Monday, September 15, 2014

Science, Esthetics, Public Health, and the Social Determinants of Health

The closing session of the 2014 ASTHO (Association of State and Territorial Health Officials) Annual Meeting was entitled “The Intersection of Public Health and Clinical Medicine:  Addressing Social Determinants of Health.”  I was asked to give a Minnesota perspective on what needs to be done to assure “that all systems integrate to further address the social determinants of health.” 
As I prepared for the session, I reviewed the World Health Organization (WHO) definition of Social Determinants of Health:  “the conditions in which people are born, grow, live, work and age.  These circumstances are shaped by the distribution of money, power and resources at global, national and local levels.”  The WHO goes on to say that “social determinants usually identified as influencing health and health equity include those such as housing, employment and education.”  While clinical medicine is commonly viewed as a ‘downstream’ determinant of health, there is a growing realization that healthcare systems themselves are a social determinant of health because of their impact on the broader socio-political environment.  According to the WHO, ”when appropriately designed and managed, health systems can address…the circumstances of socially disadvantaged and marginalized populations…and they may be influential in building societal and political support for health equity.”
Health systems in Minnesota recognize the impact that social determinants of health have on the health of the population they serve and most, if not all, understand that they have a responsibility to help address those determinants.  The increasing focus on total cost of care and population health indicators underscores that responsibility.  How that gets realized is a work in progress.  Health Care Homes and the development of Accountable Care Organizations (ACOs) are part of that work.
Minnesota’s public health agencies also recognize the need to effectively engage with health care systems in order to use the strengths of both systems to affect the social determinants of health.  The work being done through the Statewide Health Improvement Program (SHIP) demonstrates that local public health agencies can serve as the backbone for magnifying the collective impact of community-based health equity efforts.  Embedding ACOs in a community context and using the Community Leadership Teams and the ‘policy, systems, and environment’ approach of SHIP in the development and implementation of the Accountable Communities of Health holds promise for effectively addressing the social determinants of health at a local level. (
Because this session was held on September 11th, a day when an act of violence changed the course of our history, and because “peace” is at the top of the WHO list of determinants of health, I felt compelled to add some comments about peace to my presentation. 
2001 was not the only year when acts of war occurred on September 11.  On 9/11 Scotsman William Wallace defeated the English in 1297, the French conquered Milan in 1499, Imperial troops under Eugene of Savoy defeated the Turks in 1695, Anglo-Dutch-Austrian forces defeated the French in 1709, the U.S. fleet destroyed a squadron of British ships in the Battle of Lake Champlain in 1814, and Mexican troops captured San Antonio in 1842 to name just a few battles and wars.  Most striking to me was that the groundbreaking ceremony for the Pentagon occurred on September 11, 1941 – exactly 60 years before an attempt was made to violently destroy it. 
I included these historical references near the end of my presentation and closed with a quotation from Isidor Isaac Rabi, a Polish-born American physicist, a 1944 Nobel laureate recognized for his discovery of nuclear magnetic resonance, and a participant in the Manhattan Project.  He died on September 11, 1988.  He said:  “Science is an expression of the human spirit, which reaches every sphere of human culture.  It gives an aim and meaning to existence as well as a knowledge, understanding, love, and admiration for the world.  It gives a deeper meaning to morality and another dimension to esthetics.”
Given that public health is both a science and an art, this quotation provides those of us in public health a way to approach peace and all the other social determinants of health.  The quotation begins with ‘Science’ and ends with ‘esthetics’ (“a set of principles underlying and guiding the work of a particular artist or artistic movement.”)  By including both science and esthetics, public health gives us a better understanding, love, and admiration of the world while providing a set of principles based on social justice that can guide the work of all sectors to create a better, peace-filled world for all.

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