Social determinants of health, the life circumstances in which we are born, educated, work and play, are powerful drivers of as much as 90% of our health status. Lasker Foundation President Dr Claire Pomeroy discusses ways that race, ethnicity, gender, socioeconomic status, the safety of our neighborhoods, having good access to food, and feeling part of a community all combine to impact health. It follows that policy affecting all of these things also affects health, hence a call to action that health considerations should be part of all policy making. Soda taxes are a good example. Dr Pomeroy believes more systematic approaches to social determinants are needed, together with intersectoral collaboration, but this is a challenging process. All citizens can help by adding their voices to the call for “health in all policies”. With Dr. Bonnie Simpson Mason.
How the Lasker Foundation champions the importance of social determinants to all aspects of research and to shifting focus upstream. Featuring Dr. Claire Pomeroy.
Bonnie: Hello, once again, and welcome to our next episode of the Health Disparities Podcast. I am Dr. Bonnie Simpson Mason and this week, we are recording our conversations at the National Harbor in Maryland, where we are enjoying a packed program of speakers and workshops, at the annual Movement Is Life Caucus. Today’s podcast features, Dr. Claire Pomeroy, who is the president and CEO of the Lasker Foundation in New York City. An infectious disease expert by training, Dr. Pomeroy held professorships at the University of Minnesota, University of Kentucky, and the University of California-Davis, where she was also dean of the School of Medicine. She is a longtime advocate for patients, especially, for those with HIV and AIDS and in the public health arena. She has a special interest in healthcare policy with a focus on the importance of the social determinants of health and we will focus on that today. Dr. Pomeroy, thank you so much for joining us today.
Claire: Delighted to be with you.
Bonnie: Wonderful. Well, let’s clarify this at a very basic one-on-one level for our listeners. What are the social determinants of health? And tell us, how the social determinants of health, influence your role at the Lasker Foundation.
Claire: The social determinants of health are all the life circumstances into which we are born, work, play, age and it turns out that they’re really powerful drivers of our health status. A lot of people think that the health status of an individual, or a person or a community is determined by going to the doctor or going to the hospital or getting clinical care, but it turns out that only about 10% of our health status is determined by clinical care.
Bonnie: 10% only?
Claire: Only 10%. It is these other factors, like the social determinants of health, are much more powerful drivers and determinants of how well we are doing in our physical health, as well as, our mental health and our ability to thrive in life. It turns out that things like race, ethnicity, gender, socioeconomic status, living in a safe neighborhood, having access to good foods and, one of the ones that I find most fascinating, is it turns out that being part of a community, feeling a sense of social support, something that we call social cohesion is one of the most powerful drivers and determinants of our health.
Bonnie: Social cohesion, I love that. That’s a new term for me today. So, how does the Lasker Foundation support efforts to integrate the social determinants of health into your mission?
Claire: The mission of the Lasker Foundation is to inspire support for medical research and one of my messages is that the values of our society and the values of medicine and the values of us as scientists and clinicians are reflected in the kind of research we do. The kind of research questions that we ask. The kind of research that we care about. The kind of research results that we teach our students about. And so, at the Lasker Foundation, we celebrate the full range of research from basic discovery to clinical trials to, what we call, public service, which is making sure that the benefits of medical research actually reach everybody and improve health for all. I’ll just give you one recent example.
Claire: This year, when we gave out the Lasker Aware for Public Service, we gave it to GVA, the Global Vaccine Alliance, and they make sure that children in underdeveloped countries, around the globe, have access to basic vaccines and the lifesaving benefits of those vaccines. Now, here’s an example where we have lots of research that shows that vaccines are lifesaving for children. Over the past few decades, they’ve been disproportionately available to rich countries, and not so available to underdeveloped countries. So, GVA works to make sure that everyone gets those benefits. Now, the irony here is that many parents in the rich countries like the United States are now saying they don’t want to vaccinate their children. I will tell you that one of the most powerful statements I ever heard was from Melinda Gates, the wife of Bill Gates, who runs the Gates Foundation. She said to me, “I went to Africa and I saw mothers walking for hours to bring their children to get vaccinated. I come to California and I see mothers working to avoid having their children vaccinated.” I think this is one of the messages that the Lasker Foundation is trying to say. We have evidence of things that can save people’s lives. We need to make sure they benefit people and we have lots of evidence that the social determinants of health, if they are adequately addressed, save lives.
Bonnie: So, how do we create that shift, Dr. Pomeroy. That sounds like a huge undertaking, certainly, it is, to help us shift our mindset in the US, to one that wants to address the social determinants of health as being part of the solution and I know you’re an advocate for transformative healthcare by examining and channeling resources more towards the social determinants of health. Maybe you would like to share some details about how that could actually happen, maybe your thoughts on that.
