BY: NATHANIEL BLANTON HIBNER, PhD (c)
In 2010, the Centers for Disease Control and Prevention published the initiative Healthy People 2020: An Opportunity to Address the Societal Determinants of Health in the United States. In its opening statement the authoring committee states its goal to be "a day when preventable death, illness, injury, and disability, as well as health disparities, will be eliminated and each person will enjoy the best health possible."1 The five determinant areas that the initiative names as key issues include: economic stability, education, social and community context, health and health care, and neighborhood and built environment. The document necessitates a multipronged approach involving community leaders from across industries. The committee calls upon leaders of "transportation, housing, agriculture, commerce and education" to collaborate with health care for the promotion of these goals.
Since the creation of that document, the topics of social determinants of health and population health have dominated the field of health care.2 We have seen an increase in the awareness that these factors play on the ultimate health outcomes for our patients. The predictive abilities of this data are extraordinary. However, these connections raise the question of the role that health care providers should have in a number of different underlying issues. Can health systems provide free housing, vouchers for healthy food, funding for struggling schools, bus routes to their clinics? Such questions linger in the board rooms, conference halls and offices in health systems across the U.S. Are we as health care providers being asked to do too much?
What is striking about this inquiry is that at the same time health care providers are being asked to do more, others in society are critical of medical professions' response to issues in the past. Medicalization has many different forms and comes from a variety of sources; however, the term is one of negative repute. Peter Conrad names a type of medicalization as "interactional medicalization" — when a physician, or the greater medical profession, "redefines a social problem into a medical one."3 We hear this lately in crises affecting our ministry. The medicalization of pain is seen as a leading factor in the overprescribing of pharmaceuticals and the opioid epidemic now destroying communities.4 The medicalization of death is highlighted in the demand for physician-assisted suicide and the idea that medicine can overcome the dying process.5 The medicalization of life has led a scientist in China to use CRISPR gene-editing technology to alter the very code of human life.6 Of course, I am merely skimming the surface of both the debate about medicalization and the preceding examples. What I want to highlight is a potential downside towards the use of health care for the resolution of issues outside its traditional purview.
When people discuss the need for health care to resolve social issues, a plethora of voices sound out. Some respond with the phrase "stay in your own lane," to limit medicine inside its professional boundaries and to keep medicalization at bay. Those within the field feeling overwhelmed by budget constraints, the scale of the problem or personal limitations may decide "this is someone else's challenge." Still, a few stand up and shout "let us handle this," (though these are few and far between). So how can the health care ministry remain faithful to the great goals of its mission without losing hope? How can health providers be successful partners for solving social determinants of health without sliding into medicalization? This is the challenge.
Surprisingly, I believe we can begin to answer this dilemma by drawing from Pope Francis' apostolic exhortation, Gaudete et Exsultate. In his introduction, Pope Francis writes that his "modest goal is to repropose the call to holiness in a practical way for our own time, with all its risks, challenges and opportunities."7 Reading through the text, one finds that holiness should not become something unattainable for the people: the goal of sainthood can become discouraging. In the context of public health, the belief that the health care ministry alone must resolve all adverse social determinants is overwhelming. For Francis, holiness is achieved through daily acts of faithful living and a continued desire to bring about God's kingdom. In our holy living, we act as catalysts to change in the world. Health care must also recognize its own limitations and be humble in doing so. However, success in the health of a community can be achieved with a similar day-to-day attitude fueled by the grace and hope granted by God.
Additionally, it is important that "each believer discern his or her own path, that they bring out the very best of themselves, the most personal gifts that God has placed in their hearts (cf. 1 Cor 12:7), rather than hopelessly trying to imitate something not meant for them."8 Health care has such a path and is endowed with many personal gifts. What is required of the ministry is to admit that our way forward is not the same as public health, social work, public policy and other specialties. Though we have the same goals in mind, our tools to reach them are not identical and we must adapt to new information. When medicine desires to use the means of the past to solve the problems of today, it would be wise to remember that "the same solutions are not valid in all circumstances and what was useful in one context may not prove so in another."9 The risk of medicalization must be present in the minds of our ministry leaders when they turn toward the social needs of our time. If it is determined that medicine is not the appropriate answer, then it is a sign of self-awareness to seek the aid of another.
The debate about health care's role in social determinants of health will continue. The struggle over adverse social conditions is one that our ministry must remain in as a contributing partner. We are a transformative ministry of the Church. However, more discernment needs to occur to draw clear lines around the appropriateness of the medical field to answer social injustices. Like the everyday faithful of our Church, the call to bring God's kingdom into this world can be achieved by "laboring with integrity and skill in the service of (our) brothers and sisters."10 Our ministry of health care labors every day to the service of all who enter, or live near, our doors.
NATHANIEL BLANTON HIBNER, PhD (c), is director of ethics for the Catholic Health Association, St. Louis.
- Secretary's Advisory Committee on National Health Promotion and Disease Prevention Objectives for 2020, "Healthy People 2020: An Opportunity to Address Societal Determinants of Health in the United States," (July 26, 2010): https://www.healthypeople.gov/2010/hp2020/advisory/SocietalDeterminantsHealth.htm.
- Resources on this topic are available on CHA's website, chausa.org/communitybenefit.
- Peter Conrad, The Medicalization of Society: On the Transformation of Human Conditions into Treatable Disorders, (Baltimore, MD: Johns Hopkins University Press, 2007), quoted in Antonio Maturo, "Medicalization: Current Concept and Future Directions in a Bionic Society," Mens Sana Monographs 10, no. 1 (2012): 122-33.
- Bertha K. Madras, "The Surge of Opioid Use, Addiction, and Overdoses Responsibility and Response of the U.S. Health Care System," The Journal of the American Medical Association: Psychiatry 74, no. 5 (2017): 441-42.
- Hadi Karsoho et al., "Suffering and Medicalization at the End of Life: The Case of Physician-Assisted Dying," Social Science and Medicine 170, (2016): 188-96.
- Gina Kolata et al., "Chinese Scientist Claims to Use Crispr to Make First Genetically Edited Babies," The New York Times, November 26, 2018. https://www.nytimes.com/2018/11/26/health/gene-editing-babies-china.html.
- Francis, Gaudete et Exsultate, March 19, 2018, para. 2.
- Francis, Gaudete et Exsultate, para. 11.
- Francis, Gaudete et Exsultate, para. 2.
- Francis, Gaudete et Exsultate, para. 11.