“There’s a 15-year difference in the life expectancy between the richest and poorest Americans.” That’s the first sentence of Chapter 7 in my book, HealthConsuming: From Health Consumer to Health Citizen.

This data point comes from research published in JAMA in April 2016 on the association between income and life expectancy in the U.S. (That’s endnote #399 in the back of the book, one of 519 notes I use to support the plotline).

Today, the Brookings Institution convened a meeting on the funding for social determinants of health to address disparities, costs, and quality of healthcare in America. The overall theme is about building healthy neighborhoods through cultures of health with touchpoints of housing, nursing and local health workers, public libraries, grocery stores, schools, “third places” (beyond home and work, like a retail store for mental health meet-ups or online social networks) and, indeed, hospitals that bolster community health.

Chapter 7 of my book, HealthConsuming: From Health Consumer to Health Citizen, is titled, “ZIP Codes, Genetic Codes, Food and Health.” The plot begins with the importance of “place,” our personal physical geographies and what they portend for our individual health — beyond our genetic code and inherited health risks. As the JAMA article notes, “The differences in life expectancy were correlated with health behaviors and local area characteristics.”

This graphic on SDoH comes out of the book, illustrating the many external factors that influence personal and community health: among them, food, job security, education, environment (think: clean air if you live in Los Angeles, clean water if you live in Flint, Michigan), job and income security, and safe and green spaces among them. While not traditionally called out as a social determinant, I’ve added in broadband connectivity (with net neutrality baked in) as an influence on health and wellness, as well.

To introduce the ideas in each chapter of the book, I ask big hairy “What If?” questions that I endeavor to answer. Here, I wonder, “What if… America reduced health disparities, increased health equity, and our ZIP codes didn’t determine our health outcomes and life expectancy?”

The shocking reversal of life expectancy in the U.S. has been termed the “deaths of despair” by the brilliant researchers Anne Case and Sir Angus Deaton who are based at Princeton University. Their latest work on the phenomenon has revealed the role that (less) education plays as a risk factor for shorter lifespans, which I discuss in HealthConsuming as a tragic feature in U.S. public health — uniquely American versus the rest of the developed world. Opioids and social isolation (read the book Bowling Alone for more insights) contribute to this reversal-of-longevity.

“There is mounting evidence that some of these [SDoH] initiatives are associated with improved health outcomes and reduced health care utilization,” a report from Deloitte asserted in a new report on social determinants of health published this week. The growth of public sector incentives in Medicare for social supports, and growth of value-based payment in commercial plans, are forces nudging health care providers toward bundling SDoH services into targeted programs. The graphic from the Deloitte study illustrates a few of those strategies, including multi-tasking social needs, referring people to services with high-touch, partnering in the community with service providers, and monitoring and tweaking the SDoH interventions in a continuous-improvement mode.

This seventh of eight chapters of HealthConsuming concludes: “Our communities are our local health ecosystems. Centuries’ worth of evidence, from Hippocrates in Athens, Greece to
Geisinger Medical Center in Danville, PA, shows us that how we live, the daily choices we make or are constrained from making, and the built and natural environments we live in shape our health well beyond the local doctor and hospital do.”

As U.S. policymakers are in the throes of designing an infrastructure bill allocating $trillions of taxpayer dollars, they should be mindful of “baking” social determinants of health into the plans. This concept is recommended in the last chapter of HealthConsuming as the plot moves to the question of whether health consumers will emerge as health citizens in America.

Tomorrow, we’ll focus on the promise of digital health and the perils of privacy. Digital platforms and tools can help scale social determinants to people who need services. But without privacy protections that address our current reality of how we live and share online, the best-designed technology won’t be effective, or worse…could exacerbate already-challenged health outcomes and disparities.