As a part of our most recent health equity research, we've spoken with countless of the most progressive health care leaders about their roles in the industry-wide effort to combat inequities and racism in the health care space. These conversations are always at least a little loaded, and we prepare ourselves for both productive discussion and some inevitable pushback. If you’ve ever broached a sensitive subject like this, you’ve likely experienced this dynamic firsthand. But in one of our most recent conversations with a progressive health plan, we were surprised when a nearly instantaneous debate broke out around one of the most commonly used terms in the equity space—the social determinants of health.
The pushback we never expected to get
Right at the start, the leaders on the line posed an interesting question—is it problematic to call the non-clinical drivers of health outcomes the social determinants of health?
Now, it might be easy to see this debate as a distraction—especially when you consider the invaluable strides that many institutions have already made in addressing “social” needs. But as more and more audience members pushed back on the terminology, we started to understand their perspective. And these health plan leaders weren’t the first to question this longstanding terminology. The concept stemmed from a Health Evolution article back in April that criticized the term for a number of reasons:
- Do we say social determinants of health when we really mean poverty or racism?
- Does "determinant" wrongly imply that the conditions are unchangeable?
- Are these aspects of life like housing and employment truly "social," or are they environmental?
Ultimately, the central argument against the term "social determinants" is that it hides the uncomfortable reality that some of the biggest drivers of health are rooted in racism and intergenerational poverty. And it may unintentionally push leaders to Band-Aid approaches that don’t address these root causes.
We don't bring this up to say that we're ready to renounce the term. But the debate alluded to a broader conversation that is worth having in this space: Are we characterizing equity challenges (and solutions) in a way that advances our efforts? What downstream impact could our language have on our workforce, patients, and community? How do we balance the need for precision without splitting hairs so much we never actually make progress? And when is a change in language truly meaningful vs. virtue signaling?
How the language we use can have real, unintended consequences
Like anything else, we can't let perfect be the enemy of good. Especially in this work, the language we use day in, and day out will never please everyone. That said, the language we use does matter. And sometimes there is a right and a wrong answer. Language can be directly harmful to historically marginalized groups, imprecise language ultimately leads to inaction, and sometimes even the most well-intentioned messages have ripple effects that threaten the very goal we’ve set out to achieve.
Here are some of the terms we believe can be retired for good:
- Cultural competency. People generally have the right intentions when they use the phrase. Their goal is to deliver high-quality care that is tailored to a patient's cultural or social context. But historically, that mindset has run the risk of actually perpetuating stereotypes, as care teams strive to become "competent" in identities that are not their own by using simplified checklists or reference guides.
Instead, we should strive for cultural humility. The concept acknowledges that while we can never truly be an expert in another person's experience, we should still strive for ongoing learning, self-reflection, and skill-building to surface the individual needs and preferences of the patient in front of us. This shift in language is important because the solution set is also very different—it requires an authentic commitment to person-centered care, ongoing education about power and privilege, and reflection how our own identities influence our interactions with others.
- The digital divide. As Rachel talked about in a recent episode of the Radio Advisory podcast, the term "digital divide" perpetuates serious misconceptions about the downside of all the recent digital investment and how to address these challenges. The status quo language tends to make folks think solely of broadband access, implies a false binary rather than a spectrum of need, and sets up an assumption that there a single solution to "bridge" the divide. It starts us off with too narrow a view of the problem.
We prefer the term "digital inequities," which go beyond basic infrastructure to include affordability, digital literacy, and the inclusive and accessible design of digital tools and experiences. It already sets us up with a more nuanced understanding of how to tackle a complex challenge, and it doesn't "other" or alienate people who might face these barriers.
- Race (or any demographic domain) as a social determinant of health. When we position race (or gender, sexuality, etc.) as a social determinant of health—rather than racism, sexism, or homophobia—we inadvertently put the blame on marginalized groups for the inequitable outcomes they face. It also obfuscates our goal of addressing the harmful societal structures in place, hindering our progress of tackling the problem at the root.
Shifting our language here can amplify our efforts beyond the individual, patient-by-patient solutions (like referrals to food banks or shelters) to strategies that target broader community conditions (like ending food deserts and expanding affordable housing) and eventually impact the design of our systems themselves (with policy advocacy, for example).
Using "DEI," "equity," and "diversity" interchangeably. The terms are closely related, and of course "DEI" encompasses the other two terms along with "inclusion." But equating them can unconsciously make us feel that taking action on one translates to progress on all. Ultimately, it overly narrows our investments—we hear this the most from leaders who instinctively default to efforts to diversify the workforce, which alone will not solve these complex challenges.
That's what led us to develop our three-part framework on what it means to be an equitable organization—advancing diversity, equity, and inclusion for your workforce, patient outcomes, and community conditions. Applying a DEI frame to each of these constituencies—as intertwined as they are—helps shine a light on blind spots and build a holistic strategy.
Guiding principles for navigating ever-changing language in the equity field
In all of the examples above, the shift in language is more than cosmetic. These changes will reduce the risk that our terminology unintentionally alienates the very groups we are trying to serve. But we know that we can debate and nitpick the best word or phrase into eternity (and remember, our guidance is that you will never be able to please anyone).
When considering new terminology—determine if a shift in language results in a necessary shift in strategy. If amending our language shifts or adds precision to the action steps that will ultimately reduce inequities, those are the changes we should make.
Our goal is that the language we use helps—not hinders—our progress toward equity. If that's our guiding principle, it makes it easier for us to answer these questions:
- Is the language we're using precise and specific enough? How might it obscure potential blind spots?
- Who is involved in the deciding what language we use? Are we centering the preferences of our target populations and the most historically marginalized groups?
- What language will be the clearest to the groups we're hoping to engage? How do we meet people where they are and use terms that folks understand?
- Does our language help us prioritize the efforts that will be most meaningful for our equity goals, allowing us to best serve our workforce, patients, and community?
Inevitably, we will make mistakes. We at the Advisory Board have certainly be in that position—from using "cultural competency" just a few years ago to talking about the "digital divide" during the beginning of the pandemic. That's natural, and we recommend that folks get comfortable owning up to mistakes when they happen. The goal is not perfection, but progress. We haven’t decided if “social determinants of health” is worth retiring, but we believe that ultimately, we must live the language that we use. Let's bring rigor to these choices, so our actions can represent our intentions.