Claire: We spend more than any other country in the world on medical care. What we label clinical care. However, if you want to address the social determinants of health, that money has been in the bucket of social services. What we call upstream prevention, upstream determinants of wellness. If you add up the amount of money that we spend on clinical care with the amount that we spend on social services to address the upstream determinants of health, actually, the United States spends about that total is about in the middle of all developed countries. So, this is not a question of spending more money on health. It is a question of how we choose to spend our money. Do we want to spend it downstream on end of life care, on ICU care or do we want to spend it upstream to prevent some of these things? Let me give you an example.
Claire: Do we want to spend it taking care of diabetic ketoacidosis, diabetes, out of control, in an intensive care unit, or would we like to invest upstream so that we have anti-obesity programs for kids and we have diabetic cooking classes for adults, so that we can prevent that diabetic ketoacidosis from ever happening in the first place? It turns out that not only is that a better approach for the patient, so, it’s a good thing for the patient. It also is more cost-effective. So, I believe that one of the reasons that we have to change our approach to a more social determinants of health model is that we cannot continue in this country to spend the amount of money that we’re spending, that’s not sustainable, and by the way, even though we spend more money than any other country, we have some pretty dismal outcomes. We rank very low in maternal mortality among developed nations. We rank low in life expectancy. Furthermore, we have huge disparities that are shameful. So, to some folks, I talk about, we need to adopt this new model because it is the right thing to do from a sort of a social justice, caring about your neighbor, point of view to other people I say, there’s a real economic argument about why we need to do this for the economy of our nation.
Bonnie: So, I’m hearing, and tell me how effectively those conversations go, if we’re shifting more towards the upstream prevention, wellness, investing in health versus investing in the 10% of healthcare on the backend. How’s that being received?
Claire: I started talking about the social determinants probably 20 years ago, and at that time, no one was talking about that, and at that time, I mostly got blank stares like, you know, no, we need to invent new medicines and fancy surgical techniques. All of which are great, but they didn’t have the, and, we need to address the social determinants of health. Now, many more people are talking about the social determinants of health. We have a great deal of evidence that if we were to shift this model from our traditional model to a more social determinants that that saves money and improves outcome. We have lots of evidence, but it is predominantly been in pilot programs, demonstration projects, individual philanthropy funded types of activities. So, when you ask how did those conversations go, I think there are many people who say, yes, that makes sense, but I don’t know how to make this big change. There are a lot of incentives to maintain the status quo.
Claire: There’s a lot of money in healthcare and there’re a lot of people who have jobs in the current system and change can be threatening. So, I go back to, we are not financially sustainable in healthcare and we have to improve our outcomes. I think we’re making progress. What I want to see is more systematic approaches to adopting a social determinant SMILE.
Bonnie: So that sounds like that’s going to take a collaborative approach between the federal government, industry, private hospital systems. Do you see that being actually achievable, because if we’re going to scale the investment of the social determinants of health or in the social determinants of health, it’s going to take all those parties? Is that realistic? Do you feel that that could actually happen?
Claire: So, it has to be realistic because we have to change. You are exactly right. This will require intersectoral collaboration, new partnerships, new coming together. We’re going to have to bring the clinical care community, together with policymakers, together with the criminal justice system, together with faith-based institutions, together with our schools, and many more partners to do this. I believe that we can do it. I believe that we must do it. I’ll give you an example of why it’s so challenging. I ran a large academic health hospital for many years, and the fact is that you have to have financial results that allow you to continue to operate that hospital. If I envision starting a nutrition counseling program and physical education program for underserved kids, there would be no ROI on that program.
Bonnie: There would not.
Claire: But if I bought a new PET scanner, there would be great cashflow to the hospital. Now, it’s easy to say, well, you should care about your mission and not worry about the money, but in the classic saying, “No money, no mission, no mission, no money.” Right? And so, to continue to do the good, I had to pay attention to the finances of that hospital. And so, what we have to do, I believe is switch to a longer term perspective on how we invest our money in health, the full range of health, and as we do that, and as we see advances, I believe that the progress will accelerate.
Bonnie: So, does that lend itself to one of the phrases you’ve used, health in all policies, talk about what that means and maybe some policy examples that could help us see that this could work.
