BY: FR. MICHAEL ROZIER, SJ, PhD
Illustration by Larry Moore
The ideas behind social determinants of health are quickly growing from a whisper to a chorus. You know an idea is finally popular when the term itself becomes a point of debate. For example, some suggest that "social influencers of health" or "social risk factors" are better terms to use than social determinants of health because they avoid the fatalistic notion of "determinants" or lessen academic jargon.1 Regardless of the term, we are starting to appreciate that health is influenced by a host of factors outside of medical care and genetics, including education, housing, transportation, environment, neighborhood characteristics and much more. This realization has become particularly acute in health care delivery, where new payment models require an organization to attend not just to a patient's medical complexity but also to his or her social complexity.2, 3
The Catholic Church is uniquely positioned to contribute to effective interventions related to the social determinants. The church has ministries in health care, of course. But we also have a significant presence in education and social services. Even more, we have parishes in nearly every neighborhood or town, which engage people at the early and late stages of life, two particularly vulnerable moments, and which often become safe harbors for people on the margins of society. This network of community-level connections would be the envy of any organization looking to leverage the overlapping effect of the many determinants of health. And yet, the church's history and structure make it challenging to capitalize on these unique opportunities.
The beauty of so many religious congregations contributing to the ministries of the church also brings a real drawback when looking to coordinate efforts. For Jesuits, we struggle to gather leaders of our parish, high school, university and retreat house in the same city for a simple conversation, much less to act on shared objectives. It becomes even less likely when four or five different religious congregations or diocesan entities sponsor ministries in different sectors. Even more, each diocese has set up administrative structures that organize our work in a logical manner — education, health care, parish life — but in a way that often makes collaboration across sectors, including on social determinants, less natural.
While I am thrilled that Catholic health care is considering ways to improve the social determinants of health, I believe the Catholic community of ministry has an even bigger role to play than we've yet imagined. No other nongovernmental organization has as many pieces of the puzzle as the Catholic Church, which provides a unique opportunity to help resolve some of the most vexing social problems we face.
A COLLECTIVE VISION
Despite our best efforts to understand one another, it should surprise no one that we each see the world through our own social position. This should be obvious even with the phrase social determinants of health. It makes sense that we in health care would think about these factors insofar as they influence our outcome of interest. But many of these same factors are also the social determinants of education — meaning that our health status, level of neighborhood violence, employment status of parents, housing and other factors affect our education level. And many of these same factors influence whether we can fully engage in parish life. Therefore, while I appreciate the need to communicate value to specific sectors, the real task for people of faith is to understand these as bigger than social determinants of health or of education or of parish life. I suspect if we looked at these things through the eyes of Jesus, we would see that we are really talking about social determinants of human dignity. We are helping stack building blocks of the common good.
This collective vision is the fundamental difference that I hope we in the faith community bring to the conversation about social determinants. We are uniquely positioned to bring our various types of ministry together to improve these determinants, but that is a practical challenge that can be achieved through better management strategies. Those strategies are necessary and by no means easy, but cross-sector collaboration would still fail to achieve the full potential of what the church has to offer.
Most of the significant problems we face today can be thought of as "wicked problems."4 That is, they defy straightforward solutions and instead require systems thinking, where several actions must be brought to bear on the problem at the same time, but even those actions risk creating unintended new problems.5 For example, the growing challenge of mental health care in the U.S. is a wicked problem. Its causes are multiple, including growing isolation, not enough mental health providers, low reimbursement for care, continued stigma and the history of deinstitutionalization. Solutions are many and include building communities that lead to greater social interaction, training law enforcement on mental health first aid, improving reimbursement and increasing access to care. One begins to see that this wicked problem requires participation from many actors, including health care, urban planners, educators and technology innovators. We in health care likely measure success based on reducing the morbidity and mortality associated with mental health issues. I also work in higher education, and my colleagues there measure success based on outcomes such as retention, graduation and job placement. But ultimately, we all focus our efforts on the many determinants of mental health because doing so secures the dignity of those affected. In addition, we realize a common good when we build environments where mental health concerns exert less power over our communities.
The wicked problems are easy to name: the intractable nature of poverty; persistent disparities across race, immigration status, and geographic location; climate change. But if there are wicked problems, there must surely be grace-filled solutions. The recent turn toward social determinants, and the move away from our siloed ways of thinking and acting, are signs of grace in our work.
A COLLECTIVE IMPACTThe Temptation of Power
Many readers are probably familiar with the collective impact model.6 First articulated less than a decade ago, collective impact is premised on the idea that individual organizations can have isolated impact on social problems, but large-scale social change requires multiple organizations to work together in a structured way. The five conditions of collective impact are: a common agenda; shared data and measurement; mutually reinforcing activities; open communication; and backbone support to convene and coordinate activities.7 The networks of Catholic organizations that work on the social determinants are perfectly positioned to employ a collective impact model, but there are, of course, some barriers.
