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ALEXANDER GARZA, MD
SSM Health Chief Community Health Officer and
COVID-19 Incident Commander of St. Louis Metropolitan Pandemic Task Force

As the story goes, a businessman was walking home from work one evening. He noticed another man on his hands and knees under a streetlight, searching frantically for something. Feeling pity for the man, the businessman put his briefcase down and joined the searcher, asking him, "Can I help you? What are you looking for? "

The man replied, "Oh, thank you; I have lost my keys, and I won 't be able to get into my home unless I find them. Could you help me?"

"Of course," said the businessman, thinking the search would not take long, and he got to work scouring the asphalt underneath the light. After a couple of unsuccessful minutes, the businessman sat up and watched the searcher combing the same ground again.

He then asked, "Where do you believe you were when you lost your keys?" Without looking up, the searcher blindly pointed to a dark field a few dozen yards away. "I am pretty sure I dropped them over there."

The businessman looked at him incredulously and then at the darkened field, remembering he was now late getting home. He pointed to the ground and said, "If you lost them over there, why are you looking here?"

"Because," the searcher explained, "this is where the light is."

I use this story as an analogy in attempting to explain the approach to "health" in the United States. It illustrates the concern that we will forever be looking under the lamppost of health care delivery — searching incessantly and without success — for the answers to what ails us without looking in the areas where health is lost.

The statistics and correlations regarding the "health" of the U.S. seem redundant now. They are so accepted that the magnitude of their shock value has become background noise, or an expectation that this is just how things are. The political talking points about what is right or wrong with health care and health — amongst other social issues — are as predictable as the sun rising in the east and setting in the west.

Importantly, we must be clear with what we mean when we discuss the "health" of our country. "Health" is distinctly different — yet connected — to "health care," or the act of addressing medical problems in the country. In the U.S., health and health care are paradoxically related. For much of our history, we have falsely equated the health "of our communities" with the delivery of health care "to the community." The premise of this mindset is that if we only delivered "more" health care — or similarly, better access to it — then our communities would be "more" healthy. If only we looked harder under the lamppost, we might find our keys. Unfortunately, most evidence does not support this cause and effect.

DETERMINING IMPACT ON HEALTH WHERE IT MATTERS
Year after year, as a country, we spend more and more on health care with little gain in overall health. In fact, we seem to be getting worse. In 2020, according to the Centers for Medicare & Medicaid Services' (CMS) National Health Expenditure Account, the U.S. spent $4.1 trillion on health care, $12,530 per person and a staggering 19.7% of our GDP.¹ This spending far outweighs any of the other countries in the Organization for Economic Co-operation and Development.² For this vast amount of money, we receive little in return at the population level. In 2020, the average lifespan of a U.S. citizen was one of the lowest of any of the Organization for Economic Co-operation and Development countries, at 77 years.³ Life expectancy has decreased from 2019 to 2021 to 76.1 years, the largest drop over a two-year period since 1921.⁴

Buried beneath these summary statistics lie the hard facts that make these rankings attainable. The U.S. has one of the highest suicide, maternal mortality, infant mortality, obesity and chronic disease burden rates of any of the Organization for Economic Co-operation and Development countries, which, of course, translates to more and younger deaths.^{5, 6} This burden is not equally distributed in our society, with the poor and vulnerable much more likely to fall in these categories.

There is no doubt that tremendous advances have been made in the delivery of health care, medical devices and therapeutics, all of which are impactful at the individual level with some — such as the COVID vaccines — affecting entire populations. However, there is limited evidence to suggest that many of these technical advances have had a significant impact on the health of the community in general, or on the overall health of our country.

Instead, great advances in health are more generally correlated with improved standards of living and other measures outside of health care delivery. In his groundbreaking study, British physician Thomas McKeown found that advances in lifespan in England and Wales from the mid-19th century to the 1960s were more attributable to things such as improved nutrition and sanitation, and not as much from medical discoveries, such as antibiotics.^{7, 8} This was supported by the work of American physician and epidemiologist J. Michael McGinnis, who famously estimated that health care delivery was responsible for 10%-15% of preventable mortality in the U.S.⁹ Numerous studies have concluded that being able to afford nutritious food, housing, clothing, transportation and education have all contributed to the improvement in health throughout history. Indeed, this was recognized in the World Health Organization's Constitution in 1948, which acknowledged how health was impacted by political and social issues as well as the importance of working across other domains — such as education, agriculture, housing and economics — if we were to improve health globally.^{10, 11} Despite this, the world shifted to the belief that "health" was equal to medical care, and that if we just focused on health care delivery, that this would somehow solve the problem.

