2. Examining health through a different lens helps to uncover bigger, underlying
social issues that can’t be solved by the latest app or device alone. This visual
exploration helps us to “see the forest for the trees” as it relates to health in the
Metro Washington D.C. area.
Sto ry & Ph otos By Ted Eyta n, M D
W e are relying too much on modifying a
person’s individual choices to improve health.
The social determinants of health can loosely
be defined as how the circumstances in which
people develop and live affect their mental and
physical well-being and life expectancy, and have
been characterized as the causes of the causes
of health (or ill health)1
Insights Vol. 7 59
3. Seven Visual Insights on Social Determinants
Many citizens,
1
few health
professionals
If you look visually at a health system, like this example based on Kaiser Permanente, you can
see that we are out-personned. There aren’t enough people working in health care to reach every
person we serve to guide their daily choices. People and organizations outside of health care are
needed.
0.18 Million Staff
0.05 Million Nurses
9.0 Million Patient Members 0.017 Million MDs
The Actions of a relativley small staff/Nurse/Physician group
and population approaches.
60 Insights Vol. 7
4. Seven Visual Insights on Social Determinants
People aren’t hoping that we’ll improve their health care experience; they are hoping that we improve
their ability to live a long healthy life.
The groundbreaking Marmot Review in 2010 depicted big differences in life expectancy and
disability-free life expectancy among the best-off and worst-off neighborhoods in England.
The graph above (licensed under the Open Government License v1.0)2 is full of information that
shows that people who are socially deprived will not (a) get to a certain age and (b) if they get to that
age, are unlikely to get there without a disability.
We don’t usually measure this in United States health care today.
What we are
working to
2
improve,
should matter to
people.
Insights Vol. 7 61
5. Seven Visual Insights on Social Determinants
3
Use images, not
words
MOST
HEALTHY
The difference between the
most healthy and the least
healthy people describes
the health inequality in a
patients staff population. Society is better
off when there is a smaller
difference in this range. We
can show the spread via the
disability-free life expectancy
metric, using smooth bars.
Their height is equal to
the disparity between the
healthiest and the least healthy.
The gray bar shows the spread
for or own staff – their health
inequality matters, too. And
images are the most powerful
way to demonstrate this.
LEAST
HEALTHY
# OF PEOPLE
62 Insights Vol. 7
6. Seven Visual Insights on Social Determinants
The Future We Want
MOST MOST
HEALTHY HEALTHY staff
patients
patients staff The Future That Scares us
MOST MOST
HEALTHY HEALTHY patients staff
INTERVENTIONS patients staff
LEAST LEAST INTERVENTIONS
HEALTHY HEALTHY
# OF PEOPLE # OF PEOPLE
LEAST LEAST
HEALTHY HEALTHY
# OF PEOPLE # OF PEOPLE
There are two alternate futures. The future we want is the one where everyone is healthier.
There is less of a disparity between the most healthy and the least healthy. Our staff shows
even greater health gains, leading our members.
The future that scares us is the one where the most advantaged are much healthier, the
least advantaged are only a little healthier, and our staff is no healthier than the people they
are serving.
4
Two alternate
futures
Insights Vol. 7 63
7. Seven Visual Insights on Social Determinants
5
A total health
approach
“These serious health inequalities do not arise
emphasis by chance, and they cannot be attributed simply
on to genetic makeup, ‘bad’ unhealthy behaviour,
,
or difficulties in access to medical care,
individual important as those factors may be.”2
This image describes the interventions that
are focused on individual choices – this could
be a calorie counting app or a game that
promotes competition among friends. If 100% of
our effort is applied to these interventions, we
won’t reduce health disparities.
Individual & Family
On the other hand, a Total Health approach,
based on the social ecological model first
advanced nearly 30 years ago, addresses the
family, community, and societal environment Home, School & Work
that shapes individual behavior choices.
There’s some investment at every level, as the Neighborhood & Community
image below depicts.
Society
64 Insights Vol. 7
8. Seven Visual Insights on Social Determinants
MOST MOST
HEALTHY HEALTHY staff
patients
patients staff Total
Health
Approach
Individual & Family
Home, School & Work
Neighborhood & Community
Society
LEAST LEAST
HEALTHY HEALTHY
# OF PEOPLE # OF PEOPLE
TODAY: 2013 TOMORROW: 2020
Using the visual thinking approach, this is the one image that includes the Who/What and How
of behavior change and social determinants to improve health.
If we spend the right amount of time at the individual level as well as the societal level,
people at all levels of the health gradient will improve their health, and the gap between them
will decrease. We will model the improvement in our own workforce.
6
The tomorrow we
want
Insights Vol. 7 65
9. Seven Visual Insights on Social Determinants
7
The tomorrow we
don’t want
If we invest poorly, and do what seems easiest, we’ll get the outcome we don’t want. The
most advantaged, who didn’t need as much help in the first place, will get healthier. The least
advantaged may or may not get healthier. Our workforce will not achieve greater health gains.
Our costs, and more importantly their costs (money, time, lives) will not be manageable. That
will make all of us unhappy.
MOST MOST
HEALTHY HEALTHY patients staff
patients staff
emphasis
on
individual
LEAST LEAST
HEALTHY HEALTHY
# OF PEOPLE # OF PEOPLE
TODAY: 2013 TOMORROW: 2020
66 Insights Vol. 7
10. Seven Visual Insights on Social Determinants
However, we are not trying to fix
an image. We’re trying to fix real
social problems like obesity and
crime represented in the images
to the right (data and images from
present day, Washington, DC,
USA)
We need to understand the
role of health care in improving
health; we cannot do it alone
We need to have a measurable
goal in mind – not just pounds
lost or blood pressure lowered,
but longer, healthier life, and
less inequality between the
most healthy and the least
healthy
When we talk about innovating
in health, we need to think beyond
individual interventions – this is
in the scope of health care and a
health care Innovation Learning
Network.
The ambition is to create the
conditions for people to take
control over their own lives. If
the conditions of daily life are
favourable, and more equitably
distributed, then they will have
more control over their lives in
Visualization of crime in Washington, DC, with the biggest cutouts being homicide, the
ways that will influence their and smallest assault.
their families’ health and health References
behaviours.2 1. Royal College of Physicians, How doctors can
close the gap: Tackling the social determinants
of health through culture change, advocacy and
education. 2010.
2. Marmot M. The Marmot Review: Strategic Review
of Health Inequalities in England post-2010.
3. Garner T, Trombatore D, Raza U. Obesity in the
District of Columbia. Washington, DC; 2010.
4. Eytan, T. Quantified Community: Visualizing the
Health and Illness of Washington DC Through
Open Data and Art. www.tedeytan.com. 2012
Ted Eytan, MD
Physician Dir., Center for Total Health
Kaiser Permanente
Washington D.C., USA
Insights Vol. 7 67
