Building a System of Health
Intersections and Interdependencies
Cover story, January 2019 SSW Perspectives magazine
Picture a Hoberman sphere: a seemingly simple structure that, when expanded, you see is made up of a complex system of intersections and interdependencies. If any segment is missing or broken, it weakens – or even collapses - the entire structure. This image was at the heart of the School of Social Work’s thinking about total health and building healthy communities when planning the seventh annual Summit on Emerging Issues in Social Work Practice on Aug. 7, “Healthy Communities: Broadening the Lens of Healthcare, Equity and Policy.”
Across Minnesota and the country, there is a renewed focus on the true meaning of human health and its connection to everything around it. Like the Hoberman sphere, health is supported by myriad social, environmental, political and individual factors linked together - the ‘determinants’ of health. With this in mind, we come closer to recognizing health for what it truly is, “a state of complete physical, mental and social well-being,” as the World Health Organization describes it, “not merely the absence of disease or infirmity.”
More and more there is a recognition of the complex correlation between individual and environment.
“Studies show that the circumstances of our lives – in particular where we live – play the largest role in our health. Where we live determines our options and influences our choices no matter how well-intentioned or motivated we may be to ‘make healthy choices,’” reads the 2017 Minnesota Statewide Health Assessment. “Decades of study on the social determinants of health show that the policies and processes that shape the daily circumstances of our lives are what really create health. … Everything in our lives – our families, homes, neighborhoods, jobs, schools, the land, water, and air - must support our health.”
It takes a certain philosophy and skillset to work across these intersections, from the micro practice of direct care to the mezzo and macro practices of community and large-scale systems. Luckily, the field of social work has been dedicated to training people to do exactly that for nearly two centuries.
“This is what social work is,” said SSW professor Katharine Hill. “This is what defines social work and makes us different than other helping professions. … This is how we go about our work. It’s about the whole person, the environment. You can’t have one without the other.”
Extension of tradition
Some people raise an eyebrow when they learn that social work is considered a cornerstone of the health programs to be offered at both St. Kate’s and St. Thomas. They intuitively understand that clinical social work is considered a health profession, but may fail to connect in their minds generalist practitioners as true health professionals.
At the SSW that connection is constant. The social work curriculum not only prepares students to use the person-in-environment perspective, but to thrive within it and fully embrace social workers’ role in health and well-being. The state’s health assessment specifically calls out the types of policy changes that would generate good health, including, “policies that assure all children thrive, equitable educational and job opportunities, shared power and decision-making, access to health care, affordable housing, multiple transportation options, and unpolluted environments.” It also highlights the role structural racism and aspects of belonging (inclusion in community and connections with each other) play in health and health equity. Social workers are practicing and advocating across all of these areas.
As evidenced at the Aug. 7 Summit, policy-makers and traditional health systems are looking to this philosophy and practitioners of it more than ever.
“In an egocentric way, as a profession, it’s very validating to hear. Every person who spoke [at the summit] was talking about the systems approach and systemic thinking, which is endemic to social work,” said Lisa Richardson, the School of Social Work’s director of MSW Field Education and one of the summit’s main organizers. “As social workers, we can’t help individuals and communities without thinking systemically and with that person-in-environment model.”
“Is this new for us? Absolutely not. This goes all the way back to settlement houses and how we think about people. That’s why in the settlement era we went out to people’s houses instead of building an office and asking them to come in. This is the full tradition of what we do,” said Eva Solomonson, SSW’s director of BSW field education. “It makes me really pleased, because we feel the best way to help people in the long term … is recognizing that we’re not just focusing on the identified problem and saying, ‘Let’s go attack it.’ Instead we ask, ‘What are the root causes in the community, within the systems and history, that are perpetuating the problem?’ And how do we find a solution that comes out of that community, versus thinking we have a solution and bringing it to them.”
Social workers’ role in the collective process of improving communities’ overall health is evident in many ways as seen through the 2017 health assessment’s breakdown of determinants of health: 40 percent social and economic factors; 30 percent health behaviors; 10 percent clinical care; 10 percent physical environment; and 10 percent genes and biology. Outside of the genetic and biological factors, there is a major role for social workers and their skillsets across every other determinant of health.
“It does feel like right now there’s a moment of real recognition of community indicators of health and that you can’t help individuals without understanding those indicators, and vice versa,” Hill said. “So we’re working to seize this moment.”
Baked into every level of education at the SSW is the preparation for students to contribute to this moment as they recognize the connection between micro, mezzo and macro practice.
“Social workers providing direct services must ask, ‘What can I do in my community, with local government, community organizing, policy … to really have the voices of the individual people I serve represented and heard?’” said SSW assistant professor Carey Winkler, a lead summit organizer. “And how can I ensure that all determinants of health are acknowledged and addressed within the systems and interprofessional teams meant to support them?”
An example at the macro level is Hill’s work focused on voting, looking at populations who are less likely to vote, and why, and also the benefits that come from voting.
“There is an empowerment aspect to voting - encouraging people to vote and telling them that their voice matters - that is huge,” Hill said. “Research shows that higher participation in voting creates stronger, more engaged, healthier communities.”
A call to action
Within the summit and throughout the SSW, there is an urgency in recognizing everyone’s ability to contribute to this process. A rallying cry at the summit was for every person to “pull their lever,” doing whatever they can do in their area of influence. Those efforts can ripple upward and, with intentionality, make a huge impact to both individual and community health.
“That mentality [of pulling your lever] is built into the philosophy of the School of Social Work,” said Corrine Carvalho, interim dean of the SSW. “For example, the social work major is the first ‘changemaker’ major declared at St. Thomas because of the push for social change and systems thinking at every level of practice. It’s very exciting that way.”
Again, the 2017 statewide assessment provides a useful framework for understanding how important the acceptance of that role is for everyone, not just social workers. The state of Minnesota is changing: By 2035, for the first time, there will be more adults over age 65 than children; that same year the population of people of color is expected to rise from its current 14 percent to 25 percent. The growing, myriad diversities of our state – class, race, age, sexual identity – mean the complexities of connection between individual and systems will only grow; it will be a collective effort to bring health equity across the board. As the assessment points out, “We all share a responsibility of creating healthy communities where everyone can thrive, instead of each of us being solely responsible for our health.”
There is a role for all of us as we work toward better understanding the connections and interdependencies represented by the determinants of health. In no small part thanks to the tradition of social work, we have a foundation of understanding for what connects them.
“The intersection between the human and the system is empathy,” Richardson said. “That’s the bridge.”
It is time, then, to walk that bridge together.