Going Further Upstream on the Social Determinants of Health
Going-Further-Upstream-on-the-Social-Determinants-of-Health-bq2sri
Scott Wolfe
Coordinator @FBCE | Board Member @TPBInc | Creator of “The Machine Economy” at machineeconomy.world | I work at the intersection of political-economic analysis, disruptive technology, community development and social impact.
20 min read
March 11, 2024
It’s hard to admit when cracks begin to appear in one’s worldview. It’s even more challenging to reorient oneself to new processes of learning and un-learning, and to then re-engage the world with revised perspective. I know because this is the journey I’ve been on in recent years.
For more than two decades, I worked in the areas of global health and community health/development. This included a stint at the World Health Organization , a few years with a global not-for-profit organization focused on HIV/AIDS care ( IAPAC ) , and 20 years working with “community health centres” both in Canada and globally ( Canadian Association of Community Health Centres (CACHC) Alliance for Healthier Communities International Federation of Community Health Centres ). These entailed roles in communication, policy and government relations, and executive leadership.
A thread that ran through all of this work was shifting the attention of healthcare providers, policymakers, and other civil society stakeholders to the upstream causes of illness and social distress. We often refer to these as the “social determinants of health (#SDoH)”.
Our understanding of the SDoH is grounded in a significant body of research, theory, and practice. Major early milestones include the groundbreaking work of 19th century Prussian physician, Dr. Rudolph Virchow (1) who practiced and advocated “social medicine”, as well as Dr. Michael Marmot's seminal Whitehall Study in London, UK (2). Marmot’s 1967 study documented clear differences in risk factors, morbidity, and mortality among British civil servants correlated to their grade of employment and socio-economic status. The lower the grade and income, the greater the risk factors and greater the morbidity and mortality rates.
Since the late 1960s, an ever-growing body of research has further documented the correlation of risk factors, morbidity, and mortality with various social factors. This body of research underscores the importance to health of factors like adequate income, access to shelter/housing, access to adequate nutritious food, freedom from social exclusion, and many others. In fact, these SDoH are vastly more significant to the health of individuals and groups than strictly genetic and biomedical factors (3).
It’s also important to note that what we have come to understand about SDoH via Western processes of learning was already deeply embedded in other cultural perspectives on health and wellbeing. Indigenous practices throughout the Americas, for instance, provide abundant examples (4, 5, 6). We must honour these.
The SDoH may sound like common sense, and they should. However, it’s important to have actual evidence of these correlations and to use this evidence to guide us in developing frameworks and plans for action at a societal level. In other words, what should we do about these social factors? Should we treat the SDoH as strictly personal responsibilities? Is there a role for the state and, if so, what? What is the role of civil society groups, of individual health practitioners, and so on? These are complex questions which merit continued attention as a matter of political philosophy.
I remain convinced that we should attend to these matters as a shared responsibility, with important roles for the state, for civil society groups and organizations, for health and social service professionals, for educators, for families, and for individuals.
Since the late 20th century, health and social service organizations, government agencies, and many other relevant stakeholders have increased attention and activity focused on the SDoH. We should celebrate this evolution in thinking and action. It reflects an ethic of mutual benefit and an orientation toward prevention before treatment. A shift toward the SDoH also provides a systematic way to safeguard against pathologizing the human experience, where every aspect of dis-ease is handed over to a perversely incentivized medical-pharmaceutical industrial complex. This is not to disavow allopathic medicine, nor our major advances in diagnostics and treatment. It is simply to say that we need balance. We need to avoid spending scarce energy and resources on treating downstream that which can be prevented or better treated upstream.
As part of this movement, health and social service agencies have embedded a wide range of programs, services, and policy/advocacy positions that explicitly address various SDoH. For more than two decades, I have been an active participant in this movement and a vocal proponent of this approach. In diverse ways, I helped to translate our understanding of SDoH and health equity into practical lines of action within the organizations for which I worked, up until late 2023 when I embarked on a new vocational journey.
In practical terms. SDoH focused programs within the organizations I worked for included things like developing protocol and tools for individual doctors, nurses, and other practitioners to better connect vulnerable patients with much needed social supports. It included social workers and community health workers securing shelter or employment or food for at risk clients. It included integrating services like childcare and transportation with clinical services in order to reduce barriers for mothers seeking care for themselves and their children. And, it included advocacy for public policy and government investment that supports school nutrition programs, affordable housing, and other social inputs for health. These are just a few examples to illustrate the point.
I’m incredibly proud of this past work and I believe that the emphasis on upstream thinking and action needs to persist and to drive public policy and systems design. However, over the past few years I have become increasingly attuned to important new information (new to me, that is) which has caused me to reconsider my perspective on some of this work. I have come to believe that, despite our best intentions and the nobility of our efforts to address upstream causes of illness and social distress, we have still been labouring too far downstream. Our scarce energies have been misallocated. In certain instances, we have unwittingly been a marginal part of the problem too. I’ll try to unpack this.
