As healthcare providers, we can do a lot to help patients feel better. We can diagnose and treat many illnesses. We can prescribe medication, perform surgery, offer counseling, and educate patients so they can make informed decisions. But our ability to help patients attain optimum wellness is limited by the social determinants of health.

It is well-established that even the best clinical care cannot overcome structural causes of poor health. Years ago, Harvard University bioethicist Norman Daniels noted that “by the time a 60-year-old heart attack victim arrives at the emergency room, bodily insults have accumulated over a lifetime. For such a person, medical care is, figuratively speaking, the ambulance at the bottom of the cliff.”

Poverty, ethnicity, inadequate education, poor housing, and lack of access to healthy food or safe places to exercise all affect people’s health. In an article in the New England Journal of Medicine, Harvard University social scientist David Williams and former CEO of the Robert Wood Johnson Foundation Dr. Risa Lavizzo-Moureny point out that these structural health disparities “cannot be reduced by targeting individual clinical conditions.”

So, the question becomes: how can we improve the health of all people in our community, including those who are negatively affected by the social determinants of health?

It is not an easy question to answer. One way to improve community health is to ensure people’s access to quality care. To that end, a network of federally qualified health clinics (FQHCs) and community health centers (CHCs) provides care in communities where structural barriers to health are high.

MCHC Health Centers is one of several FQHCs in Lake and Mendocino Counties. We see a third of all patients in Mendocino County and one in every ten patients in Lake County. Statewide, community health centers like ours see one in every five patients.
Locally and nationally, these health centers provide a disproportionate amount of the care to uninsured individuals and to ethnic minorities. They also serve areas with higher-than-average rates of chronic diseases like obesity, diabetes, and fatty liver disease, so access to quality healthcare, and the successful interventions that come with it, can lead to significant benefits.

CHCs are doing great work, and we are well-situated to do even more—to extend our reach by collaborating with other community service providers, including local governments and schools, to address issues related to the social determinants of health.

Working with root causes of poor health is complex and necessarily involves close partnerships across various sectors. As Harvard-trained physician and medical anthropologist Paul Farmer said, “Practitioners of medicine and public health must make common cause with others who are trained to intervene more proximally.” These partnerships are vital because “clinicians are not trained to understand. . . social forces, nor are we trained to alter them.”

All healthcare organizations must consider widened mission statements that reaffirm the need for excellence in healthcare delivery while also acknowledging the importance of addressing structural drivers of health. To improve community health, communities require new metrics. Along with focusing on controlling and preventing disease, we need to expand our scope.

Making Mendocino County the most livable and healthy place possible requires looking outside the healthcare system and addressing root causes of poor health. Healthcare decision makers should collaborate with agency partners to target things like:
Increasing kids’ access to transitional kindergarten

• Literacy, including programs increasing young people’s use of the library (especially during summertime!)
• Building more parks/green spaces supporting outdoor activity and exercise
• Increasing community member mentorship to at-risk youth
• Sponsoring socio-economically disadvantaged youth to participate in youth sports and clubs, including providing transportation if needed
• Decreasing consumption of sugary drinks
• Enhancing school-based nutrition programs with healthy ingredients
• Building affordable and safe housing

Until we see and acknowledge the structural vulnerabilities that put some in harm’s way while protecting others, our society will not be able to resolve the deep defects that perpetuate inter-generational poverty, disease, and untimely death. A broadened understanding about structural inequities can help our communities plan interventions to address these influences.

At MCHC Health Centers, we want to deepen our work with community partners. We recognize that bringing down structural barriers to good health is daunting—all the more reason to start now.

Paul Hupp is a primary care provider at MCHC Health Centers—a local, non-profit, federally qualified health center offering medical, dental, and behavioral health care to people in Lake and Mendocino Counties.