As the COVID-19 pandemic has made increasingly visible, high U.S. death rates stem from a range of conditions influenced by race, ethnicity, socioeconomic status, migrant status, housing status and other markers of social inequality. Medical practitioners are increasingly aware that social inequalities are major drivers of poor health outcomes, but the vast majority .
Rochelle Dicker, MD, professor in residence of Surgery and Anesthesiology at UCLA and vice chair for Surgical Critical Care and the Co-Director of the Program for the Advancement of Surgical Equity (), says that 40% of patients’ health status is influenced by the social determinants of health – the conditions or environments in which people are born, live, work, worship and play. Determinants include financial stability, education, working conditions, social support, access to health services and more.
Addressing the social determinants of health is essential to improving overall individual health and, more broadly, achieving health equity – and according to Dr. Dicker, will take a “paradigm shift” within the culture of medicine.
Achieving such a paradigm shift will require drawing on the social sciences as basic sciences of medicine - just as genetics, neuroscience and other bench sciences inform medicine - says Helena Hansen, MD, PhD, professor of Psychiatry and Biobehavioral Sciences at UCLA and associate director of the Center for Social Medicine.
“American medicine has long neglected studying the mechanisms underlying social determinants of health,” says Dr. Hansen, who serves as the Translational Social Science Research Theme Lead. She is a board-certified addiction psychiatrist and cultural anthropologist internationally recognized for her research on opioids and race. “That is one reason we spend the most per capita on health care of any nation, yet we have the worst health outcomes in the industrialized world. To turn that around, we’re going to need new forms of social-scientific collaboration and medical training.”
In November of 2020, UCLA Health launched the Research Theme in Health Equity and Translational Social Science to promote equitable care by studying and developing new models to address the impact of social determinants of health.
The new theme, led by Drs. Hansen and Dicker, will foster collaborations among social scientists, life scientists, clinicians, and clinical researchers and will study the integration of social interventions with medical care; for instance, hospital-based violence intervention programs.
Hospital-based violence intervention programs () provide violently injured patients with a pathway to mentoring, follow-up assistance and long-term case management. Through community, private sector and city partnerships, the programs may also help patients seek viable employment, safe housing, mental health services and other critical services to mitigate the impact of structural societal barriers.
“As a trauma surgeon, I know that homicide is the number one killer of young Black men,” says Dr. Dicker, who has spent 20 years working in such programs and is the Health Equity Research Theme Lead. “If you look at why that's occurring, it's because there is structural racism, there is poverty and there's a lack of opportunity.”
Throughout medical school, Dr. Dicker teetered between a decision to practice family care or become a surgeon. Then she encountered a 16-year-old patient who had been shot.
When she asked him what he wanted to be when he grew up, she was stunned by his response.
“He said, ‘Grow up? I don't know that I'm going to live past 20,’” Dr. Dicker says.
When she was 16 years old, Dr. Dicker recalls, she was thinking about her plans for Friday night, her volleyball team and where she would go to college.
A few weeks later, the same patient was back in the ER with another bullet wound. That was when Dr. Dicker says she realized violence was like a chronic disease.
“It really was a call for me to look at why this is happening, look for solutions,” she says. “That led me to the hospital-based violence intervention.”
Studies show that engaging victims of violence with a credible messenger is a critical component to enrollment into these programs and a path to addressing the root causes of violence and other chronic diseases – for instance, addiction.
Dr. Hansen has studied the unseen ways that structural racism – such as the assumptions that white people were less susceptible to addiction – shaped pharmaceutical development and marketing, addiction neuroscience and drug regulation, and have led to the ongoing overdose crisis in the U.S.
Addressing these deep-seated and often invisible structures of inequality will not be easy, she warns: “It's going to require thorough-going collaboration between social scientists and clinical researchers to bring that to fruition in clinical research and scholarship.”
Dr. Hansen grew up in Oakland at the height of , where she says she bore witness to the effects of federal disinvestment in mental health care.
Referring to herself as a “latchkey kid,” raised by a single mother, Dr. Hansen remembers running home from the bus stop after school to avoid the multitude of homeless people in the streets, many of whom were talking to themselves. She later understood that they had been released from state mental hospitals as part of a policy of closing hospital beds without investing in community-based mental health care.
She also watched three of her uncles struggle with mental health, substance use and incarceration in the midst of what many have called a public mental health disaster.
“I think we as clinical practitioners have to draw on our own backgrounds and motivations and really be clear about the fact that practicing medicine is a political act: that we are driven by something,” Dr. Hansen says.
She coined the term translational social science to explain that academic medicine should look to the basic social processes that influence clinical phenomena – rather than only investigating those phenomena as biochemical in nature – and use those social scientific insights to inform clinical interventions.
The next generation, she says, must be prepared to take on this type of interdisciplinary work through collaborative research opportunities and cross-training in the social sciences.
“I'm hoping that many, many more of us can choose medicine, not because it's a stable source of income, but because we really want to do something about the horrible injustices and outcomes that we see in our current system,” she says. “If we as medical practitioners do not understand institutional and social systems, we will practice in a way that deepens inequalities and ultimately harms the health of us all.”
While approaching health inequalities from different directions, Dr. Dicker and Dr. Hansen say they have found themselves united in a mission to stem social determinants of poor outcomes at their roots.
An important element will be rebuilding trust with the community, Dr. Hansen says.
“We have to rebuild public faith through a really deep engagement with community,” she says, “and should take the lead in that.”
Dr. Dicker says she believes this team has an opportunity to impact the greater Los Angeles community in a way that hasn’t been done before. If successful here, the research theme could serve as a model for other communities across the country.
“We have unbelievable resources here in social science and in our clinicians,” Dr. Dicker says. “If we do this right, we really think that we’ll be able to mitigate the inequity caused by social determinants of health and structural racism.”
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