Social Determinants of Health: Building Wide Coalitions Around Well-Honed Messages

As public health professionals know, the United States spends more per capita and achieves poorer health outcomes than other high-income countries. The reasons are equally apparent: a bloated medical care system and insufficient investment to create conditions that most determine health.^1,2

THE PROBLEM

Moreover, efforts to mold our preferences are everywhere and few are healthful. Our everyday actions are influenced and shaped by the selling and messaging that silently envelop us. Why do we buy that brand of bread or model car? Like it or not, our lives are heavily influenced by the 5000 ads we see daily.

A significant fraction of these ads is for health products and services, many of dubious effectiveness. Virtually none help the public recognize the most significant determinants of their personal health, their family’s health, and the health of their community. Companies spend billions of dollars every year to convince businesses and individuals to buy their products and services. However, most of these companies do not strike a responsible balance between their explicit mission to maximize shareholder value and their implicit moral obligation to provide social value. Therefore, we in public health must take the lead in building social and political support for maximizing health for all. This requires the sales and marketing skills to alter the public’s perspective regarding health and disease.

People intuitively sense the main drivers of our collective health. But they are socialized to equate medical care with health and to believe more is always better. Lack of public appreciation of the fundamental health determinants to their individual and societal health and productivity means there is no demand that leaders create conditions essential to health. In the absence of demand, is it at all surprising that we misprioritize our economic resources?

We mechanistically understand that the accumulation of plaque in arteries narrows blood flow, causing heart attacks and strokes. But how does low social status increase heart disease risk? How can discrimination and constant anxiety about having enough to eat or paying the rent contribute to an epidemic of overweight, obesity, and diabetes? And how can poor social connectedness increase mortality? That we seek pathophysiological answers to these questions spotlights the problem. Reductionist medical thinking leads to identification of highly specific conditions and therapies, yet poor education; lack of access to healthy, affordable food; and unsafe communities and other underlying determinants have much broader effects. To counter their effects requires interventions with less specificity but greater impact on health and well-being.¹ We should strive for health equity, but that requires individuals to receive the resources to achieve their full potential.

Few leaders are aware of the World Health Organization’s Commission on Social Determinants of Health³ that combed through all available evidence and confirmed the major societal contributors to health and equity. Recent scholarship underscores that social determinants correlate with health outcomes in the United States,⁴ including poor life expectancy in southeastern and Appalachian states. The report emphasizes that the states with the poorest health outcomes cannot improve without addressing problems of poverty, job creation, education, transportation, and the built environment.

If only our elected and appointed leaders understood that the unequal distribution of health-damaging experiences are “the result of a toxic combination of poor social policies and programs, unfair economic arrangements and bad politics.”^3(p1) But they never will unless we “make the sale” to policymakers at all levels. Yet most of them lack training in marketing, sales, or strategic communications and cannot command sufficient resources to pierce the clutter of competing messages. What do we do?

TOWARD A SOLUTION

Here are two strategies that could make a difference right now. First, build coalitions of organizations that share values and interests in communicating the message. But how do we get the diverse groups to make the broader message paramount? Will groups with targets as different as heart disease, addiction, pregnancy outcomes, and Alzheimer’s disease coalesce around this broader construct that affects all their targets for health improvement? Can funders be convinced that selling social determinants is a good use of limited funds? Can we incorporate groups critical to the broader vision of health but with a different primary mission?

It is unlikely that the multitrillion-dollar medical care sector will put its substantial muscle behind this notion. Indeed, changes to the Affordable Care Act and proposed budgets threaten funding for core public health and preventive services. But we can build multisector coalitions around specific health objectives. Public health’s role can be leader, convener, data source, modeler, and strategist. But no role is more important than personalizing these issues by telling the human stories, both negative and positive, that catalyze action: a family helped to find an affordable home; effective treatment of a parent with a substance use disorder; helping a parolee get a job and reintegrate into society.

The second strategy is to hone our messages to elicit more positive responses. Messages about social conditions can appeal to both conservatives and progressives. Examples include combining the notion of personal responsibility with the notion of opportunities or talking about the importance of Americans having equal opportunity to make choices that lead to good health. The term “social determinants of health” does not resonate with the public, but “health starts in our homes, schools, and communities” does.⁵

But even a well-honed message will languish unheard without a robust dissemination activity. We do not lack good models. Think of the well-funded disinformation campaigns of the tobacco and energy industries, and the successful campaigns to reduce tobacco consumption, to use designated drivers, to receive timely immunizations, or to fortify foods with essential elements supporting normal growth and development.

For public health to become a more potent force in setting the national, state, and local priorities for action, we need to plan and act collectively with other sectors, to hone our messages for bipartisan appeal, and fashion compelling stories. Resources from multiple sectors and organizations can make it impossible to ignore the policies, programs, and systems essential to collective health and health equity.

A tall order? Yes. But without well-defined strategies and tactics, the health of our nation will continue to lag that of other developed nations. Can we afford to be distracted by narrow interests and watch from the sidelines?