Healthcare has the 5 social determinants of health; policymaking has its 5 states of mind
vol. 1 issue 26
Lots of drama getting the new website live, thus the delay in this email reaching you. But it’s up now, and I hope you will visit it. Even more, I hope when you do visit, you will recommend docu-mental to others. Thank you.
You might be aware that in the last decade, the World Health Organization has defined five social determinants of health as “the conditions in which people are born, grow, work, and age.”
There are five of these determinants:
These five social determinants describe material conditions and their impact on health outcomes. According to the New England Journal of Medicine:
“Social determinants of health are an underlying cause of today’s major societal health dilemmas including obesity, heart disease, diabetes, and depression.”
The NEJM also suggests there is a feedback loop created by these five determinants:
“Poor health or lack of education can impact employment opportunities which in turn constrain income. Low income reduces access to healthcare and nutritious food and increases hardship. Hardship causes stress which in turn promotes unhealthy coping mechanisms such as substance abuse and overeating of unhealthy foods.”
Implicit in the NEJM’s feedback loop example above is that if we identify and address socio-economic disparities, we can lower the overall cost of healthcare.
There are plenty of examples of how this is actually working, but a favorite of mine is how in impoverished Camden, NJ, preventive primary care teams are dispatched to care for people who have difficulty accessing behavioral, social, and medical care services, and so forego them until their only avenue to health is the emergency room.
How does the primary care team know where to find these people?
The meticulous collection and analysis of data. One study-turned-solution used emergency room admissions data from across the city to determine who were the city’s emergency room high utilizers. These were the people who the teams went to visit pre-emptively. They developed good old fashioned relationships with these patients, got their trust, and were able to attend to small health issues before they precipitated an expensive ER trip.
Now, outcomes data show that hospitals in the city are spending less on uncompensated care, and the patients are enjoying measurably better health.
I love this because it’s smart and humane. It’s also nonpartisan.
It also begs the question: if attending to the five determinants of health leads to better health outcomes, then isn’t it possible to fix bad policymaking the same way by addressing its determinants?
I think so.
Over the past decade, I have been tracking somewhat informally another five important “determinants”, only I have been calling them states of mind. I have noticed that they also create a feedback loop, which when in a state of deficit, leads to faulty policymaking:
Here’s an example of a painful feedback loop these five states of mind might generate:
A man now in his early 50s, born in the US, grows up thinking that by getting an education, he is entitled to the “American Dream” of buying a modest home in a safe neighborhood at an affordable cost. Turns out, the supply of this kind of home is limited and demand is high. But if that “dream” was the expectation, and he has fulfilled his obligations, then the dream is fulfilled if he beats the competition who wants what he wants. Now he needs to prove he merits the resource more than someone else. So, he gets a job that pays more, but is further away from where he can afford the home.
To keep the house and the dream that goes with it, he has to do whatever is necessary to keep the job, and so feels his agency is diminished, but the messaging of the American Dream continues to haunt him. Either he isn’t working hard enough or the story and the dream are no longer true (if they ever fully were).
What should he trust, the dream or himself? He isn’t sure. The dream, the story — they are so pervasive. It’s central to who so many of us Americans are, this idea that we can achieve anything if we put our minds to it. We don’t, as a nation, challenge the assumptions that for that dream to come true, we need the resources to be in adequate supply.
The man starts to feel worn down and burnt out, which of course leads to stress, anxiety, and depression, which then leads to hopelessness. This state of mind often leads to apathy, a sense of "nothing matters, so what have I got to lose?", which then can lead to either violence against others (including the state) or against one’s self, such as suicide.
Eventually, depressed for a while, he despairs and does believe suicide to be his best option. His is the death that tips a scale for a community that then demands policy changes that address the pain, that invests more money in treatment for depression and training for how to recognize suicidality. All good things to do.
What the policies do not do is address the root of the cascade of negative mindsets that brought him to the pain, which in this example, was his core belief in a story that cannot be supported by the facts. Further, even if we addressed the social determinants of health to help make housing in safe neighborhoods affordable for this man, the reality is that the calculus of social determinants of health do not typically address the needs of persons with his education and income.
Do we need a new national story or was his life “wrong”?
The story of the American Dream is flawed, I suggest, and this hypothetical outcome is all too familiar to so many people in this country where anxiety, depression, and suicide are higher across almost every demographic than at any time in our history. Suicide is the fourth leading cause of death for middle aged adults in the US, and has been rising across all groups at a rate of 2% annually since 2006.
There are many reasons people decide to take their own lives, and we still don’t know all the components of depression, but this hypothetical is not implausible, and I personally have heard enough stories anecdotally about how the stress of not being able to “measure up” caused people to lose hope and then it spiraled from there.
But enough of us cling to the myth that there is enough to go around in this country, to our detriment. We cling to the myth that if you work hard, all will be yours. We cling to the notion that inequality is a state of mind, a point of view, not a reality.
And we still determine lending, housing, and education related policies on this myth.
Enough of us are harmed by the cognitive dissonance created when we are told the American Dream is still true, even though the resources necessary for it to be available are no longer as accesible, and are more limited than ever, for any number of reasons.
Our policies should reflect that. They should be made with the awareness that fear of scarcity is real, that actual limits on resources do exist, and that not everyone who met the education and work ethic requirements once required in order to receive their bounty actually result in that bounty coming through.
The place to start would be an honest assessment of why messaging around this myth persists, and follow it to see who still benefits from it, even though it clearly is unsupportable. The ones benefitting from it — are they involved in the policymaking that results? Then why do we continue to trust them with this power?
Similar to how addressing our socio-economic systems to communities with poor health outcomes turns out to be more effective than continually applying the expensive and broken healthcare system, I suggest that if we want good mental health outcomes, or any kind of good outcomes, we revise our myths and legends and attend to the states of mind foundational to our policymaking.
What do you think? Please leave your thoughts in the comments section.