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March 17, 2008

On Disparities, Social Determinants, and Early Childhood Development

We've covered these issues before, but as part of their theme issue on disparities and SDOH, Health Affairs Blog has been running a series of columns on the subject.

Thomas Miller has a particularly insightful column today, touching on many points and issues we've noted and advocated for here on this blog.  Here's an excerpt:

When the primary measures for health disparities concern relative access to given quantities, and qualities, of health care services, they overlook the more complex total mix of possible inputs that combine to produce health outcomes. To some extent, increased emphasis on various “upstream” determinants of longer-term mortality and morbidity — such as socioeconomic status, education, neighborhood/geography, social interaction, culture, and family — can help move our disparities remedies beyond the confines of the medical services tool kit.

Indeed, this is in part why it is inadvisable to reduce matters of public health policy and what I call the ontology of public health -- what is it that makes populations healthy or ill? -- to data-driven health services research and health economics.  This is not to disparage the latter; they are both imperative for a variety of reasons, and any health policy discussion that omits such data is ill-informed, to say the least.  What I am disparaging is the tendency to reduce health policy to such modalities, in no small part because they typically do not address the normative questions implied by the larger ontological questions.

More from Miller's column:

Yet even on this front, the temptation is to see the problem too narrowly, as one of improving the “health” rather than improving the overall “life” of any given group or larger population. After all, the benefits of growing up, and living, in environments of economic opportunity, stable family structure, safe streets, effective schools, supportive friends, and, yes, even abundant fresh fruit and vegetables extend well beyond adding another year or so of average life expectancy or delayed chronic condition onset. Recommending the obvious is preferable to ignoring it, but this raises the question of what should be done in more prioritized ways for the most disadvantaged groups and individuals with the least tractable conditions and problems.

Indeed.  As important as prevention is, for example, true attention to the ways in which social and economic conditions largely determine health requires we go far beyond the kinds of screening that is generally deemed to be paradigmatic for prevention.  Here, the proper concern is prevention writ large, prevention going all the way back to early childhood, and quite possible even further, to prenatal care.

Miller offers several different recommendations, all of which are well-worth considering.  As they say, go read the whole thing.


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