Social Determinants Pave the Road to Health Equity

Philadelphia has the dubious distinction of being the place where “social determinants of health” were identified as such in the U.S. The University of Pennsylvania commissioned W.E.B. Du Bois to conduct a sociological study here in the 1890s. The sample was limited to the city’s diverse Seventh Ward, where the western side was occupied by affluent whites, the center section was densely populated by “Black elites,” and the eastern side was predominantly occupied by poor Blacks. The study concluded that rather than being related to racial differences, the “plexus of social problems” (e.g., crime, poverty, drug addiction, illiteracy) stemmed from the exclusion of Blacks from the city’s industrial jobs, housing market, and educational opportunities.

Fast forward more than a century and, sadly, the same conditions perpetuate racial and ethnic disparities and health inequity in Philadelphia and across the U.S. — from our major cities to lower-income rural areas. Although most healthcare systems have made efforts to improve the wellbeing of the communities they serve (e.g., targeted disease management programs), few have made achieving health equity a central strategic goal. The notable exception is Chicago’s Rush University Medical Center (RUMC) — and David Ansell, MD, MPH, is the motivating force.

Ansell’s book “The Death Gap: How Inequality Kills” effectively called out structural racism, economic deprivation and neighborhood conditions as afflictions the source of health inequities and advanced the notion of structural violence as a root cause of low life expectancy in marginalized communities because it is “designed into” laws, policies, and norms. He challenged academic medical centers (AMCs) to confront these issues as a first step in identifying ways to address health inequities.

As it shifted to a population-based health model, RUMC widened its lens from a narrow focus on healthcare delivery to a panoramic vision of improving health in the diverse communities it serves. In 2017, RUMC fully embraced Ansell’s premise that improving health requires a commitment to a community-partnered approach with metrics focused on the complex causes of poor health. Like many AMCs, they had some community partnerships, but the initiatives were not designed to move the needle on community health outcomes.

Earlier this year, Ansell and colleagues published an excellent article. In recounting RUMC’s groundbreaking journey to health equity, the authors provide the rest of us much food for thought. I’ve summarized the article below, but it is well worth reading in its entirety!

After examining data on more than half a million individuals living in its primary service area, RUMC analysts found that common chronic conditions (e.g., cardiometabolic disease, cancer) accounted for a significant proportion of premature deaths. Importantly, they clearly documented the stark 14-year life expectancy gap between the affluent, largely white downtown area and the racially segregated western side neighborhoods with substandard housing, food deserts, unsafe streets, and poor educational outcomes. On the basis of these findings, they undertook a multi-year, culture-changing, enterprise-wide strategy and adopted a 5-pillar framework for achieving the monumental goal of health equity. This was not an easy reach by any measure!

Unpacking the 5 pillars, the first – “naming” racism and poverty as primary causes of poor health — strikes me as the most courageous. The rationale is quite simple; it flows naturally from a well-established approach to quality and safety improvement known as root cause analysis, a technique that leads to investigating why untoward events occur and names them without bias.

Pillar 2 identifies the enterprise as an “Anchor Mission” — an understanding that large, non-profit, place-based entities very are often critically important economic drivers in their communities. RUMC committed the enterprise to hiring, training, purchasing, investing, and volunteering locally. For instance, total enterprise spending on anchor mission-related initiatives for fiscal 2019 through Q2 of 2021 was $20.4 million, and the enterprise opened 16 employment hubs during the same period to support local hiring.

The third pillar focuses on creating wealth-building opportunities for employees, many of whom had experienced extreme financial distress and were not saving for retirement. Initiatives include things such as a pension reform program to significantly increase retirement savings, a healthcare career pathways program for incumbent employees, and training programs in financial wellness and credit.

Pillar 4 calls for actively addressing health care inequities. A multidisciplinary committee provides input for performance improvement projects addressing racial, ethnic, gender, and age inequities in healthcare outcomes. For example, patients are now being screened for social determinants of health: food, housing, utilities, transportation, and access to primary care.

The final pillar is a challenge to address the social and structural determinants of health. RUMC is accomplishing this through a community-engaged racial health equity collaborative that includes every health system on the city’s west side. With a shared long-term vision, the collaborative avoids unnecessary duplication of programs, establishes common standards and best practices, coordinates resources, and works to improve health outcomes. The goal is to decrease the life expectancy gap between the affluent downtown and western neighborhoods by 50% by 2030.

I salute Ansell and RUMC for their commitment to facing the thorny issue of health disparities head-on and working to resolve those disparities. Wouldn’t it be great if all 150 U.S. AMCs were to follow their lead? This is likely to remain aspirational for most, but many health systems are beginning to nibble around the edges. Here in Philadelphia for instance, Thomas Jefferson University and Novartis recently executed a 3-year, $3 million contract to help close one of the city’s longstanding healthcare gaps. The goal is to reduce cardiovascular health disparities in 5 city Zip codes.

Ansell has demonstrated that AMCs can change their stodgy culture and pivot successfully to tackle the social determinants of health. He has given us a roadmap, and it is solely up to us to replicate his milestones.

David Nash, MD, MBA, is founding dean emeritus and the Dr. Raymond C. and Doris N. Grandon Professor of Health Policy at the Jefferson College of Population Health. He serves as special assistant to Bruce Meyer, MD, MBA, president of Jefferson Health. He is also editor-in-chief of the American Journal of Medical Quality and of Population Health Management.