Social determinants of health does not mean the poor are sick

Last week I saw an article from Time titled “Pediatricians Should ‘Screen’ Kids for Poverty, Says Group” making the rounds in my LinkedIn network. The article is about an American Academy of Pediatrics recommendation that doctors be responsive to how poverty can affect health by referring low-income families to social programs. The recommendation is based on the largely accepted concept of the social determinants of health.

The World Health Organization defines social determinants of health as “…the conditions in which people are born, grow, work, live, and age, and the wider set of forces and systems shaping the conditions of daily life.” The literature connecting poverty and health is solid. As the Center for Disease Control states, “We know that poverty limits access to healthy foods and safe neighborhoods and that more education is a predictor of better health.” This is both intuitive and factual.

I have no qualms with the linking of poverty and health outcomes, but rather object to the suggestion that one ought to be diagnosed poor, as this perpetuates a stereotype that poverty is something that is wrong with the poor rather than the result of a social and political environment we (humanity) collectively create.

Furthermore, the analogy wrongly simplifies poverty into something that is curable via proper prescription. From the Time’s article:

The recommendation also provides guidelines to help pediatricians connect families who might be struggling to the proper resources, from local housing bureaus to food pantries and job listings. The hope, says Dreyer, is to help the 50% of families who currently qualify for additional support but aren’t getting it to access the resources they are entitled to.

The recommendation makes it sound as though once diagnosed, poverty is “cured” via the social safety net. Implicit in this analogy is that the cure for poverty is proper prescription and utilization of the right dosage of social service intervention. In this thinking, either the poor do not know about or refuse to utilize services that are assumed beneficial.

Given this logic, the obvious question is why do so many families not pursue such help if the safety net is the cure to poverty? The core assumption in this line of reasoning is that families do not know about available services. Indeed I made this assumption for a number of years while selling systems to governments and nonprofits that “connected” people to social programs.

Since joining the Family Independence Initiative and getting access to a sizable volume of data directly from families moving in and out of poverty, my perspective has shifted significantly. Whereas I used to assume people simply did not know about social programs, I now wonder if utilization is low not on account of informational asymmetry, but rather because:

  • Existing services do not necessarily help as much as we assume.
  • The social stigma of accessing social programs outweighs the benefit.
  • Services are such a small part of escaping poverty as to not be worth the hassle.

The poor are not sick, even if they have worse health outcomes, as poverty itself is not a disease. It is the absence of money, a social phenomenon we collectively support, and often benefit from. The causes of poverty are not individually acute, but rather socially, racially, and spatially broad.

Indeed, the disparity in life expectancy between lower and upper income households is growing. Where you live and how much you make can affect your health in lots of ways, from experiencing higher levels of violence, air pollution, poor food access, and several other factors. None of these are solvable through a diagnosis of poverty.

The real “cure” to poverty is not in small doses of guided interventions at all. Nonprofits are not doctors of poverty. As sure as evidence supports the social determinants of the health, a growing body of literature also supports the benefit of investing directly in low-income families.

Analogizing the poor as diseased perpetuates the myth that the poor are weak, feeble, and infested. Nothing could be further from the truth.

Anti-interventionism combats poverty and threatens the nonprofit sector

There is a subtle shift taking place in pockets of the social sector, challenging the historically interventionist approach to social change. Microfinance was perhaps the first in modern memory (or at least my memory) that eschewed the conventional wisdom that nonprofits know the path out of poverty better than the poor themselves, extending loans to low-income families to use as they saw fit.

More recently GiveDirectly has popularized the concept of unconditional cash transfers, whereby cash is given to low-income families with no strings attached. Domestically, homeless services are increasingly realizing the futility of trying to “treat homelessness” while people live on the streets, and instead are shifting resources toward simply putting people into homes.

Similarly, at the Family Independence Initiative we are investing in the initiatives low-income families are taking across the United States to improve their own lives and their communities. What all of these approaches have in common is that none of them make any assumptions or judgements about who the poor or homeless are. There is no real theory of change in the traditional sense. No layering of one expected outcome that ought to come before another.

Instead, these are straight forward common sense approaches that put trust in the poor and make them the center of social change. If someone needs a loan, let’s give them one. If someone is extremely impoverished, let’s transfer cash. If an individual is experiencing chronic homelessness, extend that person permanent housing.

All of these approaches are inherently anti-interventionist, and they seem to work really well. So why don’t we see a tidal wave of anti-interventionism?

The anti-interventionist threat

While anti-interventionism is great for the poor, it’s an affront to much of the nonprofit sector. Nonprofits raise funds on the assumption that their programs and services hold the key to lifting low-income families out of poverty.

These anti-interventionist approaches greatly reduce the role of nonprofits, as in the anti-interventionist’s view the nonprofit is no longer the driver of change, but the impoverished themselves. In a world of anti-interventionists, nonprofits are reduced to distributors of funds rather than architects of change.

In the interest of self-preservation, nonprofits have and will continue to argue against anti-interventionism. However, thus far the evidence is not on their side.

We in the sector talk a big game about “working ourselves out of business”. To the contrary, we have worked damn hard to stay in business while consuming dollars that are better spent by the poor themselves. As anti-interventionism grows, the social sector will have to more publicly reconcile its pro-social rhetoric with its own self-preservation.