I see two interrelated problems. First, we have reached a point where our remedial programs and services focused on SDoH are at risk of becoming institutionalized and self-perpetuating. I fear that we are becoming captive to the collective, organizational inertia of these remedial efforts instead of allocating more of our energy and resources to the larger public policy challenges that engender individual and social distress. Secondly, and more insidious I believe, our typical approach to those larger public policy matters (when we do direct energy to them) sometimes fuels many of the problems we seek to correct. I’m referring here to our tendency to seek increased public spending as a panacea for socio-economic disparities.
So, what new information has caused me to change perspective? Well, it has been a journey of learning about the mechanics of financial and monetary systems, and about the nature and consequences of money itself. That is to say, what money actually is, the history of money, what makes for sound versus unsound money, and the many consequences of the money we choose (or are forced) to use.
As a result of this educational journey over the past few years, I now believe that the most significant cause of social disparities is something which has actually escaped our attention: our “broken money” and its deleterious impact downstream. I still believe that it’s very important to continue providing services that address SDoH on the ground, and to continue drawing attention to housing, food security, and other inputs for health. However, my revised perspective is that in order to effectively achieve our diverse goals related to the SDoH, we must reallocate a significant portion of our attention and our resources to tackling the major cause which has escaped our attention. We must paddle further upstream to fix the money.
For a proper examination of our broken money and its downstream impact, there are several resources that I would recommend. Among them are Lyn Alden 's Broken Money: Why Our Financial System is Failing Us and How We Can Make it Better (7); Dr. Saifedean Ammous ’s The Fiat Standard (8) and The Bitcoin Standard (9); and Seb Bunney 's The Hidden Cost of Money: How Financial Forces Shape Our Lives & the World Around Us (10). For the sake of this brief essay and my call to action, I will offer a high-level breakdown of key points. I hope that I do them some justice.
The money which dominates globally -- our national and regional “fiat” currencies like the Canadian dollar, U.S. dollar, Euro, Mexican peso, Kenyan shilling, and so on -- can be produced in unlimited quantities to pay for government expenditures. When governments increase the supply of these currencies, which they have been doing at alarming rates over the past five decades (see Figure 1, for example), they cause inflation and reduced purchasing power as the currency debases in value. Not only does this exacerbate the challenges faced by individuals and families looking to meet their ongoing needs, it also unleashes a wide range of market forces that disproportionately harm individuals and families at the lower end of the income curve.
It’s hard to admit when cracks begin to appear in one’s worldview. It’s even more challenging to reorient oneself to new processes of learning and un-learning, and to then re-engage the world with revised perspective. I know because this is the journey I’ve been on in recent years.
For more than two decades, I worked in the areas of global health and community health/development. This included a stint at the World Health Organization , a few years with a global not-for-profit organization focused on HIV/AIDS care ( IAPAC ) , and 20 years working with “community health centres” both in Canada and globally ( Canadian Association of Community Health Centres (CACHC) Alliance for Healthier Communities International Federation of Community Health Centres ). These entailed roles in communication, policy and government relations, and executive leadership.
A thread that ran through all of this work was shifting the attention of healthcare providers, policymakers, and other civil society stakeholders to the upstream causes of illness and social distress. We often refer to these as the “social determinants of health (#SDoH)”.
Our understanding of the SDoH is grounded in a significant body of research, theory, and practice. Major early milestones include the groundbreaking work of 19th century Prussian physician, Dr. Rudolph Virchow (1) who practiced and advocated “social medicine”, as well as Dr. Michael Marmot's seminal Whitehall Study in London, UK (2). Marmot’s 1967 study documented clear differences in risk factors, morbidity, and mortality among British civil servants correlated to their grade of employment and socio-economic status. The lower the grade and income, the greater the risk factors and greater the morbidity and mortality rates.
Since the late 1960s, an ever-growing body of research has further documented the correlation of risk factors, morbidity, and mortality with various social factors. This body of research underscores the importance to health of factors like adequate income, access to shelter/housing, access to adequate nutritious food, freedom from social exclusion, and many others. In fact, these SDoH are vastly more significant to the health of individuals and groups than strictly genetic and biomedical factors (3).
It’s also important to note that what we have come to understand about SDoH via Western processes of learning was already deeply embedded in other cultural perspectives on health and wellbeing. Indigenous practices throughout the Americas, for instance, provide abundant examples (4, 5, 6). We must honour these.
