Social Determinants of Health and the Public Health Enterprise

Recently my local newspaper (Louisville Courier Journal, August 9) published a story about high school graduation rates in Kentucky and the local public school system. The news article included recent statistics on the graduation rate in the local school system as a whole, as well as a Table showing the graduation rates of freshmen students in the individual high schools.  In the system as a whole, about 1/3 of freshmen don't graduate. The other very dismaying data in the article is the disparity in graduation rates between the school with the highest rate (Manual High School, 92%) and the school with the lowest rate (Iroquois High School, 40%). The article did not give details about the analysis methodology, so the possibility is that some of the students included in the non-graduation group later finish school in some other way.  Nevertheless, it is disturbing that so many young people fail.  Such failure to complete a high school education has a huge impact on youth for the rest of their lives, including the expectation of poor health status compared to their peers who have more success and achievement in school.

Not being a K12 educator, I'm sure there are some things about this problem that I don't understand.  Failure to graduate is a function of student effort and motivation, parental support, instructional practices and standards, curricular options (e.g. practical career training), student suspension rates, special education services, second language programs, school leadership, and many other factors.  The problem is not simple, which is why drop out rates do not change easily.

The reason I'm writing about this is not to shed light on how to solve the drop out problem, but to point out the glaring contrast between this huge social problem that has a significant impact on the public's health, and the fact that almost no role is being played by the public health enterprise.  Poor educational achievement is what we refer to as a "social determinant of health."  Students  who do not finish high school live, as a group, seven years shorter lives(Washington Post, March 11, 2008)  than others.  Along the way, they are likely to have more sickness and sick days and a poorer health-related quality of life.  There are not many threats to health that take a seven year toll, making high school drop out a giant threat to health.

And so we return to the public health enterprise.  How should we address education as a basic factor to promote health status?Indirectly we contribute to student success in school, but measures to promote child and adolescent health, such as with immunizations and health screening.  We are very comfortable with designing interventions with outcomes stated in terms of health status.  For example, to decrease the rate of hospital admission among children with asthma.  However, what if we made school success and high school graduation the outcome measure?  What then would be the role of the public health enterprise, and how would we proceed.

Rectifying the startling results of health inequity, and addressing the social determinants of health will require revolutionary change in the ways we deal with public health problems.  It will be an uphill battle, given the current social resistance to brave new enterprises undertaken by we the people in the form of government initiatives.