COST-EFFECTIVE”

Think differently, Speak differently, Act differently

*Downer et al 2020

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Triage and Treatment

Prompt participants to consider the waiting room as a starting point for addressing health disparities.
Discuss the importance of social screening tools in emergency departments and the need for triage based on social determinants of health.
Encourage participants to consider the role of healthcare providers in addressing food access, stable housing, social relationships, and transportation issues.

What are we Waiting For:

Waiting room Medicine (What are we waiting for? Why not start in the waiting room)

Registering to vote while waiting not just during election time (remember law and policy are drivers of health)

Social Screening tools in ED and retriage if necessary: Siren Network evidence-library

93% believe providers should ask about food access

83% should ask about stable housing

78% social relationships �77% transportation

50% of EM docs thinks that this is not their job

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The Health Equity Accelerator at BMC & Child HeLP Cincinnati Children’s�

Transform healthcare

to deliver health justice

and well being

Cincinnati Child Health-Law Partnership

(Child HeLP)

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Social EM

Community and Legal Landscape

Built Environment

Education and Economics

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The Social Change Method

EDUCATE*

ADVOCATE

COLLABORATE

INNOVATE

CELEBRATE

REPEAT

*EVERY lecture should integrate at least 1 slide with a social driver/social EM lens for that topic.

Lewis et al 2024 Academic Emergency Medicine Education and Training

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Questions?

More to come…

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SEMINAL STUDY

Integration of social drivers of health into clinical practice

1.3

2.1 // Research in Social emergency medicine

1.4 // Projects in social emergency medicine

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