The source of what the philosopher Immanuel Kant called “the moral law within” may be mysterious, but its role in the social order is not. In any nation short of dictatorship some form of moral compact, implicit or explicit, should be the basis of a just society. Without a common sense of what is “right,” groups fracture and the fragments wander. Science and knowledge can guide action; they do not cause action.
No scientific doubt exists that, mostly, circumstances outside health care nurture or impair health. Except for a few clinical preventive services, most hospitals and physician offices are repair shops, trying to correct the damage of causes collectively denoted “social determinants of health.” Marmot1 has summarized these in 6 categories: conditions of birth and early childhood, education, work, the social circumstances of elders, a collection of elements of community resilience (such as transportation, housing, security, and a sense of community self-efficacy), and, cross-cutting all, what he calls “fairness,” which generally amounts to a sufficient redistribution of wealth and income to ensure social and economic security and basic equity. Galea2 has cataloged social determinants at a somewhat finer grain, calling out, for example, gun violence, loneliness, environmental toxins, and a dozen more causes.
The power of these societal factors is enormous compared with the power of health care to counteract them. One common metaphor for social and health disparities is the “subway map” view of life expectancy, showing the expected life span of people who reside in the neighborhood of a train or subway stop. From midtown Manhattan to the South Bronx in New York City, life expectancy declines by 10 years: 6 months for every minute on the subway. Between the Chicago Loop and west side of the city, the difference in life expectancy is 16 years. At a population level, no existing or conceivable medical intervention comes within an order of magnitude of the effect of place on health. Marmot also estimated if the population were free of heart disease, human life expectancy would increase by 4 years,1 barely 25% of the effect associated with living in the richer parts of Chicago instead of the poorer ones.
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