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Steve Rothschild on the Robert Wood Johnson Foundation Report, "A New Way to Talk about the Social Determinants of Health"

Health & Medicine Policy Research Group (HMPRG)
November 17, 2010
Steve Rothschild, MD is a Health & Medicine Board member and co-author of a chapter in Urban Health:  Combating Disparities with Local Data; Steven Whitman, Ami Shah and Maureen Benjamins, eds.; recently relased by Oxford University Press.


Whenever discussing health disparities, it is important to avoid using the following words and phrases:  “injustice”, “immoral”, “unconscionable”, “outrage”, or any variation of “equal”, “equality”, or “equalizing”.                                                                                                                                                      
So says a recently issued Robert Wood Johnson Foundation report, A New Way to Talk about the Social Determinants of Health.  Foundation staff felt that the phrase “social determinants” had little resonance with their grant recipients and with lay people, and set out to find a simple, tidy proxy that would be more meaningful to the general public.   They commissioned researchers, focus groups, and communications specialists to find messages about the root causes of health disparities that would be clearer and more acceptable across the political spectrum.    The resulting report makes for reading that is both interesting and highly disturbing.                                                                            

The authors are, of course, right about “social determinants of health” – it IS a sterile, academic phrase that fails to capture the issue.   Explaining health disparities can be difficult; many of us, after giving a well-documented presentation describing excess deaths from cancer, diabetes, or heart disease among blacks and Latinos have found ourselves repeatedly being asked if the problems aren’t really the result of bad genes or high risk individual behaviors.  So we try, yet again, to explain the concepts of food deserts, and the impact of high chronic stress and discrimination, and environmental racism and pollution, and the rapidly disappearing health care safety net.   We try to infuse a sense of urgency into our presentations through vivid illustrations; for example, in the city of Chicago alone, three black women die from breast cancer every day, who would not die if their mortality rate were the same as white women.   For some audiences, our words are persuasive, but many more seem to tune them out.                                                                               

In this context, the Foundation’s report is a welcome addition to our armamentarium.   Words matter, and the report explains the benefits of tested phrases such as “All Americans should have the opportunity to make the choices that allow them to live a long, healthy life, regardless of their income, education, or ethnic background” or “Your neighborhood or job shouldn’t be hazardous to your health.”    I will certainly plan to incorporate many of the report’s suggestions into my own presentations.                                                                                                                                                                                     

At the same time, the recommendations that we stay away from speaking of outrage and injustice seem facile.   Shouldn’t everyone be outraged by the current situation?   Aren’t these injustices?    When did inequality become an acceptable American core value?    Hearing about the recommended phrases, my wife said the language sounded more appropriate for Sesame Street than a serious policy discussion; a colleague at Health and Medicine rejected them as Orwellian.  At the very least, they seem to soft sell the needless death and disability of thousands of Americans every year.  Reading the report, I found myself building up self-righteous indignation over the idea that I should avoid speaking of “leveling the playing field” lest I prompt a negative reaction from people who prefer Sarah Palin, and Glenn Beck, and the other propagandists at Fox News.  Why should I even care what conservatives think?  Do they worry what I think about their daily attacks on gays, immigrants, Moslems, and the poor?

OK, so that rant makes me feel better for a moment… but if we are to achieve an equitable health care system, millions of our fellow citizens must come to recognize health inequities as inconsistent with their personal understanding of what it means to be American.   This will require speaking in language that they can hear and relate to.   If it is easier for them to accept that “Health begins where we live, learn, work, and play” (another one of the report’s tested and approved phrases), then perhaps we should put aside our indignation for a few moments and use these more measured approaches.

And yet… I can’t help but think of the powerful language used by a highly persuasive speaker who once said “Of all the forms of inequality, injustice in health care is the most shocking and inhumane.”   Wow – both “shocking” AND “inhumane”.   I wonder what the consultants who wrote the Foundation’s report would think about Dr. King’s choice of words?