In recent years left-of-center public health advocates have tried to expand the scope of what is considered public health care. Drew Altman, president of the Kaiser Family Foundation, wrote about it recently.
Health professionals, health care institutions and public programs have been expanding their purview, taking on socio-economic problems with targeted programs addressing what those of us in health care call the “social determinants of health.”
Social determinants of health are socioeconomic conditions like jobs, education, neighborhood, community, housing, family structure, etc. They are seemingly unrelated to health care but are highly correlated to health status. Because jobs, education, neighborhood and family structure are correlated with health, public health advocates argue that affecting a change in these determinants is within the purview of public health.
Yet while it’s long overdue that medicine look beyond its stethoscopes and “remunerectomies,” and that public health look beyond the traditional mission of public health agencies to the more fundamental drivers of the health of communities, the question is whether and when the “healthification” of everything makes sense and is productive.
A few examples of mission creep includes calling homelessness a public health issue. Another is calling gun violence a public health issue, rather than a crime issue. Poverty is even being considered a health issue, because income is positively correlated to health status, as is education. More from Altman:
Labeling socio-economic problems as public health issues and expanding the scope of public health is a more nuanced issue. Gun violence is viewed as a public health issue because it has such drastic health consequences, and in the U.S. has taken on epidemic proportions. Housing, poverty, food insecurity, racial inequality, homelessness and more are also often now characterized as public health issues for the same reason.
Altman goes on to say that each of these conditions, socioeconomic status, homelessness, gun violence, etc. are in and of themselves huge problems to solve. Merely recognizing they correlate with poor health does not make them any easier to solve politically.
Putting a health label on socio-economic problems doesn’t change the politics of the issues or the partisan division we have in the country about addressing them. It hasn’t helped with Covid or with gun violence, as obvious examples. It doesn’t make red states any more eager to spend money on public health or social programs for low-income people and people of color. Quite the contrary; public health has been under attack in the red states.
I would argue a primary reason that public health is looked at with skepticism in Red States is due to the ever-expanding nature of what is considered public health. Voters are naturally more sympathetic to sickness than they are cash welfare payments. Claiming that housing assistance, food stamps, Medicaid and Obamacare are to alleviate sickness rather than free up income for a lifestyle boost is an easier sell to voters. Altman concludes:
There is both good and bad about the “healthification” of socio-economic problems…
Then three days later in a different commentary Altman added guaranteed income (GI) programs to the discussion of social determinants of health.
One huge advantage of GI programs is their “implementability” (a word I am making up that we should put into use). Unlike most of our “non-medical interventions” in health care, they do not present the issues Professor Martin Lipsky at MIT used to write about as the overlooked challenges of implementing programs that require a new “street-level bureaucracy” to deliver services.The debate about service vs. income strategies is an old one. Both are needed. But both do not get equal attention, particularly in discussions of social determinants of health. If poverty is a core social determinant, income always matters.
In other words, it’s easier to just give people money. You don’t have to identify them, monitor their progress and measure results. You just dole out money every month. Something I’ve never heard discussed in the GI pilot projects that Blue Cities have tested is whether they are measuring success or experiencing the Hawthorne Effect. The Hawthorne Effect is a phenomenon in the social sciences where test subjects change their behavior because they are being watched. Would sending a check for $500 to every adult member of a household have the same effect on poverty and health as carefully selecting 1,000 families and sending the head of household $500 each month? Would it make a difference if they’re told it’s a pilot project in which they are being observed? Would it matter if they were told it was a daycare subsidy? I have suspicions any positive results may not persist over time.