Dr. Steven Woolf, M.D., M.P.H., is the Director Emeritus of the Virginia Commonwealth University (VCU) Center on Society and Health. The Center focuses on the connections between society and health – researching impacts of social factors on health. Dr. Woolf was the Director of the Center for more than a decade, from its founding in 2007. As Director Emeritus, he continues to influence public policy through his focus on population health and social justice. Dr. Woolf has shared his thoughts on improving public health and health policy, as well as some words of wisdom for those who are striving to make transformative change in the health care environment.
- In a recent book review published in the American Journal of Preventive Medicine, your comment that “human health is its own ecosystem, influenced by far more than biology,” provides readers with an opportunity to explore health beyond the confines of the scientific method. Many understand that our physical environment can impact individual health, but what other factors exist that influence human health? Which factor has the greatest potential improving human health? Health is about more than health care. I’m a physician, but I understand that only 10-20% of health outcomes are determined by what happens in hospitals and doctors’ offices. Much of our health is a product of our behaviors, such as smoking or physical inactivity, and these in turn are shaped by socioeconomic status (e.g., education, income) and our environment. The physical environment includes not only classic health risks, like air or water pollution, but also the built environment, such as access to green space, sidewalks, playgrounds, and other places that promote physical activity. Health is also affected by the social environment, such as social isolation or residential segregation. And all of these factors—health care, health behaviors, and the environment—are shaped by public policy. Which of these matters the most? It’s a difficult question to answer, because they include so many multilevel interrelationships, but my money would be on education. In our knowledge economy, education is the pathway to economic opportunity and social mobility the escape route from multigenerational poverty, and one of the strongest predictors of health and life expectancy.
- How can we, as agents of change for health care in Virginia, work to address this identified factor? Are there any services or projects in Virginia aiming to address this? If not, do you know of an example from another state or have an idea for possible implementation? Your question asks about agents of change for health care, but I again emphasize that health care is necessary but not sufficient to move the needle on health. I think the spirit of your question is how we can improve the one factor I consider most important, in this case education. The first place to start is early childhood. Studies show that the first 1000 days of life are critical in shaping the trajectory of young people and ultimately determine their risks for disease as adults. Toxic stress can cause lasting damage. Studies have also documented the benefits of early childhood education (e.g., pre-K), which should be available universally. We must improve academic achievement in secondary education, especially for students at underfunded schools suffering from weak tax bases. Students of color and those from low-income families face an uphill battle in graduating and getting into college, not least because they are priced out by high tuition rates. Many states are underinvesting in education, causing self-inflicted wounds, such as greater poverty and demand for social services and a less competitive workforce, which in turn discourages new businesses from entering the state and hurts the state economy.
- In your opinion, what opportunities exist for policymakers and practicing clinicians to work together to improve public health? Further, how can we engage our patients beyond the confines of the executive suite or patient exam room? Increasingly, health systems and physicians like myself recognize that they cannot improve population health without addressing the social needs of their patients. Insurance companies, the administrators of Medicare and Medicaid, and employers concerned about the spiraling costs of health care (and insurance premiums) realize that social needs like unstable housing and food insecurity cause disease and drive up admission rates and utilization of services. Many hospitals and providers are hiring case managers or other staff to help screen patients for social needs and refer them to agencies and programs in the community. But your question also asked what policymakers can do. Elected officials lament the rise in health care costs and so-called “entitlement spending” on Medicare/Medicaid but often—especially in the current political climate—they are cutting spending on social programs. This “penny wise and pound foolish” approach causes disease, sends more patients to hospitals and emergency rooms, and drives up the costs of health care. Investments in education, jobs, housing, and community wellbeing are not only good for the economy, they are also good for our health and will help control health care costs.
- You continue to serve as an agent of change for health care, championing many innovative ideas which have impacted policy. What advice do you have for students who want to inspire change within the modern health care environment? My advice to students is to not lose your passion and idealism. Young people are the incubator for new ideas and bring energy to our most pressing social causes. That was true in the 1960s, when I grew up, and it’s true now. Today’s leaders have left behind a complex and daunting set of problems, but I believe today’s students have a clarity of vision to tackle the challenges and the courage to take bold steps that prior generations considered “non-starters.” This is an exciting time for students interested in health policy, because the landscape is very dynamic and there will be a growing need for a new cadre of professionals who understand the drivers of health and their interconnections to other major social issues. Transformative change in health and economic opportunity will require cross-sector collaboration, and today’s students have the opportunity to bridge silos and work across disciplines to fashion creative new solutions.
- As a scholar and professor, you have likely served as a mentor to others. Who has served as a mentor in your life? What was the most valuable lesson you learned from them? I’ve had several important mentors who helped me along the way, beginning with my parents and their crucial role in instilling core values about social justice. But others helped me in various stages of my life and gently steered me in the right direction: my sixth-grade teacher demanded excellence, my college English professor taught me to write, and the faculty at the Johns Hopkins University School of Hygiene gave me the skills for research. But my most important mentors showed me what it meant to be principled and inspired me to speak truth to power, especially for vulnerable populations who don’t have a voice. I saw their courage and the great risks they took to follow their principles, knowing that—whatever the outcome—they could always take pride in doing the right thing. Many of my mentors were famous and widely admired by their colleagues, and I knew that their path to greatness was paved by courage. My parting advice is to do what makes you proud.