This blog was inspired by topics covered in Episode 6: Upstream Doctors & Social Interventions Research with Dr Laura Gottlieb.
If you haven’t listened to it yet, check it out on Apple, Spotify, Substack or wherever you get your podcasts.
The Starting Gun.
The adage ‘genetics loads the gun, but the environment pulls the trigger’, describes the interrelationship between our genes and the environment in determining our health and well-being.
Our biological blueprint defines the potential of our health, but it is our environment that realises this potential.
This is particularly evident during our first 1000 days of life (from conception until our second birthday), as this period significantly impacts our cognitive and physical development, as well as our future economic and educational prospects.12
Our genes and the environment are two sides of the same coin, flipped out of our control and predicting so much of our lives.3
Choice and Agency.
While we have no say in our genetics, or where we were born etc. - our agency emerges as we mature. This is most apparent in mid to late adolescence when choices around medical consent, criminal justice, military service and voting come to the fore.
In healthcare, our agency is particularly at play during the act of consent. This is when, at any age, our ability to understand and weigh up options when making a healthcare decision is a pillar of autonomy within ethical medical practice.
Choices can be shaped by the choice architecture surrounding them. That is how they are presented and designed. Through this design, we can be nudged into decisions - often due to the number of choices presented, their framing, and the use of defaults. Everyday things, often assumed to be neutral or passive, can have a measurable impact on behaviour, from enrolling into pension programs or saving on credit card bills.4 However, it is worth not overstating their power given some challenges to their ability to replicate in some circumstances.5
Broader Determinants.
Factors like the cleanliness of the air that we breathe, access to transport and employment, clinical care, and our behaviours encapsulate the major contributions to our health and well-being.
Collectively, these are known as the Social Determinants of Health.
In other words, ‘conditions in the places where people live, learn, work, and play that affect a wide range of health risks and outcomes’.6
Depending on where you live your health is impacted by housing affordability, access to outdoor spaces, poor air quality, rate of crime etc. This is not only important for individual and population health but also for a fair equitable society.
Given Clinical Care accounts for only 20% of health factors, this offers some interesting questions;
Is our public conversation about health and well-being too focused on clinical care?
Are we expecting too much of clinical care providers when factors sit outside their control?
How should these stakeholders work together around the common goal of well-being?
Major Actors.
The Commercial Determinants of Health are the ‘private sector activities that affect people’s health, both directly or indirectly, positively or negatively’.7 This includes activities such as marketing strategies, product placement, and pricing. But also includes lobbying, supply chains and labour conditions, amongst other activities.
The health impacts from Commerical Determinants of Health are wide-ranging; from their impact on pollution, alcohol, smoking, gambling use, obesity, and mental health conditions.
For example; the choice a fast-food company makes to target advertising at children and it’s impact on obesity.8
These actors, along with the features in the Social Determinants of Health are all enabled, or disabled, by our Political Determinants of Health. They are the policies, regulations, and investment decisions that impact the society we live in. This results in a dynamic interplay between the political and the commercial determinants that shape the social determinants.
What are our choices?
In many ways, it can seem like these forces disempower our ability to fix or change our current circumstances. For some actors in this space, that is their hope. However I believe, many - if not most, would like to do the right thing but require the right support, collaboration and direction.
Despite what we read in the news, we have had incredible success in the past and there are more opportunities for improvement. This of course includes political and social action -where there is a long list of success stories of major health-related and adjacent reforms e.g.
Affordable Care Act in the US with an estimated 40 million benefiting9.
At least 85 countries implemented some type of sugar-sweetened beverage tax to combat obesity.10
Global action in 1987 to stop Ozone Hole depletion.11
There is also a huge opportunity for leadership from healthcare institutions. This is because they can have an outsized role in communities as Anchor Institutions.
That is, not only through their clinical provision, but their employment practices, procurement policies, and service decisions have widespread impacts, influencing local economies and community well-being.
These choices, are often not always considered as part of their role but have important ripples across communities. This can shape not only their economic position but also the goodwill within the community.
For example, many organisations make multi-year multi-million dollar exclusive deals with food and beverage manufacturers that have a profound impact on staff and patients’ access to healthy affordable foods.
These sorts of decisions can build or undermine trust, potentially distancing an organisation from its values. This can impact staff retention due to the purpose-driven orientation of the profession12.
Healthcare institutions also have significant political heft. If trusted, their political clout can significantly shape positive (or negative) health policies.13
Summary.
Our health and well-being are determined by a complex web of social, commercial, and political determinants. Understanding this interplay is key for healthcare leaders to address many of our public health issues.
This means that health and well-being are not confined to only clinical actors, but sit as a collective responsibility across society. A healthy community, country and globe therefore must have health considerations built into every decision.
Healthcare institutions play a crucial role in this ecosystem, with the potential to foster positive change.
So while genetics may provide the bullets, it’s our influence on the environment that determines the gun, the target, and who gets to pull the trigger.
Stewart-Brown et al. Parent-child relationships and health problems in adulthood in three UK National birth cohort studies. European Journal of Public Health, Volume 15, Issue 6, December 2005, Pages 640–646, https://doi.org/10.1093/eurpub/cki049
M. Marmot et al. Fair Society, healthy lives. Journal of Public Health, Volume 126, Supp 1. September 2022, Pages S4-S10. https://www.sciencedirect.com/science/article/abs/pii/S0033350612001862?via%3Dihub
Stumm et al. Predicting educational achievement from genomic measures and socioeconomic status. Developmental Science. 2020 May; 23(3) https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7187229/
Beshears et al. Nudging: Progress to date and future directions. Organisational Behavior and Human Decision Processes. Nov 2020. Volume 161. Pages 3-19. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7946162/
A Few of the Ideas About How to Fix Human Behavior Rest on Some Pretty Shake Science. https://www.nytimes.com/2023/11/30/opinion/human-behavior-nudge.html
About Social Determinants of Health (SDOH). Centres for Disease Control and Prevention. Published August 26, 2020. https://www.cdc.gov/socialdeterminants/about.html
Commercial determinants of Health. WHO. March 2023. https://www.who.int/news-room/fact-sheets/detail/commercial-determinants-of-health
The Impact of Food Advertising on Childhood Obesity. American Psychological Association. 2010. Accessed Dec 2023 https://www.apa.org/topics/obesity/food-advertising-children
Number of Affordable Care Act-related (ACA) enrollments in the Marketplace, Medicaid, and the Basic Health Program (BHP) in the U.S. from 2014 to 2023. Statista. Accessed Dec 2023. https://www.statista.com/statistics/1280656/number-of-us-aca-related-enrollments/
WHO calls on countries to tax sugar-sweetened beverages to save lives. World Health Organisation. Dec 2022. Access Dec 2023. https://www.who.int/news/item/13-12-2022-who-calls-on-countries-to-tax-sugar-sweetened-beverages-to-save-lives
The Ozone Hole Showed Humans Could Damage Earth and That We Could Heal It. By Jonathan Schienberg. Sept 2023. Scientific American. https://www.scientificamerican.com/video/the-ozone-hole-showed-humans-could-damage-earth-and-that-we-could-heal-it/
C West. The value or values alignment in healthcare. Journal of Internal Medicine. March 2023. https://onlinelibrary.wiley.com/doi/full/10.1111/joim.13626
N Counts et al. Healthcare Lobbying on Upstream Social Determinants of Health in the US. Preventive Medicine, Volume 153, 2021. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8694571/