Addressing social determinants of health from the emergency department through social emergency medicine

Abstract

Dialogue and policy surrounding healthcare reform have drawn increasing interest to the social factors, accountable for nearly one-third of annual deaths in the United States,1 that affect the health of populations. The Affordable Care Act (ACA) includes provisions for health systems to address social determinants of health, but how this is to be accomplished remains uncertain. If we are to make progress as a health system in addressing social determinants of health, we must open a dialogue and practice that reaches patients at the front lines of the medical system and population health – including in the emergency department (ED). The fact that emergency physicians care for patients who are complicated both medically and socially is no surprise, but the idea that we have an important role to play in the social determinants of health of our patients is, while controversial, gaining increasing attention among emergency physicians across the country. This interest comes largely from necessity, as we face a daunting task of providing care to the large volume of vulnerable patients who seek refuge in our EDs. The ED is a window into the community, which starkly frames the contributions of the social determinants underlying the trauma resuscitations, repeat child visits for asthma exacerbation, or sepsis due to delay in seeking care. In the ED, we diagnose and treat the medical problem – but in order to improve the health of our patients we need to expand our role to diagnose and treat their social determinants of health as well. We urge our colleagues to not only consider the social determinants underlying health and illness, but to also develop systematic interventions, measure their effects, collaborate with others, and advocate for policies that will improve the health of our patients. We advocate physicians to address the social determinants of health from the ED, in other words, to practice Social Emergency Medicine. The World Health Organization defines the social determinants of health as “conditions in which people are born, grow, live, work, and age. These circumstances are shaped by the distribution of money, power and resources at global, national and local levels.”2 It seems obvious that poverty, racial and ethnic inequities, and lack of preventive care, would lead to poor health. But the social determinants of health extend beyond these more tangible aspects of our lives. Every aspect of how we live, including social class, influences health profoundly. Even among London-based British civil servants leading relatively stable lives with guaranteed employment, salary and health insurance, there is a steep and inverse correlation between job classification level, morbidity and death.3 From a policy standpoint, this gradient is compelling, as it affects all of our patients, not just those living in poverty, but the middle class as well. Given that the structure of our daily lives are the social determinants of health, doing something about them requires moving our focus from the single patient to the population level, from diagnostics and medications to environmental and social structures and the policies that create them. While it would be clear to most emergency physicians that a patient’s frequent visits for hyperglycemia reflect poorly managed diabetes, what is easily labeled willful noncompliance might instead be a lack of access to healthy foods, and ultimately insufficient social and technical support for the entire community. Thus, medical treatment of a disease such as diabetes, without regard to the social determinants of health, suffers the danger of being ineffective. Just as we cannot treat volume overload without understanding the physiology of the kidney, heart, lungs and their interaction, we cannot begin to treat a patient’s medical problems without understanding the social factors, the life he lives. Necessity mandates action. While the ACA tasks primary care with managing these social determinants, access to medical care increasingly occurs through the ED for insured, as well as poor and marginalized populations.4 The ED is the only door open to anyone for comprehensive medical and social services, 24 hours a day, 7 days a week, regardless of acuity or complaint, age, or insurance status. The status of the ED as society’s “safety net” is reinforced by a legal imperative, embodied in the Emergency Medical Treatment and Labor Act of 1986, which requires Medicare-participating hospitals offering emergency services to provide a medical screening examination and stabilization of emergency conditions regardless of ability to pay. What we face practicing in this safety net is an imperative to act. We must embrace this role and adopt our practice to our de facto environment, as a critical part of out healthcare safety net. Applying knowledge about social determinants of health to the bedside and developing effective, systematic interventions that reach out into the community is t