Claire: So, health in all policies is a call to understand that every time we make a law or a regulation or a business decision that that has health implications. That has not been the traditional mindset. So, if you make a criminal justice decision are you think about the health implications of that. We have a criminal justice system that means that one out of every three black men will spend time in jail or prison in their life. That has dramatic health implications and, yet, when we calculate the cost in our criminal justice system, we don’t think about those health implications. So, health in all policies is a call to think about the health implications of every decision we’re making. I will give you a couple of examples, if I may, because I think this is really, important. When we give tax breaks to grocery stores to locate in the inner city, that’s good for that grocery store chain but that’s also good for the community that they’ve moved into because, now, healthy food is available. We should calculate in that benefit to our decision about how often we’re going to make those kinds of tax break policies. This is not always easy or politically palatable to many people. One of, I think, the most dramatic examples in this country is the implications of our policies on gun ownership and gun control. The United States is a huge outlier in the number of people that died through gun violence and, yet, we have not thought, always, about those health implications of our gun laws, as we make those decisions. I think there are examples where we have thought about the health implications, though, and to me, one of the most exciting things is the trend towards taxes on sugared beverages that many cities are imposing. For a very small tax, you can change people’s behavior and maybe they’ll drink more water and less sugared beverages and, by the way, many cities are taking that soda tax revenue and using it to invest in pre-K education or build parks. We know that education, especially, of children, and physical exercise because parks are available will further increase our health. And so, you get a compounding of the benefits from what seems like a very small decision to put a half-cent tax on a bottle of soda.
Bonnie: You make a very important point because the manufacturers of these sugared drinks have to be pushing back, just a little bit, but, yet, we can see how a small change, we’re not impeding their model, their revenue model, but we are making a big impact on health with that small tweet. As you say, there is a huge incentive in those businesses to continue soda sells, right?
Claire: Isn’t it interesting to watch how some of the companies have responded. And so, they’ve started to go into the bottled water business. What you can do is say, this is a value for society that we’re endorsing with this soda tax. We don’t want childhood obesity at the levels that we have, and businesses will make logical decisions. They will respond to those incentives. So, it’s easy for us to look at a company and say, “Well, it’s their behaviors that are causing all these problems,” but we, as members of society, and our political leaders, we’re sending messages to business and we need to take the responsibility to send those messages, so that businesses will respond.
Bonnie: We’ve talked in several of our podcasts about empowering our listeners to use their voice to say, maybe I have, I live in a food desert or maybe, the only drinks available are these sugary drinks. I love this because it gives our listeners another opportunity, “Aha, maybe I can talk to my alderman or my council person or even may legislator about how effective this tax has been, even in my own neighborhood because, now, I see more bottled water options.”
Claire: Exactly and every time someone has the opportunity to vote, they should ask the candidates, what are your policies on this? What are your policies on gun control? What are your policies on tax breaks to get inner city companies to come in? Let’s all take the responsibility to learn the candidates positions on those things, and then, take the responsibility to vote for the people who will make good change.
Bonnie: Right and hold their feet to the fire. Well, Dr. Pomeroy, it sounds like you and I can talk all day about these concepts but I really, would like to just summarize and appreciate your sharing some of these key elements with us. Number one starting out earlier in our conversation that really, only 10% of our health status is determined by the healthcare that we receive in a physician’s office, the hospital and an urgent care center. That the social determinants of health comprise the majority of that 90%. I hope that’s an aha moment for many of us in the audience because that was huge. I really do see the future of solving our healthcare crisis in the US as being collaborative. So, the point you made about intersectional collaboration is key. That’s what we’re doing here at the Movement Is Life Caucus, having this multidisciplinary approach and conversation to discussing healthcare disparities, race and racism and how it affects our not just health equity, but our most vulnerable populations, the health in all policies approach. Looking at every policy that’s made through a health lens. Yesterday, we were on Capital Hill listening to how some of the value-based care decisions and regulations have actually exacerbated healthcare disparities and we’ve not achieved health equity, but we’ve widened the gap. So, looking, I think that’s a critical component that I’m sure with leaders such as yourself, sounding the alarm on making sure we’re using that health lens to influence policy and regulation at the local, state and federal levels and that’s the key to being successful. So, thank you so much for your time, Dr. Pomeroy. We squeezed every ounce out of you that we could. Thank you so much for being here.
Claire: It was just fun and it’s an important message. So, thank you for sharing it.
Bonnie: Absolutely. So, thank you, again for joining us for the Health Disparities Podcast. You can follow us at MovementIsLifeCaucus.com and all leading podcast services for more conversations around health disparities with people who are working to eliminate them. These are the people who are passionate and we’re happy to spend time with them and sharing them with you. I am Dr. Bonnie Simpson Mason. See you next time.
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