FACTORS OUTSIDE OUR HOSPITAL WALLS
With improved living standards and their resultant increases in life expectancy came the rise of chronic diseases, such as hypertension, diabetes and heart disease, along with a medical model to describe their causes. Health care delivery became increasingly focused on the "proximate causes" for disease, such as poor diet, lack of exercise, smoking and others. But what has not changed is that there are populations with higher risk for the proximate causes than others, begging the question: What makes someone at risk for a risk?¹²

The "risk for being at risk" is tied to "social determinants of health," which the Centers for Disease Control and Prevention defines as "… conditions in the environments where people are born, live, learn, work, play, worship and age that affect a wide range of health, functioning, and quality-of-life outcomes and risks."¹³ Following this, the CMS has recently advanced rules instructing hospitals to screen for "social determinants of health" and to provide resources to those in need. ¹⁴

Although these are good measures, are they enough, and will they appreciably help solve the complex issue of health? One could argue that it only continues to drive the narrative that health care will improve health, which, when objectively viewed, is not addressing the problem where it lies. It is continuing to search under the lamppost while the keys are in the darkened field. If addressing the social determinants of health is the goal, because we accept that they contribute to poor health outcomes and disparities, then we should also understand why someone is at risk for negative social determinants of health. This is important to understand, especially since prolonged exposure to negative social determinants is cumulative on disease outcomes, just like toxins or other more proximate causes.

HEALTH AND STRUCTURAL ISSUES
Unfortunately, the U.S. is also an outlier when it comes to spending on the very things that impact social determinants, such as social services. The majority of Organization for Economic Co-operation and Development countries fund social services at much higher ratios to total health care spending — and as a percentage of GDP — than the U.S.¹⁵ In 2019, the U.S. spent 18.7% of GDP on social services and 16.9% of GDP on health services — a nearly 1:1 ratio. In contrast, Organization for Economic Co-operation and Development countries, on average, spent 20% of GDP on social services and 8.8% of GDP on health services — an over 2:1 ratio. To think of it another way, the U.S. spends $1.11 on social services for every $1.00 on health care, compared to the average of $2.27 on social services for every $1.00 on health care in other Organization for Economic Co-operation and Development countries, these nations experiencing better outcomes.^{16, 17}

Related but apart from this, there is an increasing body of research that correlates poverty to poor health outcomes with social determinants serving as intermediaries.¹⁸ The data has shown that across the board, as one improves their socioeconomic position, they improve their lifespan, even when controlling for race and ethnicity, suggesting the strong link between poverty and health.¹⁹ Poverty, for all intents and purposes, helps establish and perpetuate the environments where people live, work and play — the social determinants. The U.S. is experiencing very troubling macroeconomic issues with high inflation, making those who are poor even more so. In addition, income inequity has increased significantly and, similar to the high cost of health care, the U.S. is again an outlier.

To describe this disparity, we can look at the Gini coefficient, which is a commonly used metric to represent income inequality within a nation or social group. It has a range from 0–1 where 0 equals complete equality in distribution of wealth and 1 equals complete inequality. According to data from the Organization for Economic Co-operation and Development, in 2021, the U.S. had the highest inequality of all the G-7 [informal grouping of advanced democracies] countries with a coefficient of 0.38. ²⁰ People in the lowest tiers of income struggle to get out of poverty, thus the cycle perpetuates and continues the ecosystem that drives poor health.

If these are all true, then health is much more a product of structural issues set into motion from the time of someone's birth, depending on their social station in the community rather than an event solely due to proximate causes. It is difficult to then rationalize that health care, which treats disease, can impact health in any appreciable way when its foundations and origins are so far removed.

SECURING THE PEACE
Exclusively addressing proximate causes has rarely produced long-lasting solutions in health or really any other issue that plagues our society. Perhaps it is the simplicity of the answer, a direct action — more health care — that makes us feel better, or, for that matter, focusing nominally on social determinants of health. But complex problems rarely have simple solutions, and health is the definition of complexity. Trying to understand how this all fits together can be maddening. However, there are a couple of instances during my career that have helped me when thinking these issues through.

Twenty years ago, when I was serving in the U.S. Army in Iraq as part of a civil affairs team to help rebuild hospitals and clinics, we understood that as a strategy, we could not shoot our way to victory, and that the key to victory was not just the sole responsibility of the infantry. Winning the war meant making the country stable enough for us to leave. This wasn't just about combat; it was about the citizenry, the society and its population. When people feel safe and secure, assured they can work and provide for their families, and are free to live their best lives, then you have stability — a real victory. "Securing the peace," the motto of my civil affairs unit, is hard, complex and engaging work. But it was the only way to bring about our end-state, a lesson that we forgot repeatedly to our detriment.

