Sarina Schrager, MD, MS, WMJ Interim Editor-in-Chief
Despite the fact that we spend almost 90% of our health care dollars on medical care, it is estimated that only 10% to 20% of health outcomes are due to access to care and medical interventions.1 Social determinants of health, or non-medical factors that affect health, account for the remaining 80% to 90% of health outcomes.2 These social determinants of health include where someone lives, what kind of work they do, what they eat, if they have access to food, whether they smoke, and race and socioeconomic status.
Healthypeople.gov categorizes social determinants of health into five areas: economic stability, education, social and community context, health and health care, and neighborhood and built environment (human-made surroundings that define where we live and work, ranging in scale from buildings, streets, and parks to cities and beyond).3,4 All of these factors contribute to health outcomes and exist primarily outside of the clinic examination room. If your patient does not have access to healthy food or a safe neighborhood to walk in, the quality of the health care they receive may not effectively balance their high risk of adverse health outcomes. Several papers in this issue of WMJ provide information about the effects of social determinants of health on the overall health of people in Wisconsin.
The paper by Ezenwanne et al compares health outcomes in Wisconsin to the rest of the country based on similar surveys, performed first in 1990 and again in 2018.5 The survey, performed by “America’s Health Rankings,” rated Wisconsin as the 7th healthiest state in the US in 1990 and the 23rd healthiest in 2018. The difference in health ranking was related to several factors, including infant mortality, obesity, smoking, occupational fatalities, and infectious disease. The two surveys were not exactly the same, which could account for some of the variation, but the authors argue that health indicators have worsened in Wisconsin over the last 30 years. According to America’s Health Rankings, 25% of Wisconsinites drink excessively compared to the national average of 18%.6 Alcohol is the third leading cause of preventable deaths, after tobacco use and physical inactivity. Health care is excellent for most people in Wisconsin, so one must presume that much of the decrease in health rankings are related to social determinants of health.7
The paper by Krawisz entitled, “Health Effects of Climate Destabilization” provides information about the science behind climate destabilization, as well as a description of how climate changes can affect human health.8 The author examines how floods and changes in air quality and temperature can lead to increased incidences of infectious diseases and respiratory illnesses. Changes in temperatures can provide an enhanced environment for ticks and mosquitos, which, in turn, can lead to more disease. The paper also discusses the mental health effects of climate changes—namely an increase in anxiety levels.
Maurice et al use a case example of how price changes at the University of Wisconsin Hospitals and Clinics cafeteria affected changes in dietary habits.9 When there was a simultaneous increase in the price of fried foods and a decrease in the salad bar’s cost, the authors observed a significant increase in consumption of the salad bar and decreased consumption of fried foods. A similar finding was observed from decreased prices of bottled water as consumption increased. These changes had a neutral effect on revenue but could significantly improve health outcomes.
Bicycling is associated with both health and environmental benefits but also poses a risk of injury. Schmidt et al explore ridership and helmet use throughout Wisconsin and found that differences between sex, race or ethnicity, and education level were associated with both.10
Researchers at the University of Wisconsin School of Medicine and Public Health have developed a website called the Wisconsin Health Atlas (wihealthatlas.org), where people can find health indicators broken down by ZIP code throughout the state. The site also ranks where Wisconsin health indicators fall compared to other states (eg, 30 out of 51 for adult obesity, 16 out of 51 for percentage of minors who live in poverty, and 10 out of 51 for percentage of adults meeting weekly physical activity goals). It is time for the medical community to recognize and emphasize the effect that social determinants of health have on our patients. We can work together to help make sure that all ZIP codes in Wisconsin are equally healthy.
- Bipartisan Policy Center. Accessed June 1, 2020. https://bipartisanpolicy.org/wp-content/uploads/2019/03/HEALTHY_0.pdf
- Hayes TO, Delk R. Understanding the social determinants of health. American Action Forum. Published September 4, 2018. Accessed May 23, 2020. https://www.americanactionforum.org/research/understanding-the-social-determinants-of-health/#ixzz6NHi2jl2B
- Impact of the built environment on health. National Center for Environmental Health, Division of Emergency and Environmental Health Services, Centers for Disease Control and Prevention. Published June, 2011. Accessed June 1, 2020. https://www.cdc.gov/nceh/publications/factsheets/impactofthebuiltenvironmentonhealth.pdf
- Social determinants of health. Office of Disease Prevention and Health Promotion. Healthypeople.gov. Accessed May 28, 2020. https://www.healthypeople.gov/2020/topics-objectives/topic/social-determinants-of-health
- Ezenwanne O, Crawford R, Remington PL. The race to the bottom: Wisconsin’s long-term trends in health rankings. WMJ. 2020;119(2):199-121.
- Public Health Impact: Excessive Drinking. America’s Health Rankings analysis of CDC, Behavioral Risk Factor Surveillance System. United Health Foundation. Accessed May 28, 2020. https://www.americashealthrankings.org/explore/annual/measure/ExcessDrink/state/WI
- National health care quality and disparities report. Agency for Healthcare Research and Quality. US Department of Health & Human Services. Accessed June 1, 2020. https://nhqrnet.ahrq.gov/inhqrdr/Wisconsin/snapshot/summary/All_Measures/All_Topics
- Krawisz B. Health effects of climate destabilization. WMJ. 2020;119(2):132-139.
- Warsaw P, Morales A. The potential impact of hospital cafeterias on dietary habits: a case study of the University of Wisconsin Hospital and Clinics. WMJ. 2020;119(2):122-125.
- Schmidt C, Snedden T, Malecki K, Gangnon R, Eggers S, Kanarek M. Bicycling Rates and the Prevalence of Bicycle Helmet Usage in Wisconsin. WMJ. 2020;119(2):91-95.