For quite some time now, we have understood the very deleterious effects that the negative health determinants can have upon personal health status. However, only just recently have we begun to appreciate the potential salutogenic effects of the positive health determinants. These positive effects can be characterized as both vaccination and as remedy for chronic diseases, as I will describe below.
Only 10 to 20% of the variability in personal health status can be attributed to actions by the care delivery system. Fully 80 to 90% is due to the actions of the health determinants. The negative health determinants include social factors, such as poverty, discrimination, poor education and dangerous neighborhoods, as well as physical factors, such as dirty air and rat infested housing, among others. By strong contrast, positive health determinants include factors such as nurturing families for children, social inclusion for adults, job and pay equity, and bright, clean living spaces, among others. Frequently, we summarize all of these effects in a very short-hand way: Your zip code is very predictive of your health status and your length of life.
In the most recent decade, we have come to understand that trauma is a key mechanism that links the negative health determinants to the onset of behavioral health conditions, such as depression and substance use. In fact, we now believe that up to three quarters of all behavioral health conditions are due to trauma. As a consequence, major steps have been taken by SAMHSA and others to institute trauma-informed care, with motivational interviewing and essential peer support services.
On the other hand, we don’t have as complete an understanding of the linkages between the positive health determinants and good health status. Yet, because these positive determinants involve processes such as social inclusion and good interpersonal relationships, I want to argue here that social support is a key ingredient in promoting good health status. Some other work provides supportive evidence. In that work, we have learned that a strong sense of personal and social wellbeing increases happiness, which, in turn, greatly reduces the likelihood of heart attack and premature death. Thus, the inference can be made reasonably that the positive health determinants can vaccinate against the chronic diseases.
What about the positive health determinants as remedy for poor health status? If we examine personal recovery from a serious behavioral health condition, social inclusion and social support are almost always central to the recovery process. Clearly, it is very, very difficult to achieve recovery if one is socially excluded, socially isolated, and very lonely. That is why peer support services work so well and are essential ingredients to the recovery journey.
Looking a little more broadly, the same can be said about the salutogenic role of social services—good housing and supports, good jobs and supports, and good social supports themselves. Clearly, they also are part of the remedy for poor health status.
For both countries and states, recent research shows that large spending on health services, coupled with small spending on social services, will produce less effectiveness of health services than smaller spending on health services and larger spending on social services. Taken together, these findings support the inference of a remedial role for the positive health determinants in improving poor health status.
We have an urgent need to move the national agenda for the vaccination and remedy roles of the positive health determinants. Clearly, vaccination always will be better than remedy, but we need to engage both as key priorities moving forward. Literally, the health status and lives of millions of American will depend upon what actions we do take.