Likewise, in approaching community health, I think about when I was SSM Health's chief quality officer and the tools we used in patient safety — the "five whys." As any safety professional understands, you keep asking the question "Why?" until you arrive at the root cause. Though we are very good at doing this for errors in the delivery of health care, we are very poor in doing this for health overall, which would eventually lead us outside of the four walls of the health care system.

So, although we will address social determinants of health within the health care system, there is only so much we can do to address issues that are much bigger — and really outside — of health care delivery. True health rests with us as a nation and as a society. Without the collective efforts to improve those things that drive the social determinants, we will forever be looking under the lamppost and wondering why we can never find the keys.

ALEXANDER GARZA is chief community health officer for St. Louis-based SSM Health and COVID-19 incident commander for the St. Louis Metropolitan Pandemic Task Force. He is the winner of CHA's 2022 Sister Carol Keehan Award.

NOTES

1. "NHE Fact Sheet," Centers for Medicare & Medicaid Services, August 2022, https://www.cms.gov/Research-Statistics-Data-and-Systems/Statistics-Trends-and-Reports/NationalHealthExpendData/NHE-Fact-Sheet.
2. "Health at a Glance 2019," Organization for Economic Co-operation and Development, https://www.oecd.org/unitedstates/health-at-a-glance-united-states-EN.pdf.
3. "Life Expectancy at Birth," OECD iLibrary, https://doi.org/10.1787/27e0fc9d-en.
4. "Life Expectancy in the U.S. Dropped for the Second Year in a Row in 2021," Centers for Disease Control and Prevention, August 31, 2022, https://www.cdc.gov/nchs/pressroom/nchs_press_releases/2022/20220831.htm#.
5. Roosa Tikkanen and Melinda K. Abrams, "U.S. Health Care from a Global Perspective, 2019: Higher Spending, Worse Outcomes?," The Commonwealth Fund, January 30, 2020, https://doi.org/10.26099/7avy-fc29.
6. Eric C. Schneider et al., "Mirror, Mirror 2021 — Reflecting Poorly: Health Care in the U.S. Compared to Other High-Income Countries," Commonwealth Fund, August 4, 2021, https://doi.org/10.26099/01DV-H208.
7. Thomas McKeown and R.G. Record, "Reasons for the Decline of Mortality in England and Wales during the Nineteenth Century," Population Studies 16, no. 2 (1962): 94-122.
8. James Colgrove, "The McKeown Thesis: A Historical Controversy and Its Enduring Influence," American Journal of Public Health 92, no. 5 (2002): 725-29.
9. 9. J. Michael McGinnis, Pamela Williams-Russo, and James R. Knickman, "The Case for More Active Policy Attention to Health Promotion," Health Affairs 21, no. 2 (March/April 2002): 78-93.
10. "Constitution of the World Health Organization," in Basic Documents: Forty-Ninth Edition 2020 (Geneva: World Health Organization, 2020).
11. Theodore M. Brown, Marcos Cueto and Elizabeth Fee, "The World Health Organization and the Transition from 'International' to 'Global' Public Health," American Journal of Public Health 96, no. 1 (January 1, 2006): 62-72, https://doi.org/10.2105/AJPH.2004.050831.
12. Bruce G. Link and Jo Phelan, "Social Conditions as Fundamental Causes of Disease," Journal of Health and Social Behavior (1995): 80-94.
13. "Social Determinants of Health," Centers for Disease Control and Prevention, https://health.gov/healthypeople/priority-areas/social-determinants-health.
14. "CMS Proposes Policies to Advance Health Equity and Maternal Health, Support Hospitals," Centers for Medicare & Medicaid Services, April 18, 2022, https://www.cms.gov/newsroom/press-releases/cms-proposes-policies-advance-health-equity-and-maternal-health-support-hospitals.
15. "Social Expenditure Database (SOCX)," Organization for Economic Co-operation and Development, https://www.oecd.org/social/expenditure.htm.
16. "Social Spending," Organization for Economic Co-operation and Development, https://doi.org/10.1787/7497563b-en.
17. "Health at a Glance 2021," OECD iLibrary, https://doi.org/10.1787/ae3016b9-en.
18. Raj Chetty et al., "The Association Between Income and Life Expectancy in the United States, 2001-2014," Journal of the American Medical Association 315, no. 16 (April 2016): 1750-66, https://doi.org/10.1001/jama.2016.4226.
19. Paula A. Braveman et al., "Socioeconomic Status in Health Research: One Size Does Not Fit All," Journal of the American Medical Association 294, no. 22 (December 2005): 2879-88, https://doi.org/10.1001/jama.294.22.2879.
20. "Income Inequality," Organization for Economic Co-operation and Development, https://data.oecd.org/inequality/income-inequality.htm.

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