January 15, 2018
As we celebrate Martin Luther King Jr. Day, we reflect upon his legacy and impact on our world. For me, his words, “Of all the forms of inequality, injustice in health care is the most shocking and inhumane,” are still painfully true today.
As physicians and caregivers, we uphold the Hippocratic Oath as we work to provide the best care for our patients. Our researchers develop the most innovative treatments, and we work together to improve the health of our community through enhanced access to care and the discovery and delivery of the latest evidence-based medicine. But what if good medicine isn’t enough?
The social determinants of health – conditions in which people are born, live, work, play, worship, age, and are educated, are increasingly acknowledged to play an important role in health outcomes.
It is estimated that 60 percent of disease is directly related to poverty, education, and housing inequality. A recent report from Princeton economists reveal how a college education affects health and life expectancy and is profiled in the Chronicle of Higher Education.
We asked several of our faculty to comment on social determinants of health in reference to their area of clinical expertise and to different populations of patients—women, children, the elderly, others.
Dr. Baha Sibai, professor of Obstetrics and Gynecology, and Dr. Lisette Tanner, Instructor of ob/gyn told us: “It has been said that communities, countries, and ultimately the world are only as strong as the health of their women. While genetics and personal health choices play a large role in women’s health, there is growing evidence that environmental and socio-political conditions play a major role as well, especially in reproductive health. Social determinants of health, such neighborhood safety, availability of healthy food options, access to quality education, and freedom from discrimination based on race, gender, and sexual orientation have been shown to affect several reproductive outcomes, including preterm birth, unintended pregnancy, severe maternal morbidity, and maternal mortality. As physicians, by recognizing the importance of social determinants of health we can help to create more patient-focused care on the individual level and more innovative approaches to public health policy on the population level.”
The World Health Organization (WHO) defined health in its 1948 constitution as “a state of complete physical, mental, and social well-being and not merely the absence of disease. Governments have a responsibility for the health of their peoples, which can only be fulfilled by the provision of adequate health and social measures.”
Dr. Tom Murphy, assistant dean for Community Affairs and Health Policy, says “social determinants of care today include housing insecurity, food insecurity, income insecurity, loss of benefits (insurance), access to care, gender, social and physical environment, personal violence, and other factors which directly impact the health status of the individuals within a population. Attention to the social determinants of care is required if there is to be any sort of meaningful transformation of the health care delivery system in this country.
“There are lots of pages written on social determinants of health, ultimately all revolve around improving health (governmental ) policy, improving access to care and increased focus on the 1948 statement of the WHO. Better late than never to finally do what is right.”
By developing a medical legal partnership at UTHealth, Dr. Murphy is spearheading a new dimension to the clinical care team at UT Physicians to help address issues not normally addressed in our clinics. The addition of a lawyer to our clinical team will provide skills to help guide patients as they navigate issues such as inadequate or unsafe housing, child custody, violence, or other family issues that could impact health. What if the patient’s landlord is providing an apartment that is making the patient sick? That’s when the lawyer comes in.
It takes a holistic approach to health to support our patients. Dr. Keely Smith, associate professor of Pediatrics, says that when it comes to caring for children, we can’t forget about the whole family. “What I’m concerned about is providing healthcare for our most vulnerable population, our children. We need to come together as a community to help our kids, and it’s difficult to care for them if the parents aren’t healthy and have the support they need. Pediatric patients who have parents with good social support systems have a much better chance to have good outcomes.”
Dr. Carmel Dyer, Roy M. and Phyllis Gough Huffington Chair in Gerontology and Vincent F. and Nancy P. Guinee Distinguished Chair, told us: “UTHealth has the privilege of serving our patients throughout the entire community as we have two clinical partners. Harris Health and Memorial Herman Healthcare System extend their services to the diverse neighborhoods of Houston and Harris County. It is critical that we teach our trainees that one, single high standard of care be delivered to all and that we need to address social as well as direct medical needs.”
This is a complex riddle to solve that takes a network of institutions working together. Three years ago, Parkland Hospital in Dallas worked to create its Parkland Center for Clinical Innovation, which addresses the social determinants of health for its patient population. Harnessing community resources, and sharing data, they have reduced emergency room visits for nonemergency situations and improved the health of vulnerable populations. This comprehensive article in PoliticoMagazine explains how it was done.
Dr. Linda Highfield, associate professor in the Department of Management, Policy and Community Health at the UTHealth School of Public Health, was recently awarded a $2.6M grant from the Centers for Medicare and Medicaid Services to address social factors that affect the health of Medicare and Medicaid beneficiaries in Harris County. The Accountable Health Communities grant, a 5-year project scheduled to begin in August, is a collaboration between the UTHealth Schools of Public Health, Biomedical Informatics, and McGovern Medical School, as well as UT Physicians, Memorial Hermann (TMC, Southwest and Greater Heights), Harris Health, Texas Children’s Hospital, and several community organizations. Drs. Kevin Hwang and Ryan Walsh are collaborators from the medical school. Using a tablet-based questionnaire, investigators will evaluate social needs of patients when they access care at partner institutions. Core social needs include food insecurity, housing instability, utility assistance, transportation, and interpersonal violence. All patients will be provided with information about community resources to address their identified social issues; a subset will be assigned a community health worker to connect them with local social service providers. It is hoped that by directly addressing social issues we will be able to reduce hospital/ER readmissions, reduce healthcare costs, and enhance care in our community.
Dr. Kevin Hwang, associate professor of General Internal Medicine, wrote to me, “Social determinants of health are a major focus of the population health theme in the medical school curriculum. It is estimated that variation in medical care may account for only 10 to 20 percent of variation in observable health outcomes. Physicians of today and tomorrow must not only be medical experts, but also recognize, shine the light on, and address social determinants of health when possible. This is a team sport. Many of our outpatient clinics have case managers, social workers, and community health workers who help our patients with social determinants of health that previously we would have considered outside the reach of an academic health center.”
Thanks to all of you who work thoughtfully each day to offer more than just good medicine—a fitting way to remember and honor Dr. King.