Social epidemiologists have made great progress over the last 50 years in demonstrating that health happens outside the doctor’s office. In fact, it’s clear now that many conventional disease-specific risk factors (serum cholesterol, elevated blood pressure, cigarette smoking, etc.) explain only about half of the diseases they are intended to explain and that social and environmental factors play an important role in explaining the other half.
The key, then, is to prevent disease in the first place and not simply treat it once it appears. But how do you prevent disease caused or triggered by social and environmental factors? By meeting it head on in the community. The United States spends nearly $2 trillion annually treating chronic conditions like heart disease, Type II diabetes, and obesity even though we know that preventing these diseases extends life, increases productivity, and saves money. Why do we continue to choose the less effective, higher cost approach to disease when a more effective, lower cost alternative exists? Part of the problem is structural. Treatment-based payment systems encourage more, and not less, health care. Reforming these systems to reward providers for keeping people healthy—as is now beginning to happen with Accountable Care Organizations—creates incentives to prevent illness before it occurs.
Rick Brush at Collective Health has seized on this idea to reduce asthma emergencies among children. As with many diseases, the solution to reducing asthma emergencies falls outside the medical system and occurs inside the home. Frustratingly, though, while asthma emergency prevention is cheaper than treating asthma emergencies, there is no payment system in place to pay for it. Brush’s invention, the Asthma Bond, solves that problem by capturing hospital cost savings and using them to pay for programs that reliably reduce asthma emergencies.
Another impediment to preventing disease is poor cross-sector communication. Social epidemiologists know that constant exposure to stressful challenges, for example, increases cortisol levels in the body which can lead to premature death. What they don’t know, however, is what to do about it. There is no universal prescription for overcoming the challenges associated with stressful situations. Instead, making the world less challenging will require networks of community partners—social workers, employers, health workers, educators, faith-based leaders, and others—working together to identify and salve open stress wounds, like neighborhood violence, that affect community health.
In my 2009 article for the Community Development Investment Review, I argued that community developers are the most important health workers of our time. We urgently need to recognize this contribution, build payment systems to compensate their work, and leverage their knowledge to prevent disease before it occurs.
Dr. S. Leonard Syme, a leading figure in social epidemiology, has received a Fogarty International Fellowship and the James D. Bruce Memorial Award for Distinguished Contributions in Preventive Medicine from the American College of Physicians. In 1989, he was elected to the Institute of Medicine of the National Academy of Science. His major research interest has been psychosocial risk factors such as job stress, social support and poverty. In doing this research, he has studied San Francisco bus drivers; Japanese living in Japan, Hawaii and California; British civil servants; and people living in Alameda County, California. Dr. Syme was recently a Visiting Scholar at the Federal Reserve Bank of San Francisco.