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SOCIAL DETERMINANTS SOCIAL DETERMINANTS
OF HEALTH OF HEALTH

Social Determinants Health devices that alter dramatically the life course of our patients Figure 1
Many of our colleagues offer life-saving procedures and
of

hance the quality of life of our patients. Medicine in 2021 is
By Carlos Roberto Jaén, MD, PhD, FAAFP and many offer innovative therapies that prolong life and en-
bright and full of promise for those who can have access to
it. We need to celebrate with pride the nobility of our pro-
fession and what is being achieved. We also need to face with
humility the reality that what we do in medicine is but a small
fraction of what drives health in the patients, families and
communities we serve.
According to recent estimates, clinical care contributes
20% to health outcomes, with social and economic factors,
health behaviors and the physical environment accounting
for the rest (see Figure 1). The World Health Organization
1
(WHO) defines social determinants of health (SDH) as “the
non-medical factors that influence health outcomes. They are
the conditions in which people are born, grow, work, live,
and age, and the wider set of forces and systems shaping the
conditions of daily life. These forces and systems include eco-
nomic policies and systems, development agendas, social
norms, social policies and political systems.” As articulated
2
by the AMA Declaration of Professional Responsibility, we
commit ourselves to “educate the public and polity about 2015 County health rankings: model, measures and years of data
present and future threats to the health of humanity…[and] Source: County Health Rankings. Rankings Methods. 2015
advocate for social, economic, educational, and political
changes that ameliorate suffering and contribute to human development, education, health care, housing, human/social services,
well-being” . So practically speaking, if we profess “a common her- justice, labor, land use and management, media, workforce develop-
3
itage of caring for the sick and suffering” how do we address health ment, public health, transportation and others. The report also in-
disparities in Bexar County today by tackling the social determinants cludes specific examples of communities tackling health inequities.
4
of health? Bexar County residents have an excellent resource in The Health
A report from the National Academies of Science, Engineering and Collaborative, an organization that has provided comprehensive
Medicine in 2017, Communities in Action: Pathways to Health Eq- health needs assessments since 1997, most recently published a report
4
uity , presented a conceptual model that is included in Figure 2. It with details on many of the social determinants of health in 2019. The
emphasizes the importance of increasing community capacity to shape reports provide easily accessible and actionable data in graphic format.
health outcomes, of making health equity a shared vision and value, The organization has evolved to become a powerful network of citi-
and of multi-sector involvement. zens, community organizations and businesses committed to “improve
the health status of the community through collaborative means”. Full
This model lists nine social determinants of health: disclosure, our Department of Family and Community Medicine is a
1) education 6) public safety member. In addition, the City of San Antonio Council has a commit-
2) employment 7) the social environment tee dedicated to Community Health and Equity led by Council Mem-
3) housing 8) transportation ber Ana Sandoval.
4) income and wealth 9) health systems and services
5) the physical environment It could be overwhelming to contemplate action on these
SDH factors. Is there a way to focus on specific issues?

Stated in a different way, community-wide problems such as
Adler and colleagues offer us 3 pathways for action:
poverty, unemployment, low educational attainment, inadequate
1) Addressing “upstream” SDH
housing, lack of public transportation, exposure to violence, and
There is a light at the end a long tunnel as we celebrate the arrival of safe and effective vaccines neighborhood deterioration (social or physical) impact health and 2) Fostering health promoting resources and reducing health-
damaging risk factors throughout the life course
for the COVID-19 pandemic. A magnificent miracle of modern medicine, considering that contribute to health inequities. The proposed multi-sector collabora- 3) Improving access to, effects of, and the value of, clinical
the first confirmed case in the United States was identified on January 21, 2020. tion can include partners from agriculture, banking/finance, economic health services.
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12 SAN ANTONIO MEDICINE • January 2021 Visit us at www.bcms.org 13