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OBJECTIVES

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Objectives

  • Describe clinical tools for social, environmental, and legal needs screening.

  • Describe clinical tools for social, environmental, and legal needs referral and tracking.

  • Describe workforce training needs for addressing social determinants of health.

  • Describe how clinic-based interventions to address social determinants of health can both link with and reinforce population-level interventions.

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Veronica is a 40-year-old woman with asthma. She visited three emergency rooms (ER) in 1 month. Following the third ER visit, she was referred to a primary care clinic where a medical assistant noted that she lived in an area endemic for unhealthy housing. Veronica then was screened for associated housing risks. Veronica lived in a damp, moldy home. With that information, the MD correctly diagnosed her with a housing-related illness. He treated her with medications and enrolled her in a healthy housing program. Veronica and her home got better.

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INTRODUCTION

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It has long been recognized that social forces—poverty, class, gender, racism, war, and social policies—have a profound effect on disease: on who gets ill, the spread, and course of illness. Rudolf Virchow, a German physician, is credited with not only being the founder of pathology and cellular biology but also the father of social medicine. He advanced the idea that disease is not purely biological, but can be caused, spread, and exacerbated by social factors. To combat disease, Virchow suggested scientific medicine should be combined with population health, public health, and politics. In 1848, for example, he concluded that the cause of a typhus outbreak was largely due to wretched living conditions and that such an epidemic could be very simply prevented through “education, with its daughters, liberty and prosperity ….” With these insights, Virchow and others committed to social justice brought about stunning improvements in health in the 19th century, long before the advent of antibiotics and other miracles of modern medicine, through social policies addressing poverty, improving public sanitation, as well as working and housing conditions.

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Contemporary social medicine advocates still recognize inequality as a potent factor underlying disease and have been very influential globally. Tackling the HIV pandemic, for example, has required not only understanding the biology of the virus but also supporting the rights of the poor, women, sex workers, children, drug addicts, and sexual minorities and challenging systems that put treatments out of the financial reach of patients.

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In the United States, Virchow’s insights have not been widely incorporated into social policies or medical practice. Currently, the US programs created to address social conditions that undermine health are associated with the safety net and are often reviled as “handouts.” Issues such as poor housing conditions or food insecurity, which arguably would be more effectively addressed in the arena of public policy, present themselves as powerful issues undermining the health of patients. In the absence of an integrated social approach to health, clinicians struggle to care for patients suffering from ...

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