What Healthcare Students Should Know About the Social Determinants of Health

The Covid-19 pandemic illuminated several stark health disparities in America. For example, infection rates were roughly twice as high for Black individuals as they were for white individuals, and Black patients were also over twice as likely to die from Covid-19 (KFF 2022; KFF 2020). The reasons for those health disparities were in no way biological, but instead shaped by non-medical factors, which are collectively categorized as the social determinants of health.

The social determinants of health encompass the entire range of non-medical factors that influence health outcomes. These determinants include the conditions in which people are born, grow, live, work, and age, along with the broader societal forces and systems that shape these conditions. Understanding the social determinants of health is essential for healthcare professionals in providing high-quality, comprehensive care to their patients.

Covid-19 highlighted some of the health inequalities in America, but the root causes of overarching health inequality have existed for generations. To learn more about the social determinants of health and how their incorporation into healthcare practice can lead to a more equitable future, read on. 

“The system itself is arranged so that some people can optimize their health opportunities while others cannot,” Dr. White says. “We need to engage with that at a policy level, so we can redress these systems of differential power and distribution in society towards more equitable health outcomes.”

One of the seminal frameworks for the social determinants of health was a 2008 report by the World Health Organization (WHO) Commission on the Social Determinants of Health. That report created a unifying framework for public health and other health professions to consider the ways context, environment, and other conditions shape people’s health, particularly at the community or population health level. 

“The strength of the framework is that it invites us to think about the predictable patterns in population health,” Dr. White says. “We know that better health outcomes exist for those who are in advantaged positions in society.”

It’s true for almost every city that wealthier neighborhoods have better health outcomes. Sometimes the gap between outcomes is drastic: life expectancy can differ by entire decades from one subway stop to the next. The reasons for such gaps are nuanced, varied, and multiple. Collectively, they are considered the social determinants of health. 

Common factors that shape these predictable patterns in population health at the neighborhood level can include differences in funding around housing, transportation, green landscapes, and food options. They can also include environmental hazards like air pollution, water quality, and toxic dumping. Many of these conditions can also be grouped under economic or socioeconomic factors, which stem from economic inequality, structural racism, and other systems of oppression. 

“This framework has caused us to reckon with the fact that the majority of health is not determined by biology and behavior but by structural factors in society,” Dr. White says. 

Having a framework of language and analysis for the social determinants of health is an important step. Actually addressing the underlying causes for the inequalities represented in those social determinants is trickier. But at the provider-to-patient level, there are ways to implement the lessons of the social determinants of health in ways that create better patient outcomes. 

“If you’re a health provider who is working concertedly to address these broader social determinants, you don’t have to do it alone,” Dr. White says. “There are amazing medical, legal, and social service partnership programs that take a team-based approach. But the hope is that at some point there is less need to address those factors, because we’re chipping away at them systemically.”

Successful implementation of SDOH-based thinking can take many forms. At CORE, the nonprofit Coalition of Racial Equity in Mental Health, it’s about centering their work on the intersection of racism, immigration status, and mental health, to learn how those factors can affect a person’s health over time. At the Southern Jamaica Plain Health Center an explicit philosophy on addressing racial and health inequities guides practice; together with partner organizations, the health center developed a program called Liberation in the Exam Room to foster conversations about racialized trauma between provider and patient and then place those experiences—and how they shape a patient’s health opportunities—alongside traditional risk factors like smoking, diet, substance use, and sexual health. 

And at the National Association of County and City Health Officials (NACCHO), it’s a website called the Roots of Health and Equity; NACCHO also runs a virtual course on the history of health equity and some of the policies that have shaped the enduring patterns that affect population health.

“We’re really getting explicit, in those instances, about the impact of structural racism on shaping health,” Dr. White says. 

One of the chilling truths that emerges from studying the social determinants of health is that a lot of health inequality isn’t accidental. Political decisions have distributed unequal funding from community to community. Redlining—the practice by which banks and insurance companies limit access to their products to certain neighborhoods, particularly those with non-white racial or ethnic compositions—has helped reinforce several structural factors contributing to poorer health outcomes. And at a macro level, any healthcare system that eschews universal coverage inevitably leads to fragmentation of health services and unequal health outcomes. 

“Health is inherently political in that it is structured by policies and political factors that shape economic, environmental, and social inequalities,” Dr. White says. “Health is both political and politicized.” 

Healthcare students may not be fully equipped to address the political and policy-level factors at work in the social determinants of health, but many practitioners, healthcare administrators, and public health professionals are. Practitioners, in particular, have a crucial role to play in not only responding to the symptoms of inequality but also addressing the root causes themselves. 

“Health professionals can have a really powerful voice in shaping policy, because they’re seeing the effects of the social determinants of health, day in and day out, on the front lines,” Dr. White says. “What would it mean to realize a system where we don’t see those economically-driven or resource- and power-driven health outcomes repeat themselves generation after generation?” 

The language and framework around social determinants of health will continue to evolve. Subtle changes can have big impacts. Consider the notion of cultural competency, which is shifting towards the idea of cultural humility instead.

“The nuance is important there,” Dr. White says. “Cultural competency is the idea that I can learn someone else’s culture, and then I’ve checked that box. Cultural humility, however, is a lifelong journey of deep accountability. It’s not just understanding my positionality or your positionality, but thinking about how to create systems and structures that redress inequitable power relations, including between practitioner and patient.”

In all 50 states, there is a government office specifically focused on the social determinants of health. And, increasingly, there’s a shift towards the language of health inequity. Again, the difference might appear slight, but it’s meaningful: health inequities are unequivocally unjust, unfair, and unnecessary. They didn’t just happen on their own, and they aren’t irreversible. 

“These systems and structures that lead to health inequities are constructed and reconstructed and then perpetuated in society,” Dr. White says. “And we have choices about whether we let that continue or whether we reverse the deeply embedded catalysts of inequity.”

Already, modern curriculums are getting better at equipping healthcare students to intervene not just behaviorally with patients but with an understanding of the social determinants of health at work in their communities. Over time, more practitioners will be able to get involved in the political solutions and advocacy work needed to treat the larger illness of inequality rather than simply treating its symptoms. 

“We have to really take a critical lens and eye to unpacking why these health inequities persist,” Dr. White says. “We have to ask the hard questions, and they’re often political questions, about why inequities persist and what we can do about them. Simply put, we have to get to work.”