…some thoughts. I could go on about this topic for days and days and days, and eventually I will, but I think it best to break it up into a few easily consumable pieces, so a few hundred words will do more than suffice for today. This topic has been of interest to me for a number of years, and the more I learn, the more fascinating it becomes. Part of the discussion is the old nature/nurture debate, but another part of the discussion, and the one that captures my interest is how social determinants can affect health—physical, mental, emotional, and spiritual. 

That much-maligned, but ever useful online compendium of knowledge, Wikipedia, defines social determinants of health as “the economic and social conditions under which people live which determine their health. They are ‘societal risk conditions’, rather than individual risk factors that either increase or decrease the risk for a disease…” I might go beyond that and expand health beyond physical disease to include mental, emotional, and spiritual health in our discussion of “disease.”  The challenge is, when faced with the dire statistics that implicate the social determinants of health, how do we continue helping? At times, it seems the odds are insurmountable. Are they? I don’t think so. If I did think so, I’d be working in a Fortune 500 and going to work in an air-conditioned corner office everyday wearing a suit and tie and figuring out how to spend my annual bonus.  

For many of the helping professions (I will refer particularly to social work, since that is the profession of which I am currently a practitioner.) we want to believe in the power of the individual to change…it is, really, one of the foundations of the profession and a belief we must hang onto if we are to continue to cultivate empathy towards the clients (or patients, or consumers, or whatever flavor-of-the-week term we’re using). But in focusing so intently on the individual, perhaps we’re missing the bigger picture. Perhaps we need to focus more on changing the system and, through changing the system, give individuals the tools they need to change. 

I have a brief anecdote that feels apropos. Earlier this week, I attended a presentation by three graduate students who spent ten weeks in the Philippines working in various capacities with agencies whose work focuses on women and children. One of the presenters worked with a 16-year-old “street girl” who had a second-grade education and worked operating a pedi-cab. When asked by the student what her goals are, the teenager replied she wanted to study in Japan someday. When the student took this back to the agency, the message was, basically, “that’s impossible.” If we were to look at this girl—where she comes from, her family situation, her educational level, the socioeconomic level where she is beginning…in other words, all of the social determinants stacked against her—we might be tempted to agree. The question the student then asked is one of the most important and insightful questions I’ve heard in a very long time. The gist of it is, how does she (the student) go back to this girl and work with her if the belief of all the resources in place to help her don’t believe she has the capacity to improve her situation? In other words, as we work with people from different cultures, socioeconomic backgrounds, geographical areas…as we work with those populations who “have the deck stacked against them” when it comes to social determinants, how do we maintain the belief that we, as workers, can empower those with whom we work and continue to make a difference? These are questions all workers in the “helping professions”…and, really, all professions…might need to ask themselves from time to time. I know I ask myself this question, or one very similar, on an almost daily basis. Working with families, we see children from the same family come through the “System” (capital S). And, if you work in the System long enough, you’re likely to work with two, sometimes three generations of the same family, whether it is in Early Intervention, through the Child Welfare System, or another System. Often, the issues, concerns and challenges that stretch across multiple generations are the same. Do social determinants of health have something to do with this? They just might.

So how do we change the outcomes? As professionals, many of us continue to operate in a relative vacuum, in isolation from others working with the child, family, or community. We’ve increased communication with each other, but the “silo effect” is still very much a part of the reality. We focus on the individual, and might remove him or her from the environment, send them to a foster home, inpatient rehab, or other place “away from” the community. What happens when they’re done? They are placed right back into the old environment with the same triggers and dysfunctions that existed before, often with little or no continuing support. Why should it then come as a surprise that people relapse or return to unhealthy habits? Again, instead of looking only at the individual, why do we not look at the system and ask ourselves how changes in the system can change some of the things working against these populations? 

I’ve rambled on much longer than I expected, so I’ll end with a final question to ponder, and while I don’t have a short answer to it (or even a long one, for that matter), I have some thoughts I’ll express at another time. When we look at the systems that seem to fail many of our most vulnerable citizens, we should ask this question: “Who benefits from the status quo?”