The SDoH may sound like common sense, and they should. However, it’s important to have actual evidence of these correlations and to use this evidence to guide us in developing frameworks and plans for action at a societal level. In other words, what should we do about these social factors? Should we treat the SDoH as strictly personal responsibilities? Is there a role for the state and, if so, what? What is the role of civil society groups, of individual health practitioners, and so on? These are complex questions which merit continued attention as a matter of political philosophy.
I remain convinced that we should attend to these matters as a shared responsibility, with important roles for the state, for civil society groups and organizations, for health and social service professionals, for educators, for families, and for individuals.
Since the late 20th century, health and social service organizations, government agencies, and many other relevant stakeholders have increased attention and activity focused on the SDoH. We should celebrate this evolution in thinking and action. It reflects an ethic of mutual benefit and an orientation toward prevention before treatment. A shift toward the SDoH also provides a systematic way to safeguard against pathologizing the human experience, where every aspect of dis-ease is handed over to a perversely incentivized medical-pharmaceutical industrial complex. This is not to disavow allopathic medicine, nor our major advances in diagnostics and treatment. It is simply to say that we need balance. We need to avoid spending scarce energy and resources on treating downstream that which can be prevented or better treated upstream.
As part of this movement, health and social service agencies have embedded a wide range of programs, services, and policy/advocacy positions that explicitly address various SDoH. For more than two decades, I have been an active participant in this movement and a vocal proponent of this approach. In diverse ways, I helped to translate our understanding of SDoH and health equity into practical lines of action within the organizations for which I worked, up until late 2023 when I embarked on a new vocational journey.
In practical terms. SDoH focused programs within the organizations I worked for included things like developing protocol and tools for individual doctors, nurses, and other practitioners to better connect vulnerable patients with much needed social supports. It included social workers and community health workers securing shelter or employment or food for at risk clients. It included integrating services like childcare and transportation with clinical services in order to reduce barriers for mothers seeking care for themselves and their children. And, it included advocacy for public policy and government investment that supports school nutrition programs, affordable housing, and other social inputs for health. These are just a few examples to illustrate the point.
I’m incredibly proud of this past work and I believe that the emphasis on upstream thinking and action needs to persist and to drive public policy and systems design. However, over the past few years I have become increasingly attuned to important new information (new to me, that is) which has caused me to reconsider my perspective on some of this work. I have come to believe that, despite our best intentions and the nobility of our efforts to address upstream causes of illness and social distress, we have still been labouring too far downstream. Our scarce energies have been misallocated. In certain instances, we have unwittingly been a marginal part of the problem too. I’ll try to unpack this.
I see two interrelated problems. First, we have reached a point where our remedial programs and services focused on SDoH are at risk of becoming institutionalized and self-perpetuating. I fear that we are becoming captive to the collective, organizational inertia of these remedial efforts instead of allocating more of our energy and resources to the larger public policy challenges that engender individual and social distress. Secondly, and more insidious I believe, our typical approach to those larger public policy matters (when we do direct energy to them) sometimes fuels many of the problems we seek to correct. I’m referring here to our tendency to seek increased public spending as a panacea for socio-economic disparities.
So, what new information has caused me to change perspective? Well, it has been a journey of learning about the mechanics of financial and monetary systems, and about the nature and consequences of money itself. That is to say, what money actually is, the history of money, what makes for sound versus unsound money, and the many consequences of the money we choose (or are forced) to use.
As a result of this educational journey over the past few years, I now believe that the most significant cause of social disparities is something which has actually escaped our attention: our “broken money” and its deleterious impact downstream. I still believe that it’s very important to continue providing services that address SDoH on the ground, and to continue drawing attention to housing, food security, and other inputs for health. However, my revised perspective is that in order to effectively achieve our diverse goals related to the SDoH, we must reallocate a significant portion of our attention and our resources to tackling the major cause which has escaped our attention. We must paddle further upstream to fix the money.
For a proper examination of our broken money and its downstream impact, there are several resources that I would recommend. Among them are Lyn Alden 's Broken Money: Why Our Financial System is Failing Us and How We Can Make it Better (7); Dr. Saifedean Ammous ’s The Fiat Standard (8) and The Bitcoin Standard (9); and Seb Bunney 's The Hidden Cost of Money: How Financial Forces Shape Our Lives & the World Around Us (10). For the sake of this brief essay and my call to action, I will offer a high-level breakdown of key points. I hope that I do them some justice.
The money which dominates globally -- our national and regional “fiat” currencies like the Canadian dollar, U.S. dollar, Euro, Mexican peso, Kenyan shilling, and so on -- can be produced in unlimited quantities to pay for government expenditures. When governments increase the supply of these currencies, which they have been doing at alarming rates over the past five decades (see Figure 1, for example), they cause inflation and reduced purchasing power as the currency debases in value. Not only does this exacerbate the challenges faced by individuals and families looking to meet their ongoing needs, it also unleashes a wide range of market forces that disproportionately harm individuals and families at the lower end of the income curve.
