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May 23, 2022
Health Care Practice / Quality Social determinants of health
Harold A. Pollack
Mary Beth Shapley
Apr 13, 2022
Back to The Milbank Quarterly Opinion
We write this opinion as a rebuke to our own health policy colleagues, and peers. As a health policy and public health community, we have spent the last generation noting the importance of social determinants of health. Yet, in myriad ways, we have failed to recognize, embrace, and reward the profession and practice of social work, whose core mission is to address social determinants on matters ranging from youth homicide to homelessness, disability, long-term care, and now the COVID-19 epidemic.
For generations, social workers have recognized — albeit imperfectly — the relationship between individuals and broader economic, political, institutional, and cultural forces. Jane Addams’ Twenty Years at Hull House described public health challenges, such as tuberculosis, that touched Chicago’s immigrant communities. She also described social determinants in detail — poverty and discrimination, limited medical care access, and unsafe work conditions. More than a century ago, Addams wrote:
Public health is a magic word which ever grows more potent as we realize that the very existence of the modern city would be an impossibility, had it not been discovered that the health of the individual is dependent upon the hygienic condition of his surroundings.
Addams didn’t just write about these issues. She became garbage inspector of the 19th Ward. Social workers continue that work today — many barely a stone’s throw away in the hallways of Chicago’s Stroger hospital, and in the nearby neighborhoods of Pilsen and Little Village.
Social work scholars Betty Ruth and Jamie Wyatt Marshall remind us that social workers were central to Progressive-era and New Deal efforts to address infant mortality and other public health challenges. In 1926, Harry Hopkins admonished: “The fields of social work and public health are inseparable…. Social work is interwoven in the whole fabric of the public health movement and has directly influenced it at every point.”
Social workers are often uniquely positioned to address social determinants of health in family and community settings, including challenges related to housing, education, employment, criminal justice system involvement, mental health, health care coverage, and access to care. Social work education is specifically designed to train future social workers to help people navigate complex, interconnected systems of help and support. At their best, social workers operate as boundary spanners, reducing health disparities by helping vulnerable or marginalized individuals, families, and communities secure the resources and services they need.
Few within the medical care and public health communities would deny this reality. Yet, it is equally hard to deny a second reality: Social work is a neglected stepchild of American health policy practice and discourse. Although social workers are specifically charged to address social determinants and serve society’s most vulnerable, the profession itself is undervalued, under-resourced, and underpaid. Where your treasure is, your heart will be.
Consider social workers’ daily experiences in the hospital setting. COVID-19 has created tremendous bargaining power for nurses and other health professionals, many of whom now command impressive salaries. Not so for social workers. When hospitals experience nursing shortages, they are legally required to hire more, to maintain minimum nurse-to-patient ratios, and to maintain services that receive public and private insurance payment. During the pandemic, health systems became increasingly reliant on expensive traveling nurses and staffing agencies. In contrast, when there are similar shortages of social workers, those who remain simply pick up the slack. Social workers are specifically tasked to help patients in the most difficult psycho-social circumstances, and to help patients, families, and medical providers navigate fragmented and dysfunctional medical care coordination and social-service challenges in the midst of a frightening pandemic that has damaged and stressed every one of these systems.
Because government and health care systems systematically underinvest, social work remains a lagging technological sector, further damaging its practical capacities, morale, and public and political standing. This story should sound all-too-familiar within the world of public health.
Not surprisingly, increased caseloads during a challenging pandemic have accelerated burnout in many social work settings, aggravated staff shortages and loss of experienced staff, and diminished social workers’ ability to meet human needs.
Social workers face other challenges and risks. An Illinois child welfare investigator was recently murdered while conducting a home visit, the second such killing since 2017. In response, Illinois lawmakers proposed to allow social workers to carry pepper spray. What wasn’t proposed: Additional funding for organizations to hire additional staff so that home visitors can follow proper safety practices by conducting such visits in pairs.
Then there is the palpable contrast in resources available for social work and those available for medical care. Underfunded as Medicaid notoriously is, the program automatically will pay tens of thousands of dollars when an indigent patient requires a new medication or a central line. No similarly automatic funds will flow two months later, when a social worker seeks to prevent that same person from becoming homeless because she lacks $300 to complete a rent payment. Given routine lack of access to such supports, social workers often struggle to muster the meager resources needed to help clients meet basic needs. One of our colleagues assists people leaving jail or prison. Many clients request help obtaining state identification. This costs $20 in Illinois. Creating relationships and meeting basic needs are essential to engagement and assistance to the most vulnerable clients. Sometimes this requires buying a sandwich or a hamburger, or perhaps purchasing some clean socks and an umbrella for someone. Many social workers end up providing such supports out of their own pocket. When you have 50 clients, this adds up.
More awkward realities also intrude. Like doctors, nurses, and other health care workers, social workers are trained professionals who respond to market incentives. The more experienced a social worker becomes, the more attractive it becomes to pursue employment at higher-resource settings with less vulnerable clients, or to enter private practice in which the financial rewards are greatest and where the accompanying stresses and heartache are often much reduced. Stretched and underfunded organizations on the front lines of our most pressing public health challenges — COVID-19, the opioid epidemic, and more — face the difficult challenge of retaining their most experienced employees.
Social workers don’t need much, within the context of our $4 trillion health care economy. An infusion of modest, much-needed funding, and a modicum of professional and public respect would make a difference. Giving social work its due requires resources to buy hamburgers, not helicopters. We in the public health and health policy communities need to step-up–far more than we have — to support these efforts and requests, and to support our social work allies in securing these resources. This is a show-don’t-tell opportunity to truly address social determinants of public health.
Harold A. Pollack, PhD, is the Helen Ross Professor of Social Service Administration at the University of Chicago. He is faculty codirector of the University of Chicago Health Lab. He researches services for severely disadvantaged populations for individuals at the interface between Medicaid and the criminal justice system.
Jason Lerner is Portfolio Director at the Health Lab of the University of Chicago Urban Labs. He has spent the past twenty years working at the nexus of public health and public safety. Trained as an attorney and social worker, he has dedicated his career to the pursuit of fairness and equity in our nation’s criminal justice system. His work spans all major touchpoints of the public safety ecosystem, including prevention and treatment, 911/emergency response, policing, courts, corrections, and reentry services. He has extensive experience managing complex research and technical assistance projects across the country.
Jason oversees Health Lab’s crisis response and diversion/deflection portfolio, including evaluations of several promising alternative response programs and community-based interventions for multi-system “high-utilizers.” He also manages the lab’s body of 911 predictive analytics and qualitative work with 911 system stakeholders. Prior to joining the Health Lab, Jason spent several years with Crime Lab New York-one of Health Lab’s sister labs-where he managed multiple large-scale field studies, including an evaluation of the impact of outdoor lighting on crime in and around New York City. He also worked at the New York City Department of Health and Mental Hygiene, where he coordinated NYC’s RXStat program, a multi-agency public health-public safety collaboration for responding to problem drug use and overdose mortality.
Jason holds a B.A. and J.D. degree from Rutgers University and an M.S.W. from Columbia University.
Mary Shapley is a Research Manager working on the Reducing Opioid Mortality in Illinois (ROMI) project at the Health Lab of the University of Chicago Urban Labs. She completed her undergraduate studies at College of DuPage and Northern Illinois University, and her Master’s degrees from the University of Chicago School of Social Service Administration and McCormick Theological Seminary.
Mary is a licensed clinical social worker. Prior to joining the Urban Labs, she worked in a variety of justice and healthcare settings, including more than 10 years with Northwestern Medicine.
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