Some health problems are much larger than the health care system and cannot be fixed by doctors, nurses, hospitals, and the rest of the traditional health care team.

In our physician peer group sessions, my colleagues and I often share the agony we feel when sending people out of the emergency room, knowing that the patient is going right back into the conditions that contributed to their crisis in the first place. Perhaps they could not afford their insulin or have no refrigerator in which to keep it cold. Perhaps they are going home with the person who hurt them. Perhaps they don’t have a home to go to and are trying to care for their wound while living on the street. These situations are real, and they exist in rural areas, small towns, and big cities alike.

I often urge my patients to get more exercise, and we brainstorm ways to overcome the barriers they face. But options are limited for the person whose neighborhood has no sidewalks or isn’t safe to stroll through. We talk about good nutrition, and most patients know it’s best to eat plenty of fresh fruits and vegetables. But what if the only store they can reach is the convenience store which doesn’t stock healthy options?

Some of my patients come to me having researched their symptoms, and we talk about how to find reliable medical information on the internet. But what happens if they don’t have access to the internet? Sometimes I print out educational material, but that has no value for the patient who cannot read.

Almost everyone has stress in their lives, but for some people the stress is unremitting and severe. They deal with poverty and the attendant evils of housing and food insecurity, with limited education that restricts their options. They lack reliable transportation which keeps them from school or work or regular healthcare. They suffer from chronic diseases, racism and other forms of discrimination while separated from the support of family and community.

Research reveals that these chronic stressors have significant adverse effects on the health of not only the individual, but their descendants as well. We have a label for these stressors. They are called “social determinants” and we are increasingly aware that they play an even bigger role in a person’s well-being than all the things that health care providers do.

Protecting and promoting the health of our patients and our communities is a sacred mission, but we need to expand our perspective beyond medicine and surgery and helping one individual at a time. Health is larger than the health care system. We each have a role to play in recognizing and reducing the impact of social determinants for the well-being of our entire community.

Debra Johnston, M.D., is part of The Prairie Doc team of physicians and currently practices family medicine in Brookings, South Dakota. For more information, visit

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