Talking Headways Podcast: The Social Determinants of Health

This week, we're joined by Dr. Georges Benjamin, director of the American Public Health Association, who talks about the social determinants of health and how certain investments can change health outcomes for the better.

For those of you who prefer to read than listen, there's an excerpt below. If you want the full unedited transcript, click here.

Jeff Wood: Dr. Benjamin, we're thrilled to have you with us to discuss how transit and connected communities can lead to more equitable health outcomes. And for us, this is the first and the three-part series looking at the relationship between transit and public health and the social determinants of health. I'm curious, how has community specifically connected to health?

Dr. Georges Benjamin: Eighty percent of what makes you healthy occurs outside the doctor's office. And as an ER, doc, that's kind of one of those revelations. It's very, very painful, but it's true. And you know, it's about access to safe, affordable housing, is being food secure. It's about being in walkable bikeable green communities. Walkable because you can get out and exercise. Lots of public transportation because, you know, even though I live out in the suburbs and I'm in many ways kind of reliant on my automobile, but the good news is I'm in a community where there has pretty decent public transportation.

So if I wasn't in my car, I can get around my community. I can get to work and it's absolutely essential. And of course, growing up in Chicago, you learn a lot about the importance of good, solid public transportation and the ability to get from one place to another is absolutely essential for work for school, even for play.

JW: Is that something in the health community has been talking more about recently, or is it something that the health community has always talked about?

GB: The health community has always talked about these social determinants of health, which transportation is one of them, but it's getting a new life because people are beginning to recognize that we can't practice our way, from a medical perspective, out of the challenges that we have. You know, we spend twice as much as the next industrialized nation on health, and we're not getting anywhere near the outcomes that we deserve. That's because we don't spend enough on the front end, in prevention and wellness and those societal things, and really impact your health.

JW: You explained the social determinants of health. What are they, and how do they relate to public health overall? You mentioned earlier that 80 percent of what makes up your health is from those social determinants of health.

GB: For example, we know that education very well correlates with better health outcomes. So simply getting a high school education correlates with a better health outcome. We know that women and more education than a woman have the better opportunity their child is going to have. For example, less infant mortality occurs in women with more education. We know that housing is important, having safe, affordable housing, and you know, the prescription for homelessness is a house. We know that, for example, having a house grounds you in the community allows you to have, really, a relationship with the healthcare provider, that if you're in a shelter or moving around a lot, you really cannot have very well.

So you don't get access to healthcare. We know that many communities don't have access to grocery stores. They have a lot of convenience stores in their communities, which sell at a premium high fat, high salt, low nutritious foods, but you can't get fresh fruits and vegetables. And if we want people to eat more fresh fruits and vegetables, they tragically have to travel too far out of their community to get that. And let's think about what's happening right now. We're in our homes after this COVID-19 pandemic — and kids and grandkids are now home. And for many of those kids, they didn't have a linkage back to school. For some of the more affluent kids, they had a computer, they had access to WiFi. But we know there are many, many communities that don't have access to WiFi. Even before COVID, we had lots of kids who were literally sitting outside hotspots at fast food places at restaurants, etc, in order to just do their homework because their homework had moved to be online. And then when they left school, they didn't often have the technology at home in order to do their homework.

And so they're not going to do well in school, and they're going to have a deficit from that. And then the pivot to transportation and health, you know, there are many communities where just the place you can get on and off the train — they've got a great train system in the city, but the entrance ramps to get in, where you pay to get on the train are not in the hood, they're in more affluent communities. And so to get there is very, very inconvenient.

So we have to build transportation so that it aids people and their ability to get around because if you don't, you can't get to work. You can't get to the doctors. And of course you, you know, you really can't get to the recreational activities. You want to go to, too.

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JW: During the pandemic, we've seen some of the worst outcomes in terms of infections and deaths in lower-income neighborhoods and communities of color. What's driving that?

GB: Three things. Number one, exposure. Many of these individuals are public facing. So bus drivers, grocery store clerks, they work in a nursing home providing services to the clients and the nursing home, sanitary workers. So they're public facing. So they're out. They are around a lot of people. And so that we know there's a lot of asymptomatic spread. They're much more likely to get exposed.

Second, susceptibility. Some of the earliest studies from China show that about 80 percent of the people that get this disease had a mild case. They didn't get really sick. But around 15 to 20 percent of people did get very sick. And those people were the ones that ended up in the hospital, and some of those ultimately died. The people that were at risk were people that had diabetes, obesity, heart disease, chronic lung disease, and in the minority community, we know that disproportionately communities of color have all of those things and they get them at a younger age. So with that in mind, susceptibility was the second part of that.

And then the third one is a lot of new studies are coming out — again, looking at those social determinants, those things that occur in the community that impact your capacity to live a normal, healthy life. So income inequality, where you live, have a high correlation with mortality. And we, we've always known that wealth and health are strong correlates. So the more money you have, the healthier you're going to be.

And so that's one of the real challenges here. When you put those three things together — social determinants, which impact your ability to get healthcare and maybe more exposure, your occupation and any chronic diseases — put the minority community much more at risk of getting sicker should they get exposed and also much more likely to get exposed to COVID-19.

JW: Is there a way we have built communities historically that has contributed to these outcomes?

GB: You know, structural racism is we built these communities. You know, we built these communities to be segregated. We did things — such as redlining, where people could live and where they couldn't live, or how we gave people money for financing. So typically minorities had to pay more in terms of interest rates for their houses. And the houses were often devalued because of the communities they were in. And that creates a society where everyone isn't equal.

And so we structurally did that. In addition to that, we've built communities that, you know, in the inner city had sidewalks and most of your urban settings, and we just let them fall apart. We didn't invest in the inner city. And so we then moved everyone out to the suburbs and we built those suburbs so that they were based on a car. Everybody had to have a car to go anywhere and you had to have a car to go shopping. There were some, certainly some planned communities that were really built pretty smartly, but even then we still have lots of suburban communities that are built without sidewalks.

So if you're going to build a community that's not walkable, you're going to have people walking out in the street at a higher risk of getting hit by a car. So pedestrian injuries are going to go up. You're going to have much higher incidents of obesity because people aren't walking because it's not convenient for them to walk and they don't have a lot of green space. And so a lot of mental health issues about the fact that you need to be able to get out of your house and just go someplace when somebody gets on your last nerve. And I think most of us know what that means. But if you build communities that don't allow for that, that's a problem.

Now we are trying to revitalize the inner cities. We are trying to build communities where people can live and work and play within a short proximity of their homes, communities that are walkable with green space and smart surfaces so that the water runoff is appropriate. One of the things we know about lower-income communities, that there are about nine to 10 degrees hotter than other communities, because they don't have a lot of green space and they have a lot of dark surfaces.

And so now beginning to build those communities. So they have lighter surfaces and more green space is very, very, very important.