Understand factors that determine health, how they mix

Myriad aspects of life impact health, and these social determinants include multiple models that include more than the physical body.


We are social animals. Our lives engage with others, and, in general, we live in a community.

As a physician, I work one on one in partnership with the patient and his or her loved ones to the extent that the patient chooses. A second set of eyes and ears is always helpful for recollection and follow-up. As a physician, I am aware that, even when caring for a patient during the intensity of a cancer diagnosis, the time we spend together in the clinical space is but a microcosm of the patient's life. So if our goal is to impact health, and since health is more than that microcosm, our work must engage other aspects of the patient's life.

And there are myriad other aspects of life that impact health. Many have written on these as social determinants of health, and there are multiple models that include these factors. Most are marked by the recognition that health entails more than the physical body. I like to think of it as the recognition that we are multidimensional beings—physical, spiritual, psychosocial—who live within a society characterized by socioeconomic cultural factors that influence how we experience life and health.

As physicians, it is important to understand these factors and their impact on the individual and the community, and it is also important to understand the structures that shape us and our experience. If we consider an aspect of our work to be an anthropological study, a cross-cultural analysis of the many different ways to organize and support the achievement of health within a society, this global perspective may enhance our vision by informing and shedding light on where and how we might improve.

Access to health care is broadly considered foundational. In the United States, access to health care is generally linked to access to health insurance, which is generally linked to employment. Since the provision of health services is linked to a monetary exchange, whether from the patient, the insurance company, or as a subsidy from the health system, we must ask ourselves, “How does ‘what is covered’ influence what is done?” Do insurance companies in the United States practice medicine without a license? When restrictions in the provision of health care services are legislated, we must similarly ask, “Are legislators practicing medicine without a license?”

There are basic elements to health that have been well documented to be of benefit. Food and water make up our physical beings and are essential to life. A caveat on food: As we are omnivores, many things can fill our belly and stop the hunger. It is important for us to think about what can healthfully fill our belly. It is important for us to teach our patients, our families, and ourselves to choose nourishment, to turn down pesticide-laden food, sugar, and simple carbohydrates, and to increase our vegetable intake, our knowledge of nutrition, and our enjoyment of food.

Our physical bodies are an intricate array of muscles, bones, and fascia. I have gained such respect and wonder for the physical body, how our bodies work and function and how we can maintain our health. Our bodies are meant to move. Movement is not limited to activities at a gym. Physical activity may include walking the dog, playing with grandchildren, going for a walk, dancing, and more. In what way is your body called to move? Move each day. Walk. Run. Stand. Pick your form of activity. Find the muscles you may not have engaged for a while.

Move, and rest. Our bodies need rest. This incredible balance of activity and rest is important to health and well-being. Consider the quality of your relaxation time. Consider the quality of your sleep. Enough sleep. Restful sleep. Be aware.

How do you carry your body? Where are the strains and stressors? Notice how small shifts in your alignment can make big differences. Shelter, safety, and the stability they can afford have been seen as foundational to health and well-being. As our work moves more and more away from the model of patient as follower of health advice to patient as partner in achievement of health, education is critical for this partnership. Education has long been essential to health care access since it is linked to employment and consequently to access to health insurance.

These essential elements can be influenced by the socioeconomic cultural structures of the community. Do the community and the individual have access to nourishment, to clean water, to safe spaces for physical activity, to safe shelter for undisrupted rest, and to quality health care education, in words that can be understood? Communication is critical to health. How we communicate can influence what our patients do. How well are we taught communication in our medical education? Can people get to resources, to health care, to mental health care, to nourishment, to school easily? Are the streets safe for walking? For driving? Is there adequate public transportation?

And there are factors such as race, ethnicity, gender, sexual orientation, and others where we note that there is a difference and often a lack of health or a poorer health outcome when contrasted to the “standard.” For a long time, the focus of academic work in health equity was to identify and document the disparities. To some extent, there is a normalization of poor health in some populations without a recognition of the modifiable factors that are influencing health. We need to be careful not to assume or predict ill health in a person simply based on appearance, to consider ill health or good health to be natural in a population.

We can consider how women in Western culture were long considered to be ill-fitted for leadership because they menstruated, making them subject to hormonal shifts and consequent emotional imbalance, undesirable characteristics in a leader. This was considered a fact, a natural, immutable state. As physicians, we need to be aware of any such biases that we may bring to our experiences, and we must consider how to support health in all peoples. Health is a foundational element essential to the opportunity to live a good life.

From the above, you may begin to think that we know a lot about what impacts health adversely but not a lot about what impacts health positively. To go back to the start, I believe we know a lot about the social determinants of illness. I do not think we know very much about the social determinants of health.

As we begin to understand better the factors that influence health and illness, we may uncover strengths in what we now call vulnerable communities. Given the challenges and stressors that some patients experience, an objective analysis would likely uncover factors of resiliency that have allowed for strength and survival. How this translates at the molecular level will be a topic of great interest for those of us who seek to promote health. What cytokines are released to support us as we overcome adversity? To begin to uncover these questions, we will need to broaden our perspective and stop looking for the deficit in the “vulnerable.” If we move away from our thinking of what is the current standard, we may begin to interpret our findings more objectively and with less conscious and unconscious bias.

Linked to all these factors are psychological and existential stressors that impact health and well-being. We are generally increasingly aware of the impact of mental health, but we are often not cued in to the role of spiritual distress or spiritual resiliency on health and well-being. Again, our science, our approach, must begin to analyze and understand what we can do better, how we can help our patients do better, and how our communities can better thrive together.

Health considerations permeate nearly every sphere of human life. Supporting the health of a population is a staggering task, and it is not ours alone. We work in partnership with food growers, water safety managers, city planners, schools, and more to support the achievement of health. We recognize that to support the achievement of health for an individual we must consider societal factors. We must partner with patients and with communities.