Health without fairness, equity, and empathy is a dying cause

Co-authored with Dr. Sapna Ravula, Chief Medical Officer, EXL Health

The Situation: Americans are getting sicker; Centers for Medicare & Medicaid Services (CMS) indicates more than 30% of the population suffers from diabetes, hypertension, or obesity. Life expectancy is declining; it has declined one calendar year since 2010 to 2019 (pre-COVID19). However, we spend approximately $4 trillion—18% of the US gross domestic product—on healthcare.

This trajectory is unsustainable, and we need to consider levers beyond science, technology, and finance to redirect it. While the US has implemented all these levers in various ways, either individually or in combination, it has not optimized them. It has not sufficiently deployed them to address the cause of sick care, and, to make matters worse, they are driving new levels of inequality in society. To leverage the strength of these levers and others, we must inject empathy into how we treat each other, bring equity into our societal framework, and extend fairness into how we conduct business.

Moral determinants of health? Say what?

The US Department of Health and Human Services (DHHS) describes social determinants of health (SDoH) as the environmental conditions of where people are born, live, learn, work, play, worship, and age that affect a wide range of health, functional, and quality-of-life outcomes, and risks. While SDoH are the underlying drivers of human health and wellbeing, they are abstract and impersonal. The selection of SDoH attributes and their operationalization has been a struggle for several reasons, including societal abdication of their responsibilities to the government, unwillingness of commercial establishments to engage, and the patriarchal biases in SDoH. Consequently, SDoH measurements and their direct impact on health outcomes, cost of care, and other effects have been challenging.

To make SDoH effective and their attributes meaningful, we must incorporate fairness, equity, and empathy into how we think about metrics that matter, plan health and wellness paths, develop solutions, and execute them to impact SDoH. Exhibit 1 illustrates this upgrade; we refer to it as moral determinants of health (MDoH).

Exhibit 1: The three pillars of the moral determinants of health are fairness, equity, and empathy

Source: HFS Research, 2022

Interconnected humans need MDoH to change the trajectory of their lives

MDoH combine human cerebral intelligence (IQ) and emotional intelligence (EQ) to effectuate health and financial outcomes that are sustainable over generations. IQ and EQ balance internal and external influences any organization faces and connects them in a self-regenerative model in perpetuity.

MDoH escalate the expected outcomes beyond the individual to the collective to impact the individual. MDoH outcomes should be considered at two levels, nationally and locally, to strengthen their impact by flowing top-down in an organization and bottom-up in a community, expanding inclusivity and ownership of a concept designed to change our lives.

To refine our thoughts on this perspective, we spoke to Dr. Don Berwick, former head of CMS. Dr. Berwick argues for the following national outcomes here in the US as a function of MDoH outcomes which can all be connected to fairness, empathy, and equity (exhibit 1):

• Ratifying the basic human rights treaties and conventions of the international community, including United Nations agreements on human rights
• Adopting healthcare as a human right
• Supporting efforts to reverse climate change
• Reforming the US criminal justice system
• Creating a compassionate immigration policy
• Ending hunger and homelessness
• Ensuring voting rights and the integrity of our institutions

The US has been a melting pot of cultures, attracting immigrants from all over the world to bring the best they can offer, including their values and culture. We could argue that co-mingling cultures may drive some friction, but in the context of MDoH, it is only fair to assert that morality will transcend culture, which is key to aid the national outcomes we must aspire to. There must also be commensurate local and individual efforts designed to match local economic and social conditions supporting a sustainable MDoH model.

Don’t underestimate the reality of MDoH in polarized societies

MDoH require most of us to participate in defining outcomes, aligning on solutions, and organizing its execution. This is challenging even in parochial communities where ideological divides are limited, if there are any, compared to the polarization we are experiencing now. The definitions of fairness, equity, and empathy are likely to take different directions across the spectrum of societies, making it challenging to arrive at aggregable MDoH outcomes.

If we were to separate the national and local outcomes for the sake of operational efficacy, national outcomes would likely be driven by two major stakeholders: governments and large corporations. Several outcomes resonate across the aisle, while many of the same outcomes are agreeable to the economics of corporations. We will need influential leaders to evangelize the need for national outcomes.

At local levels, enterprises should explore public-private partnerships to drive outcomes relevant to the local economy and social nuances.

The Bottom Line: Healthcare (sick care) is irrelevant and an impediment to the pursuit of health. MDoH is what we must develop and execute if we truly mean to improve the health of our population.

Health is a representation of physical wellbeing, emotional equanimity, and financial security. Health is fungible, changing with time and circumstances, impacted by the action of self and others. We can quantify and measure health and its drivers. However, unquantifiable, and unmeasurable intangibles such as empathy (clinicians’ bedside manner), equity (giving each other a fighting chance), and fairness (following rules) are fundamental to health. Consequently, we struggle to develop models that achieve sustainable health instead of defaulting to sick care. Health without fairness, equity and empathy is a dying cause.