The Moral Determinants of Health
Last week we had the opportunity to hear the latest podcast in Zeev Neuwirth’s series “Creating a New Healthcare” with episode #104, Reframing Healthcare — A Moral Imperative. The podcast focuses on two articles written by Dr. Berwick in the Journal of the American Medical Association (JAMA) that reframe our thinking about how healthcare must embrace sustainable, lasting changes in the wake of the COVID-19 pandemic. In the first, titled “Choices for the New Normal,” he asserts that the rapid pace of change can be the catalyst for doing things very differently going forward.
“The ‘New Normal?’ Normal is what got us here.”
Don Berwick, MD
We are being presented with clear choices as to how to manage healthcare in a post-pandemic world. Dr. Berwick details six emerging properties of care for durable change:
The Speed of Learning: healthcare has traditionally been slow to adapt to change: the rate at which both information and innovation are now speeding around the globe has been stunning.
The Value of Standards: with respect to COVID, caregivers around the world are reaching out to each other as trusted sources to understand the best clinical responses and scientific standards, rather than holding on to clinical autonomy.
Protecting the Workforce: attention to healthcare worker safety has languished at far too low a priority for decades.
Virtual Care: COVID has unmasked many clinical visits as unnecessary and likely unwise. Telemedicine has surged for those populations that have access.
Preparedness for Threats: the foundations of this, most crucially a robust public health system, have ben allowed to erode or have never been laid in the first place.
Inequity: in Chicago, 30% of the population is African American, but they account for 68% of the COVID-19 deaths.
The last point leads directly to the next article, The Moral Determinants of Health. This article transformed our thinking about the work we’ve been doing in healthcare, homelessness, child sexual abuse prevention and other efforts here in Northwest Lower Michigan, and how the healthcare system itself must transform to focus on population health initiatives in order to improve the health of our society overall.
Michael Marmot, in his book The Health Gap, outlines 6 categories that he defines as Social Determinants of Health: conditions of birth and early childhood, education, work, the social circumstances of elders and a collection of elements of community resilience (such as transportation, housing, security, and a sense of community self-efficacy). Cross-cutting all of these is a sense of fairness: if we want to have one lever in our society that will predict well-being and population health, the disadvantaged must be helped by those who are more advantaged. As fundamental as this idea sounds, we know it’s more easily said than done.
We’ve seen that COVID has not surprised us in its inequitable distribution of suffering related to those six categories. We can treat this as a political problem (and it certainly is), but Dr. Berwick asserts that the resources must come from advocating for a more generous public policy. Despite our knowledge of how to solve these problems and examples from around the world, our country is deeply underinvested in social determinants: we put less than half the money into social programs than some of our peer nations in the Organization for Economic Cooperation and Development (OECD).
Only by checking our morals, the values that we truly believe in, will we find the political, social and economic energy to help people who are vulnerable.
Donald Berwick, MD
As a formerly practicing pediatrician and administrator of the Centers for Medicare and Medicaid Services (CMS), Dr. Berwick asserts that healthcare has to take a lead role in this movement. Because healthcare currently occupies 18% of US GDP, we must find ways to divert some of those 3+ trillion dollars into proactive investments to deal with social determinants of health.
Dr. Berwick lays out a short list of first-order elements of a morally guided campaign for better health:
- US ratification of the basic human rights treaties and conventions of the international community.*
- Health care as a human right in the US: the number of uninsured individuals in the US is 30 million and increasing. No other wealthy nation on earth tolerates that.
- Restoring US leadership to reverse climate change: the US is nearly alone in its withdrawal from the Paris Climate Agreement.
- Achieving radical reform of the US criminal justice system: the US has by far the highest incarceration rate in the world, and it imprisons people of color at 5 to 7 times the rate of white persons.
- Achieving compassionate immigration reform: state-sponsored violence, child abuse, and family separation due to US policies remain widespread at the southern border. Congress has failed repeatedly to enact immigration reform.
- Ending hunger and homelessness in the US.
- Restoring order, dignity, and equity to US democratic institutions and ensuring the right of every single person’s vote to count equally. Science is under attack within crucial US agencies, voter suppression tactics continue, and the Electoral College, in which the weight of a citizen’s vote varies by a factor of 70 from state to state, is profoundly undemocratic.**
What it comes down to is that if we care about health we have to care about each other; if we care about each other that’s got to be reflected in our social policies; and if it’s not reflected in our social policies, our moral compass says it has to be … and I think that’s on us.
Donald Berwick, MD
During the interview, Dr. Berwick states that we have to see these challenges both at the system level and at the individual level.
The System level refers to developing a ‘Health in all policies’ approach to governance and the allocation of resources. Nations that have this aim are able to recruit energies/resources from all sectors of government to help resolve these issues for their citizens. What must we do together to help our most vulnerable citizens? One theoretical question examined in the interview was this: what if healthcare, with its many lobbying organizations focused on securing government funding, could take 50% of that lobbying effort and turn it to advocating for the needs of homeless and hungry Americans, ending these problems in the next 2 years? Surely the tremendous amount of influence wielded by the industry could enact massive change in this regard.
Individually, Dr. Berwick encourages us to take four separate actions:
- Speak about these challenges with your peers, frequently and passionately;
- Write articles such as this, as well as writing your representatives at all levels, to advocate for these changes;
- Act from the perspective of health providers in issues such as criminal justice and climate change, and finally
- Vote. Then recruit five of your peers to do the same.
Each of these ideas is focused around the concept of Human Centered Design. Dr. Berwick mentions the Institute for Healthcare Improvement’s belief in practicing “What matters to You” medicine: rather than asking “What’s the matter with you?,” healthcare providers must work to reconfigure processes around what matters to individuals and respond accordingly. So often issues that are foremost for people go well beyond the immediate health care need: food security, housing, substance use, violence, legal and other challenges. Providers must be equipped to advocate for the needs of their clients beyond clinical care provision. By focusing on the needs of the individual, eventually we’ll get around to health.
[At Connect_CX, we have been working in Manistee County, MI on an initiative that employs this philosophy directly. See the module on the NMCHIR site, especially the section titled Supporting People].
This inspiring article ends with the following statement: “Healers are called to heal. When the fabric of communities upon which health depends is torn, then healers are called to mend it. The moral law within insists so. Improving the social determinants of health will be brought at last to a boil only by the heat of the moral determinants of health.”
Originally posted on October 12, 2020 on connect-cx.com
*The US, alone among western democracies, has not ratified a long list of basic United Nations agreements on human rights, including the International Covenant on Economic, Social and Cultural Rights, the Convention on the Elimination of All Forms of Discrimination Against Women, the Convention on the Rights of the Child, the International Convention on the Protection of the Rights of All Migrant Workers and Members of Their Families, and the Convention on the Rights of Persons with Disabilities.
**Bullet points quoted directly from the article The Moral Determinants of Health