Healthcare Improvements Should Start With Voluntary Changes

Truth be told, healthcare does not create health. It repairs or mitigates the effects of damage coming either from the environment or, less frequently, from within. No one can deny that this is essential and gallant work but largely reactive. The true causes of health and illness, and of inequities in health, are clear and have been documented over a long period[i]. Yet the current situation places nearly all investment into the “repair shop” of healthcare (in the US, the investment is nearly 20 percent of gross domestic product, while in Mexico it is 6.5 percent).

Rarely taken into consideration, the financial costs of this unfair investment are massive and the toll on human healthy aging is even more concerning[ii]. Although some of the variations in people’s health are genetic (25 percent), most is due to people’s physical and social environments, including their homes, neighborhoods, and communities, as well as their personal characteristics, such as their sex, ethnicity, or socioeconomic status. The environments that people live in combined with their personal characteristics have long-term effects on how they age. Physical and social environments can affect aging and health directly or through barriers or incentives that affect opportunities, decisions, and health behavior. Supportive physical and social environments also enable people to do what is important for them, despite losses in capacity.

The healthcare system’s contribution to health is important, hard fought, and currently achieved by a dedicated clinical workforce. But 40 percent or more of the variation in health status (two times healthcare’s share) derives from social determinants of health. Michael Marmot summarized these in five categories[iii]: early childhood experiences, education, workplace conditions, supports for aging, and community resources, such as food and housing security, recreational opportunities, transportation, environmental protection, and approaches to preventing and managing violence. Underpinning these, Marmot suggests, is a sixth, critical factor that he calls “fairness,” implicating attitudes toward solidarity and equity, including ageism and racism. The World Health Organization has recently released a report on this issue[iv].

Most healthcare leaders assume that running the healthcare system is already a big enough task without having to address health determinants as well. But the healthcare industry is not an innocent bystander in the world’s underinvestment in determinants of health; it is a cause.

On this issue, 2020 was a turning point. The pandemic put a spotlight on existing societal issues, accelerated the pace of change in others, and created some new ones too. Concerns about inequalities in health became more apparent to a larger number of people during these last two years. The speed and openness of the societal conversation, beyond the direct effects of COVID-19, create an opportunity and a motivation to reassess our understanding of health[v]. Even more important, it is an opportunity to reduce inequities related to who has access, who uses, and who benefits from the resources that promote health and well-being.

To this end, several questions could guide thinking about health and health inequities from now on, broadening the meaning of health to include the capability to adapt and be resilient, and leading to the question, what are the policies to be developed to support and promote health, who has the power to shape these policies and whose interests do current structures and policies serve?[vi] Next, the money to invest in early childhood, schools, housing, and the rest must come from somewhere, either the private sector or taxes. There is, simply put, nowhere else to find the necessary money than by reallocating some significant portion of healthcare expenditures, which, given the lack of enforcement from governments, can and should begin with voluntary changes in the priorities and strategies of the healthcare industry.

To catalyze these changes, healthcare organizations with the means to do so should establish and support actions that are focused on the social influences on health in the region served by the organization, which could include the following: interventions to improve health coverage, educational support, or acting on highly relevant issues, such as older adults and loneliness. The aim would be to mitigate social isolation among older individuals, which is associated with increased mortality and morbidity[vii]. Several common objections are: concern about medicalization of social problems and the healthcare industry exerting economic and political influence. That would indeed be a mistake. The idea is not for healthcare to take control but rather to be a generous and active participant in community-led activities to improve social determinants of health.

[i] Phelan JC, Link BG, Tehranifar P. Social conditions as fundamental causes of health inequalities: theory, evidence, and policy implications. J Health Soc Behav. 2010;51 Suppl:S28-40. doi: 10.1177/0022146510383498. PMID: 20943581.

[ii] Institute of Medicine (US) Roundtable on Evidence-Based Medicine; Yong PL, Saunders RS, Olsen LA, editors. The Healthcare Imperative: Lowering Costs and Improving Outcomes: Workshop Series Summary. Washington (DC): National Academies Press (US); 2010. Available from: https://www.ncbi.nlm.nih.gov/books/NBK53920/ 

[iii] Marmot M. The Health Gap: The Challenge of an UnequalWorld. Bloomsbury; 2015

[iv] Global report on ageism. Geneva: World Health Organization; 2021. Licence: CC BY-NC-SA 3.0 IGO

[v] Quantin C, Tubert-Bitter P. COVID-19 and social inequalities: a complex and dynamic interaction. Lancet Public Health. 2022 Mar;7(3):e204-e205. doi: 10.1016/S2468-2667(22)00033-0. Epub 2022 Feb 15. PMID: 35176245; PMCID: PMC8843329.

[vi] McGrail K, Morgan J, Siddiqi A. Looking back and moving forward: Addressing health inequities after COVID-19. Lancet Reg Health Am. 2022 May;9:100232. doi: 10.1016/j.lana.2022.100232. Epub 2022 Mar 17. PMID: 35313508; PMCID: PMC8928332.

[vii] Hwang TJ, Rabheru K, Peisah C, Reichman W, Ikeda M. Loneliness and social isolation during the COVID-19 pandemic. Int Psychogeriatr. 2020 Oct;32(10):1217-1220. doi: 10.1017/S1041610220000988. Epub 2020 May 26. PMID: 32450943; PMCID: PMC7306546.