"Then they came to Capernaum; and when he was in the house he asked them, ‘What were you arguing about on the way?' But they were silent, for on the way they had argued with one another about who was the greatest. He sat down, called the twelve, and said to them, ‘Whoever wants to be first must be last of all and servant of all.'" (Mark 9:33-35)
One of the biggest barriers to collective impact is the need to give up power. Unfortunately, Catholic organizations are no more immune from the allure of power than any of their peers. Yet a central task for collective impact to take hold among Catholic organizations is establishing a truly neutral backbone organization. One concern is that many dioceses interested in collective impact may centralize the backbone organization in the chancery, which would undermine the true potential of this model. Instead, it must be truly disconnected from existing power structures. The Catholic ministries would remain accountable to the diocese, but the convening organization, which has no formal authority other than that which is freely given to it, should be independent.
Freedom from the temptation of power and freedom for the sake of greater service are graces that Catholic organizations should be well positioned to seek. Imagine if Catholic health care ministries, Catholic schools, Catholic social services and Catholic parishes could sit down to build a common agenda focused on the most pressing needs of their community. Importantly, this is not just a matter of getting the logistics right; it also requires a new way of seeing the world. It is world where our organization, whatever it may be, is not at the center.The Risk of New Wine in Old Wineskins
"No one tears a piece from a new garment and sews it on an old garment; otherwise the new will be torn, and the piece from the new will not match the old. And no one puts new wine into old wineskins; otherwise the new wine will burst the skins and will be spilled, and the skins will be destroyed. But new wine must be put into fresh wineskins." (Luke 5:36-38).
It is important to appreciate the separate goodness but fundamental difference between the way we have always done things and the possibilities for collaboration on social determinants. Catholic health ministries should continue to do the very good work they've always done. No matter the community-level services we provide, we will always need excellent acute care for individuals who are sick. Yet, the new focus on social determinants and collaborating with other ministries cannot simply be bolted onto existing infrastructure. The two will tear apart and neither will be properly served. The rise in awareness within health care about the social determinants of health has been a great first step. But we have largely been trying to work within existing models. That is the natural starting point, but now we must seriously consider what the new wineskins might be.
I am suggesting that community-level concerns should take us not only outside of the hospital walls, but also outside of Catholic health care. Because of health care's significant resources, collaborative models won't happen without us. But because of health care's resources, we risk making it too much about us. For example, if we enter the conversation talking about determinants of dignity instead of determinants of health, we have a much better chance of creating buy-in for the broad social change that must take place. In addition, we have a much better chance of deepening our own understanding of the important work we already do.
I have proposed a way in which Catholic ministries can better collaborate with one another to improve the social conditions of our communities. This is not a new idea. The diocese of Cleveland, for example, has had a collaborative strategy for decades.8 There are many other examples of collaboration on specific projects, but this strategy still tends to be the exception rather than the rule. Moreover, in no way do I believe this should exclude organizations that are other-than-Catholic. Ideally, this way of proceeding includes any organization of good will. I only describe an intra-Catholic dynamic to suggest that we might as well start with the people we know best.
Catholic health care has much to contribute to the efforts surrounding social determinants of health. But I believe the Catholic contribution is even more unique than typically suggested. First, we must find a way to break through the barriers that exist between Catholic ministries. This is no small task, but it is primarily a management challenge. Second, we must see this work not only from our own social location, but see it through the eyes of Christ. Our gaze, then, will fall not just on our sector's outcomes of interest, as important as those are, but on the person and community at the center of our work. In this way, we strengthen the determinants of dignity and construct building blocks of the common good. The Catholic Church is better positioned than any organization to make practical connections that address social conditions in comprehensive ways, but it is also positioned to ensure the human person is always at the center of what we do.
FR. MICHAEL ROZIER is a Jesuit priest and an assistant professor of health management and policy at Saint Louis University College for Public Health and Social Justice.NOTES
- Gregory Simon, "What's Wrong with the Term ‘Social Determinants of Health'?," Medium, July 27, 2017, https://medium.com/@KPWaResearch/whats-wrong-with-the-term-social-determinants-of-health-8e69684ec442.
- Dawn E. Alley et al., "Accountable Health Communities — Addressing Social Needs Through Medicare and Medicaid," New England Journal of Medicine 374, no. 1, (January 2016): 8-11.
- Harold D. Miller, "From Volume to Value: Better Ways to Pay for Health Care," Health Affairs 28, no. 5, (September-October 2009): 1418-28.
- C. West Churchman, "Wicked Problems," Management Science 14, no. 4 (December 1967): B141-42.
- Derek Cabrera and Laura Cabrera, Systems Thinking Made Simple: New Hope for Solving Wicked Problems, (Odyssean Press, 2015).
- John Kania and Mark Kramer, "Collective Impact," Stanford Social Innovation Review (Winter 2011), https://ssir.org/articles/entry/collective_impact#.
- Coletta C. Barrett, "From Collaboration to Collective Impact: Baton Rouge's Story," Health Progress 99, no.5 (September-October 2018): 34-37.
- Catholic Community Connection: http://catholiccommunityconnection.org/.