Figure 1: US Money Supply (M2)
A good example of these perverse market forces is found in housing (11). As a result of inflation and our debasing currencies, individuals with discretionary income require assets that can help them preserve their earnings and wealth, such as real estate and stocks. A preferred choice has been residential housing, largely because it is a hard asset which has a clear utility value (can be lived in) and is also widely accepted socially as a “safe”, investable asset.
When people en masse channel money into housing with the expectation that it is an investment rather than simply for its utility value, this drives up prices. We are financializing the housing market rather than having housing meet our societal needs. Housing becomes inaccessible for increasing portions of the population and the strain of carrying costs places tremendous, cascading pressures and stress on individuals and families.
Figure 2: Housing price growth vs wage growth, Canada (2006-2022)
Examples of these unleashed market forces abound. They have been growing in scope and degree for more than five decades, particularly since 1971 when the U.S. dollar (as de facto global reserve currency) was de-pegged from gold. A fascinating collection of charts that paint the picture of trends since 1971 can be found at: https://wtfhappenedin1971.com.
We have been dramatically increasing the money supply in countries around the world for the past five-plus decades, with government spending outpacing government revenue at an accelerating rate. Government debt has risen at alarming rates (see Figure 3, for example), and the cost to governments of simply servicing debt is reaching dangerous levels. For stakeholders advocating increased public spending to tackle social disparities, we must recognize that we are doing so against this backdrop of persistent deficit spending and debt.
Figure 3: U.S. National Debt (1995-2024)
In order to provide increased public funding for housing programs, for food security programs, and for other social benefits, governments must either increase tax income or create new money. Since raising taxes is politically fraught and would still likely be insufficient to meet all committed expenditures for most governments, money creation is the option of choice. This is done to pay for military expenditures and social benefits alike. Conservative, centrist, and social-democratic governments alike are all guilty of money creation. This is not about ideology, it's about broken money and systems.
The creation of new money causes further inflation and reduced purchasing power. Those with greater income continue to chase assets like housing and stocks to preserve wealth while lower income earners unable to save and invest in such assets are left struggling with mounting day-to-day costs and fleeting options for financial stability. Millennials and GenZ-ers now face the brunt of this decades old experiment with fiat money creation, as hopes for future financial security become increasingly fleeting.
The experiment with fiat money creation, deficit spending, and debt has gone on for so long now, and across the political spectrum, that it is hard to imagine any possible course correction from within this system.
We are left with two viable and interconnected options. The first is to elevate public discourse about balanced budgets and the important choices we must make about priorities for spending. The second option is to move to a system where governments cannot simply create new money to fulfill promises through deficit spending. This second option has been an elusive dream in the era of fiat money. However, the introduction of #Bitcoin -- a sound, decentralized global money which has rules but no rulers -- now provides new hope (12, 13). Around the world, millions of people are turning to Bitcoin after arriving at the same conclusion: that if we fix the money, we can fix the incentives, and fix the world.
In writing this brief essay, I hope to pique the interest of individuals and groups that are actively involved in programs, services and advocacy focused on SDoH. My call to action is to take a closer look at the question of money, financial and monetary systems, and the fresh alternatives presented by Bitcoin. This is the learning journey that I have been on over the past few years. While it has been dis-orienting at times, I have never before felt such hope at the possibility for meaningful impact in reducing socio-economic disparities, both domestically and globally.
On the global front, Alex Gladstein 's books Check Your Financial Privilege: Inside The Global Bitcoin Revolution (14) and Hidden Repression: How the IMF and World Bank Sell Exploitation as Development (15) are must reads to better understand the harmful impact of fiat currencies on a global scale and why/how Bitcoin is an essential part of the solution.
I'll end with an additional appeal to anyone moved to take a closer look at resources and ideas I've touched upon here: embrace not just the content but a spirit of generosity and an openness to new civic engagements. We live in an era of such political tribalism. Matters to do with money, taxation, debt, wealth, and social disparities tend to evoke strong partisan sentiments. To the extent that we can engage on these matters across partisan lines, to discuss broken money and how to fix it, we are already beginning to fix the world.
REFERENCES
1. https://journals.sagepub.com/doi/full/10.1177/14034948211048289…
2. https://pubmed.ncbi.nlm.nih.gov/1674771/
12. https://bitcoinmagazine.com/culture/bitcoin-is-hope-for-gen-z…
13. https://bitcoinmagazine.com/culture/how-bitcoin-might-save-gen-z…
14. https://amazon.ca/Check-Your-Financial-Privilege-Gladstein/dp/B09V2NM9VJ…
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