Social determinants: Why are they so difficult to address?

“He who knows only his own side of the case knows little of that.”
John Stuart Mill, On Liberty. 1869

By Greg Gruener

At a lecture I recently attended with our students, the guest speaker’s topic was on health disparities and the data presented was, as most of us in the healthcare field know, pretty conclusive.  I have to admit that I knew and had seen this same information in prior lectures, articles, and had gone over it in small group discussions.  I also knew that health disparities existed because of various social determinants.  While the subsequent discussion moved along, I was left at the reflective starting line since I finally grasped the fact that being caused by social determinants, health disparities could only be completely addressed by changing those same determinants.  This is not news for most people in healthcare as their organizations and schools, unlike business, law, etc., have been charged (and are accredited) with addressing those determinants.  So, despite being immersed in the data, why had it taken me so long to have this aha moment?  Here is my explanation for a cognitive lapse, as informed by Donald Rumsfeld…

Societies or cultures are complicated things, but in general they bring benefits to those who are in the “us” category versus those who are in the “other”.  Personally, when in the “us” category, I was not aware of receiving any special consideration because of who I was or that others believed I had certain advantages that guaranteed my success.  I now realize this is an inaccurate belief for anyone since we have all benefitted, directly or indirectly, from the actions of others and those benefits tend to be given by members of the “us” group to those who are also perceived as part of that group.

While the direct benefits are easier to recognize and acknowledge, there may be a larger number of unknown unknowns (thanks to Donald Rumsfeld’s insight) that prevent “us” from changing our circumstances to the benefit of the “others”.  At first this resistance may not be apparent, but the realization it exists will only happen if you consider the possibility of unknown unknowns in your own “success story” and how those benefits and opportunities helped you along the way.  That acceptance starts a perceptual change as your own ego-bubble is deflated when the belief that you “did it on your own so, why can’t they?” dissipates and you start to consider that “others” deserve, to only be fair, these same opportunities.   We all have these unrealized beliefs and biases, but if they become known, perhaps we can change the determinants that perpetuate what will later become far reaching health disparities.

Gregory Gruener, MD, MBA, is a professor of neurology and medical education.  He is the vice dean for medical education at the Loyola University Chicago Stritch School of Medicine.

3 thoughts on “Social determinants: Why are they so difficult to address?

  1. I really enjoyed your insights on this topic! I would love to hear more about how we can assist others in making this shift in thinking.


  2. A good starting point is taking the IAT (implicit association test) and doing some unconscious bias training


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