Where the Political Determinants of Health Bleed Into Social Determinants of Health

An article recently published in The Lancet Public Health (Bundy, et al) reports on the results of the most comprehensive study of the impact of unfavorable social determinants of health (SDoH) in the United States to date.¹ While the study does provide statistics, figures, and facts for more than 48,000 adults, fortunately — but, perhaps, unfortunately — none of these findings comes as a revelation. The researchers examined eight social drivers from 1999 to 2018 — employment, family income, food insecurity, education, access to healthcare, health insurance, housing instability, and being married or living with a partner — among four racial and ethnic groups, including Caucasian, African American, Hispanic, and others. According to the results, multiple unfavorable SDoH disproportionately contribute to premature all-cause mortality and racial disparities in African Americans and Hispanics in the US in comparison with their Caucasian counterparts. Specifically, unemployment, lower family income, food insecurity, less than a high school education, no private health insurance, and not being married nor living with a partner were significantly and independently associated with premature death. These findings underscore the magnitude in which nonmedical factors affect the overall health outcomes of populations and shape the fabric of our communities.² One limitation of the study identified is that the findings are unable to prove direct causality between the unfavorable SDoH and premature death. However, literature attests that SDoH can be attributed to 50% to 80% of a person’s overall health.³ Moreover, a person's zip code and neighborhood have the propensity to influence their health, wellness, and life expectancy more than their genetic makeup.⁴

SDoH has become a buzzword in the healthcare community. Many are just catching up to the awareness, knowledge, and quandary we in the safety-net healthcare space have battled for decades. We encounter patients day after day who are unable to adhere to their own plan of care and reach their optimal level of health owing to unfavorable SDoH. It’s easy to categorize some patients as being self-limited, disengaged, noncompliant, or resistant to change. While there is a subset of the population that this applies to, more often than not, these individuals are simply unable to focus on and prioritize their health, whether short-term or long-term, due to compounding unfavorable SDoH, limited community resources, resource-poor programs, and allocated partnerships.⁵

Talent, intelligence, grit, and drive are all distributed equally in the US across all racial and ethnic groups. However, what are not are opportunity and resources. But, why? These are governed and dominated by political control — what we now know as the political determinants of health (PDoH), the impact of political decisions, policies, and governance on health.^6,7 Therefore, now we are at the intersection of health where we have SDoH and the PDoH and a patient population that is growing more medically and socially complex as the days pass. One could argue that the PDoH were established first and, therefore, have led to the SDoH, and their significance can either support or obstruct our efforts in the healthcare community to improve population health outcomes.⁸ An unanswered question that should be addressed in future studies is how the healthcare community can successfully begin to bridge the uncharted waters of health, SDoH, and PDoH to improve health outcomes and health equity while reducing health disparities. This isn’t to suggest that healthcare needs to become partisan; however, we must connect the dots to ensure that our communities understand how the PDoH — voting, policy, and government — impact their overall health.⁹ This requires multilevel planning, coordination, and interventions. However, there are some key aspects to consider now.

The importance of resource allocation and voting

We must develop and deploy political outreach and education for our communities so that they understand how to vote, why their vote matters, who the political candidates are — their beliefs and proposed policies — and the implications of voting or not voting, which often lead to the disparities in social drivers that our under-resourced, disempowered, and often disenfranchised communities of color face.^10-12

Political ideology and priorities

The political ideology of a government can shape its approach to public health. Governments with different ideologies may prioritize healthcare differently, and this affects funding, resource allocation, and the emphasis placed on specific health issues. For example, a government with a strong commitment to social equality may invest more in reducing health disparities among marginalized populations.

Policy and government community education

It is imperative at all levels — local, state, and federal — that we enact public policies to define the vision, outline priorities, and create tactics. Civic engagement is essential to invite and promote the voice of our patients' communities. As the population's health and medical experts, we can create models of care, solutions, and treatments. However, if the community is unable or unwilling to participate due to structural barriers, we have all wasted valuable time, resources, and, most of all, community trust and faith.¹¹

An exploration at the macro level into PDoH and innovative multilevel health policies, advocacy, and ample local, state, and federal funding resource allocation is integral to improving health outcomes. Understanding and addressing the PDoH is essential for creating effective public health policies and initiatives. Recognizing the influence of politics on health outcomes can help identify barriers to progress and promote a more equitable and healthy society across historically marginalized populations.⁶