Can your doctor cure poverty? How about homelessness? Food insecurity? For that matter, does your doctor treat the legacy of slavery and racial discrimination?
Most people answer this question readily: No. Doctors are trained to treat medical conditions, helping patients lead healthier, happier, longer lives. Yet the medical elite think the answer is “yes.” For years, health disparities between white and minority communities have been attributed to the so-called social determinants of health (SDH), which include the effects of poverty on communities, the residue of historic discrimination, and purported ongoing discriminatory practices in health care. But do these factors really determine health—or are they more properly termed “social factors affecting behaviors associated with health status”? That’s not nearly as catchy as SDH. It just happens to be more accurate.
In a 2017 report, “Perspectives on Health Equity and Social Determinants of Health,” the National Academy of Medicine went further, presenting the issue through the lens of critical race theory. As the report frames it, no social comity exists to characterize human social interactions, only a dyad of oppressor and oppressed. The goal of eliminating disparities in the social determinants of health would be the achievement of true health equity, defined as “The optimal conditions for all people by valuing everyone equally, rectifying historic inequities, and distributing resources according to need.” The last phrase evokes a certain nineteenth-century social and economic philosophy. The report goes on to tie health disparities, among other factors, to the portrayal of black men in the media and to the expulsion and suspension of black children in early education.
The report’s clearest message: no one should attribute any health-care disparities to individuals’ self-determined actions. The report also decries “getting distracted by the alleged ‘deficits’ or ‘individual behaviors’ of marginalized communities” and calls for moving away from a “decontextualized, biomedical framework.”
That “biomedical framework” is in fact the crux of the matter. The biological link between poverty and disease is undiscovered. Does some unseen factor produce more diabetes in people living in more violent neighborhoods? How does more kidney disease result from housing instability? Inevitably, “stress” becomes the culprit, the underlying physiological factor that induces disease. True, stress is well known to be associated with clinical effects. But why only in some individuals? Stress is everywhere and affects everyone. Why is some stress more significant than other stress?
A new coauthored article in The New England Journal of Medicine argues that physicians should insert themselves into the issue of SDH—not by influencing the behaviors and lack of access that are the real cause of health disparities but rather by looking at “systemic” factors, such as housing issues, transportation, and health-insurance status. The authors suggest that “rather than providing eligible patients with a list of resources or referring them to a navigator [e.g., a social worker or community health worker],” physicians “can generate a solution to meet an identified social need.”
This is an absurd recommendation. It assumes that doctors can take on the role of social workers, who are trained to deal with these issues as they affect patients. Social workers typically undergo a two-year curriculum as well as practical experience in a health-care setting before beginning their careers. Their course work specifically teaches them the intricacies of dealing with community and governmental agencies to support patients when feasible. The authors are proposing a revision of medical school curricula to train physicians as substitutes for already-available social workers.
In an era when physicians regularly lament the limited time available for patient care, and with an increasing sense of burnout among even the youngest physician cohorts, calling for doctors to assume new, non-medical responsibilities is particularly ill advised. To require training in SDH seems extremely wasteful.
The push for SDH reflects a broader trend in medicine. The social determinants of health are already taught as fact in most medical schools; activists want to go further. Yet this vision of the doctor’s role in society is profoundly flawed and will only lead to further degradation of our health-care system. Worst of all, it will not do anything to improve the well-being of patients or correct disparities in health outcomes. In fact, it is far more likely to worsen patient suffering, since patients will increasingly deal with doctors trained to be political activists instead of true medical professionals.
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