Thriving Together: Health Equity and the Social Determinants of Health

For the past 30 years, Peter Eckart has researched, worked toward, and implemented measures aimed at promoting healthcare equity. On February 24, 2022, Eckart led an HSI lunchtime seminar describing some of the highlights of his career and encouraging a spirited conversation about some of the issues he raised.

Before diving into a discussion about work and progress toward health equity, Eckart offered his definition of the phrase. Health equity, Eckart said, “means that everyone has a fair and just opportunity to be as healthy as possible. This requires removing obstacles to health such as poverty, discrimination, and their consequences, including powerlessness and lack of access to good jobs with fair pay, quality education and housing, safe environments, and healthcare. Health equity means reducing and ultimately eliminating disparities in health and its determinants that adversely affect excluded or marginalized groups.”

To talk about health equity is to talk about the social determinants of health (SDOH). These can be categorized as: healthcare, health behaviors, physical environment, and socioeconomic factors. The first, healthcare refers to access to and quality of health services. This category drives only 20% of a person’s wellbeing. Health behaviors, physical environment, and socioeconomic factors drive 80% of health outcomes. All four of these categories must be considered, not just access to and quality of healthcare.

A concrete example of working together to improve SDOH is Thriving Together. Peter Eckart contributed to this effort whose mission is to foster vital conditions for well-being and justice for everybody on local, state and regional levels. Thriving Together offers support, a place to exchange ideas and frameworks to think about how to move people and communities from struggling or striving to thriving.

Thriving Together promotes the use of Cantril’s Ladder, which Eckart calls the gold standard, a tested and validated measure of health equity. Cantril’s Ladder is an evaluation and measurement tool that consists of only two questions.  People are asked to visualize a ladder with the top, or tenth rung, marking the best they can possibly be doing and the lowest rung, the first, as the worse.

The two questions are:

1. Where do you feel you currently stand?
2. Where do you think you’ll be in five years?

This simple measure is tracked by Gallup, the OECD and the World Happiness Report. Gallup posed this question on its world poll of more than 150 countries covering more than 98% of the world’s population. The OECD uses Gallup data as an input to their research. The World Happiness Report is about to release its tenth annual publication. This year the report will focus on the pandemic’s effects on happiness and how different countries’ responses led to differing rates of healthy and connected societies. While there are many multi-question instruments that investigators can use to assess health equity, this simple one has proven to be accurate and long-lasting.

Community-based versus community-led decision making is one aspect of health equity. The aim is to move away from telling people what they need and toward relying on their lived experience. Community members ought to have a part in developing and implementing the systems that will affect their own communities. Having members with lived experience is also a crucial element for boards and organizations whose mission is to help communities. The move is to replace paternalistic beneficence with a realistic understanding that the people who experience an issue have valuable contributions to make.

Eckart also talked about the nationwide effort to establish 988 as a national suicide prevention helpline. This implementation is being led by The Substance Abuse and Mental Health Services Administration (SAMHSA), in partnership with the Federal Communications Commission and the Department of Veterans Affairs. Callers in emotional distress may be connected to appropriate mental health resources. Instead of police responding to emergency calls about people having mental health crises, properly trained professionals can be directed to offer the suitable aid.

Eckart wrapped up his talk by admitting that the challenges of achieving health equity are daunting. He notes that we as a society need to have uncomfortable discussions about race and grapple with white supremacy if we are to see true progress toward health equity. Eckart was asked what he does when he feels overwhelmed. He just tries to do the next right thing, he replied: “Ask people what they need. Do the next right thing in front of you”.