I was delighted to see the consensus paper from the American Academy of Nursing on the very timely and important topic of the social determinants of health, and even more pleased to see their emphasis on policy-level change (
- Kuehnert P.
- Fawcett J.
- DePriest K.
- Chinn P.
- Cousin L.
- Ervin N.
- Flanagan J.
- Fry-Bowers E.
- Killion C.
- Maliski S.
- Maughan E.D.
- Meade C.
- Murray T.
- Schenk B.
- Waite R.
Defining the social determinants of health for nursing action to achieve health equity: A consensus paper from the American Academy of Nursing.
). I was all the more disappointed, therefore, when I got to their actual policy proposals. Yes, they are merely examples – but examples of what?
Two of the 6 appear self-serving (ie.more funding for school nurses, full practice authority for NPs). A 3rd is about expanding the existing US healthcare system, via the deeply-flawed Affordable Care Act. A 4th (housing first) is about expanding access to social-service programs serving individuals. A 5th is very vague (nurses should speak up more about global warming?). Only one – the proposal to raise the minimum wage – is “upstream” as a way to reduce income inequality. For all the panel's repeated invocations of the central role of structural racism (or is it systemic racism?), none of these proposals explicitly seeks to dismantle those systems. Addressing the SDOH is supposed to be about the “causes behind the causes”, while the panel's examples are focused on the symptoms.
Why not – for example – suggest more funding for schools, not just for school nurses, and through channels other than local property taxes, which are inherently unequal and racist? Instead of just Housing First programs for homeless persons, why not also more affordable housing? Along with raising the minimum wage, why not stronger protections for union organizing and worker safety? Why not a universal healthcare system that really serves everyone equally and has enforceable cost controls? Why not raise the emission standards for US automobiles, or more vigorously promote electric vehicles? Why not serious tax reform to pay for all these programs? The problem, after all, isn't just that some people have too little; it's also that other people have way too much.
I wonder if the answer is that the alternatives suggested above were deemed too “political”, too controversial, or too divisive. If this paper is an example of the fruits of consensus, however, perhaps that is not the best model for advancing social change. It is not the time for nurses to “make nice”; it's time for nurses to make trouble – good trouble. Lillian Wald (not to mention her firebrand friend Lavinia Dock) would ask no less of us.
Published online: April 29, 2022
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