Social Determinants, Personal Responsibility, and Health System Outcomes

Most physicians realise that medical care is only one aspect of health, and probably not the most important one. The “Determinants of Health” model[1] illustrates the variety of factors that impact upon health. Medical care can treat conditions once they have occurred, and can do some primary prevention through immunisations and cancer screening. In addition, we can screen for social, economic, genetic, environmental and behavioral risks in our patients, although we have limited ability to alter the trajectory of most of these risks.  The physical and socio-economic environment have tremendous impact upon health, as do factors not specifically on this model, such as race.

Individual behaviours receive a great deal of attention from physicians who encourage their patients to eat better, exercise more, not smoke, etc., and from preventive medicine researchers and policy makers. And from Whole Foods, Inc. CEO John Mackey, whose credentials are being in the business of selling healthful food. He argues that people should be held responsible for the poor choices that they make, receiving fewer health benefits if they have not taken the steps to maintain their own health. Writing in the Wall St. Journal[2], he provides proposals for “controls” and “freedom” that are distinguished by their inequity: the controls are on services that would benefit people, while the freedom is for corporations to continue to have unfettered access to profit.

More insidiously, however, these arguments can appeal to others, including physicians, who see sense in expecting people to take “responsibility” for their health and act in healthful ways. Eat nutritious food, exercise, don’t smoke or take illegal drugs or drink to excess, etc., is good advice, and all of us should try to take it. I’m sure that it is advice that many of the employees of Whole Foods – the ones who are young and healthy – appreciate. It validates what they do, and they see the “outcome”: they are young and healthy. It is possible that there are other Whole Foods employees, older and/or with chronic disease, who many not find Mackey’s advice, or the company’s health plan, to be of such great value. At best, his essay may be a call to action for those who, given some combination of youth, genetic luck, good health, and socioeconomic opportunity, are still not doing all they might; at worst it is simply victim-blaming. The extensive literature on the social determinants of health is either unknown to or rejected by Mackey and his friends.

Of course, most of the discussion of these issues, whether in academic journals or the Wall St. Journal or on TV, is among those of us who are relatively privileged. This group certainly includes all the politicians, pundits, academics and successful businesspeople – and medical students. We may not be wealthy CEOs like John Mackey, but we are educated, literate, and consumers of ideas. Even if temporarily “poor” (e.g., students) we have the values and self-efficacy that comes from our class, socioeconomic, and educational background. Not part of this group, and this discussion, are the vast majority of people.

Encouraging positive health behaviors is a good thing. Punishing people who have the least social, economic, and physical reserve to enrich those who have the most of these privileges is unconscionable.

Joshua Freeman, MD

University of Kansas, USA