Public health will see you now

The World Health Organization now considers the social determinants of health to account for the majority of health care. This is long overdue, but as pioneers of the population health movement, my colleagues and I consider this an understatement.

We estimated that 80 percent of individual health is due to non-medical factors, including crime, poverty, education and opiate abuse. The silver lining of Covid is that people are finally paying attention to the large-scale social, economic and environmental issues that affect the health outcomes of different groups of people – population health – but this is only the beginning.

“Engine of Inequality”

In April 2020, Professors Ann Case and Angus Deaton wrote in The New York Times that the current health care system is an “engine of inequality.” Unfortunately, they did exactly that. The pandemic has revealed the primacy of social determinants of who lives and who does not. Now we in the healthcare business have to ask some very hard questions that have been avoided for far too long. For example, how do we care for populations that may put us at economic risk? How do we stratify care in the population? How do we coordinate care across communities?

In the past, these were considered matters of public health. Now they fall under the “roof” of population health. The central pillar supporting this roof consists of epidemiology, behavioral sciences, and the environment—all key tenets of the traditional approach to public health. However, there are other pillars, including the quality and safety of the care we provide, their costs and public policy considerations.

At the height of the pandemic, lines for food outnumbered lines for medical care here in Philadelphia. The inherent inequality in our system ensures that the death rate for people of color will be much higher than for the rest of us. Covid was a witches brew of disaster and increased mortality among minority populations.


While it’s too late to declare victory over Covid—and, unfortunately, we already have another public health crisis—let’s not wait to realize the scope and depth of the problems we face. What’s more, let’s tackle them with the right tools. If our main business is improving health, then let’s strengthen all these pillars to improve the roof over our heads. Of course, this raises another question: how will we be paid to implement these changes?

Health care is a $4 trillion business, and at least $1 trillion of that amount adds no value—except corporate profits. So one idea could be to redirect those funds to actual health care.

Burnt out

Apart from a small minority, most doctors feel like outsiders, victims of the healthcare system. Almost 42% of physicians report symptoms of burnout, especially physicians in critical care, emergency medicine, family medicine, internal medicine, neurology, and urology. I have a daughter who was on the front line with Covid as an attending physician. I understand; expecting doctors to heal themselves is simplistic during and after a pandemic.

In contrast, research says we can reduce burnout if we give providers the opportunity to improve social determinants. Why not allow doctors to write food prescriptions, connect patients to community help organizations, and mandate behavioral counseling? If we can give providers the tools to help the underserved, burnout decreases. We know that doctors are not social workers, but they can (and should) lead the charge to implement the population health paradigm. All they need is a voice and the right tools.


For example, suppliers are extremely important minimally have a unique and unified patient record. Especially as we adapt to telehealth and virtual care, organizations must have a framework that can enable rapid data exchange between members of care teams. Indeed, population health intelligence is another vital pillar as well as an important subset of population health that includes predictive analytics, augmented intelligence and artificial intelligence. We can and should create a Covid patient registry that protects privacy. From the tsunami of resulting data, we will glean useful information about at-risk populations. I also hope that we will see digital healthcare continue to drive down marginal costs. This will allow us to reach much larger populations at a lower cost than ever before.

Strategic changes

Imagine if we could go upstream to turn off that faucet of disease instead of constantly mopping the floor. What if Philadelphia’s population was healthier before Covid? If we had paid more attention to the social determinants, we would have been much more proactive. The chance of reducing the staggering death rate among minority populations would be much greater if we had addressed obesity, smoking, heart disease, exercise, nutrition, and other “soft” issues. Why didn’t we do that? No one was leading the way, probably because there was no profit incentive.

We know that healthcare is big business, but even more than that, it is the last common path to all social determinants. It is constantly rethinking what it means to take good care of the population. I firmly believe that we can still create an exemplary model of population health care—a system that encourages the inclusion of all factors related to a patient’s health to provide the most complete care possible.

Photo: marchmeena29, Getty Images

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