Social Determinants of Health: Eat Your Beans? Or Speak Truth to Power?


Before I got the degrees I have (Accountancy, Industrial Engineering, Artificial Intelligence, and Medicine) I wanted to become an Anthropologist! I still read a lot of anthropology. I consider myself a (rank) amateur anthropologist. And I’ve a bit of anthropology in my workflow work, especially ethnography, the systematic study of people and cultures. In that light, take a look at these three quotes about medical anthropology and the social determinants of health.

medical anthropologists have contributed significantly to understanding social determinants of health… through exposing the processes by and through which people are constrained, victimized, or resist external forces in the context of local social service arenas”

“Evaluation of social determinants of health interventions require rich qualitative data in order to understand the ways in which context affects the intervention and the reasons for success or failure.”

Trying to convince poor people to eat vegetables is one thing, acceptable and safe; attacking the inequity in power, money and resources is altogether less safe

That last quote is from Sir Michael Marmot, Chair of the Commission on Social Determinants of Health at the World Health Organization, author of the most authoritative textbook on the Social Determinants of Health, cited over 5300 times in Google Scholar.

The reason I’ve been so interested in medical anthropology, ever since I met of bunch of Med Anthro grad students in medical school, is that “rich qualitative data.” It is the kind of data that systems engineers, such as myself, can use to design products, services, and workflows. This is Applied Anthropology, the “application of the method and theory of anthropology to the analysis and solution of practical problems.” In other words, I’ve aimed to use the methods of anthropology to build systems. This is simply health systems engineering using anthropology as a tool.

I often define workflow to be a series of tasks, consuming resources, and achieving goals. Workflows are represented as models in the computer, and then various kinds of workflow engines operate on them. These are workflow systems. Workflow systems, organizational psychology and culture, interact with each other in complicated ways.

Replace “tasks” with “activities” and you’ll arrive somewhere familiar to anthropological fieldwork. Anthropologists document sequences of activities (particularly rituals). They document resources consumed (animal and non-animal substances, human time and attention). And they speculate about goals served (honoring ancestors, community bonding, satisfying material needs such as sustenance, safety, protection from the elements). Just as workflow professionals do, anthropologists also construct models, of rituals, families, tribes, organizations, etc. Of course, these models not usually recorded in executable formats. Instead they are written about and published in anthropology theses and journals.

Culture greatly influences the social determinants of health. Anthropology is a major contributor to social determinants of health research. Culture and workflow interact synergistically. Field anthropologists understand culture in terms resembling systems engineers understanding workflow. So naturally I am interested in connections between social determinants of health and healthcare workflow.

If you cross index Social Determinants of Health with workflow on Google search, you’ll find lots about including SDoH data gathering in clinical workflow. I’ve included, at the end of this post, some recent tweets with links to material about exactly this. It’s an important topic, but I’m going to pivot in a different direction.

There is another relationship between anthropology and the social determinants of healthcare. Anthropologist study power and the powerless. If you don’t at least acknowledge the role of power, poverty, and powerlessness in poor population health (ppppp!) I submit you are missing much of what is important about the social determinants of health.

I’m not a political person. I don’t tweet about politics much (or sex or religion, for that matter, two other potentially controversial topics). But I also think of myself as amateur political philosopher (I guess I’m an amateur at a lot of things!). If you drill down into the social determinants of health, you land on both political ideology and workflow! Bugger! I love workflow. Political ideology not so much. So this post is a bit of a balancing act.

Medical anthropologists resemble medical professionals, because, well, they are. They take medical courses. They observe strict ethics regarding divulging the identity of their subjects. Many are motivated to diagnosis and improve the health of the communities they study.

One of the most interesting aspects about anthropology, particularly medical anthropology, is a tension between techniques (for gathering data, building theories, leveraging insights) and anthropological social activism. Since anthropologists study power structures and inequity, they are a bit like a journalists torn between documenting and intervening during a news event. They see something unfair, and they are torn between objectively documenting versus getting personally involved. This dynamic can potentially bias the research. I’ve followed debates within anthropology about this tension within anthropological research for decades.

Again, I’m basically just a technocrat in search of tools to better perform my technocratic activities. However I do think it is worth reflecting about not just the technical side of the social determinants of health (collecting, using, etc.), but also the political, economic, and ethical context of social determinants of health as well…

…something to think about, while we debate the finer points of integrating social determinants of health into healthcare, and health IT, workflows.

I’ll end with a couple more quotes.

“a substantial body of scholarly work in anthropology seeks to link wider social, economic, and political forces to local experiences in sickness and suffering

From that 2008 WHO report on SDoH..

“the ‘unequal distribution of power, income, goods and services … the subsequent unfairness in the … circumstances of people’s lives … and their chances of leading a flourishing life’ (p.1) are the primary causes of the poor health of the poor.”

P.S. Here are those tweets about social determinants of health and clinical workflow I promised you!

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