There’s always a new fad in healthcare—especially in mental health care. Sometimes it’s a new nomenclature or a new technique, somewhat different than the thing it’s replacing, yet never too far from the norm. For example, “intellectual disabilities” replaced “mental retardation” after the latter term became twisted into a slur. We’ve also seen the creation of Trauma-Focused CBT, as well as other core therapy techniques becoming “trauma-informed.” These always help to initially alleviate an additional layer of suffering occurring within members of our society. Yet, many terms eventually become overtaken when faced with our victim-blaming society.
This is currently happening with one of the newer idioms: “Social determinants of health” (SDoH). The term is intended to help healthcare providers and administrators understand that certain health-traits are connected to social and environmental factors outside of an individual’s control. In care management circles, it’s becoming both an administrative requirement and institutional best practice to review and screen for negative SDoH when meeting with a person.
Currently, I am a project manager for a Clinical Quality Team for a Medicaid MCO (Managed Care Organization). One day, while discussing the creation of a Clinical Quality program, I heard the following statement:
“We need to screen our members [of the Medicaid MCO] to see if they have SDoH. Social determinants of health.”
Something clicked. I realized that this term had already taken its negative turn. You see, the idea of discussing SDoH was to describe how everyone’s health is somewhat determined by the environment we are living within. We are all “at the mercy” of SDoH regardless of whether we are suffering from poor health, or not. SDoH can determine both helpful and harmful health traits. Someone raised in cleaner air will have less chance of developing asthma than a child raised in Clairton, PA, next to US Steel’s coke works plant.
But we’ve already turned discussing someone’s SDoH into a stigmatizing situation. Someone who is healthy isn’t concerned about their SDoH, or even aware of how SDoH has benefited their existence. In our culture, they are in charge of their health and living their best life. The person suffering from a condition caused by their environment are victims of SDoH, and become the only members in our society who carry the burden of needing their SDoH “addressed.”
When we start considering mental health and substance use, we can see a familiar pattern emerging. The person who was a victim of a traumatic and unstable environment may develop mental health and substance use concerns. They start to carry the mark of society’s ills as an embodied and individualized display of social breakdown that we can “cure,” without ever having to change society. By “fixing” the individual (which happens many times without the individuals’ consent) we don’t have to concern ourselves with the inequitable structures that determine the positive health traits within some members of our society, while leaving others suffering.
- We don’t need to worry about the racial disparities in new cases of pediatric onset asthma.
- We don’t need to worry about the gender disparities for experiencing trauma.
- We don’t need to concern ourselves with the connection between economic disparity and overdose deaths.
We have taken the social and made it individual.
This piece is currently being written during day 14 of the writer’s COVID-19 quarantine. For decades, public health officials have worried about a pandemic within the U.S., as our social infrastructure, those things are were supposed to limit inequities around SDoH, were removed, privatized, and individualized. “Why should I pay for their healthcare?!” has been the battle cry of the libertarian army. Well, now we all (almost) see why.
However, many communities, mental health practitioners, public health pioneers, and so many others already know we’ve been dealing with a pandemic. Experiential conditions such as depression, anxiety, suicidality, trauma-based suffering, addiction, and other non-physiological dis-eases have been spreading through our communities for decades. The truth has always been that physiological changes connected to mental suffering are symptoms and not causes, yet they have been reduced to bio-etiological maladies curable by medication. We have ignored the fact that socially determined disparities have been at the root of this suffering and the suffering has grown as social safety nets have disappeared.
We need to stop believing that suffering people are genetically inferior or “diseased.” You, as sufferer, are not alone in having social determinants of health. They are universal. They are systemic. And they are not solvable or “addressable” at the individual level. The only way to alleviate negative social determinants of health is to create a more equitable, inclusive, and just society.