“The Service” & the Social Determinants of Health

In presentations I have made in the past year or two I have had to confess to a relative inexperience and unfamiliarity with the social factors that can adversely affect a population’s health and well-being.

My inexperience is the result of having spent nearly my entire medical and leadership career practicing in the military medical system. Until recently my patients, their parents and families were all active duty or retired military. As a group they had education, jobs, housing and access to healthcare. We know that only about 20% of what makes our patients well or not is a result of health care (despite our inclination to think that those of us in health care are located at the center of the wellness universe). For the remaining eighty percent of what influences health and well-being, our military patients had the benefit of the positive effect of education, jobs and housing.

Education: A high school diploma or high school equivalency certificate (General Education Development “GED”) is a requirement for entry onto active duty with few exceptions. Additional assessment for reading and mathematics competency result from the applicants taking the Armed Services Vocational Aptitude Battery (ASVAB) in the recruiting process. Tuition assistance and the “GI Bill” are available to enlisted personnel beginning after their first year in the service. in a study from the Congressional Budget Office, 74% of the enlisted force surveyed (who generally enter with only a high school education) had completed some college with 12% having completed associate degrees, 8% bachelor’s degrees and 1 percent advanced post bachelor’s degrees. The Service obviously selects for those who have already achieved academic success but also offers continued education opportunities and expectations.

Employment / “Economic Security:” By definition someone in an active duty military family has a job. Young service members entering active duty make $1,417 each month for the first four months of service then receive a pay increase to $1,532/mo. In many cases it may not be enough to assure economic security for a family and is admittedly below the poverty level for a family of four ($18,324 vs. $25,100). An enlisted soldier with six years in military makes $2596.50 /mo ($31,158/yr) and an entry level officer with less than two years’ service makes $3107.70/mo ($37,292/yr) well more than 200% above the poverty level for a married couple ($16,460) especially with some of the additional benefits offered to those in the Service (e.g. no sales tax on purchases from Post Exchanges and on-line shopping, subsidized commissaries and recreational opportunities).

Housing: Housing is provided to all active duty military. Service members with a family or single service members with enough time in service can draw a housing allowance to live off of the military post or base. And they can use that allowance towards a mortgage on a home that they will ultimately own. A 1997 RAND military housing study found that 43 percent of service members lived in military family housing and only 27 percent owned homes in the community. A 2010 study noted a shift from housing on base to owned housing in the community. In this latter study 29 percent of those surveyed were living in military family housing, but 32 percent rented and 38 percent owned housing in the community. The average annual increase of 5 to 6 percent in the service member’s basic allowance for housing in the last decade may have fueled a push toward early home ownership. And although it is controversial, home ownership is often thought to open the door to the opportunity for generational wealth.

Health Care: All active duty and their family members are provided free health care. There are almost no out of pocket costs for care delivered in the military system. This includes primary and specialty care, pharmaceuticals, procedures and hospitalizations. Military retirees with more than 20 years of service and those retired with medical disability are entitled to TriCare Prime which costs less than $600/yr for a family with minimal or no co-pays or deductibles. The system is far from perfect but it has a global reach, is integrated, longitudinal, and equitable. And it is a system increasingly focused on health and well-being rather than just the eradication of disease.

In addition to education, employment, housing and health care there is one additional benefit that may impact the well-being of service members and their families. Retired Air Force General Johnnie Jumper tells the story of walking through a crowd of recruits recently graduated from basic training. He asked a young graduate how she felt. “Sir,” she said, “For the first time I feel as though I am a part of something bigger than myself.”

Victor Frankl, a psychiatrist who survived the German concentration camps at Theresienstadt, Auschwitz, and Turkheim, believed that “Man’s search for meaning is the primary motivation of his life.” He proposed that “At any moment, man must decide, for better or worse, what will be the monument of his existence.” The notion of finding purpose through service for others is not a new one. Fyodor Dostoyevsky writes in The Brothers Karamazov (1879) “The mystery of human existence lies not in just staying alive, but in finding something to live for.”

There is compelling evidence that purpose and meaning (eudaimonic well-being) are distinct from happiness (or hedonic well-being) and positively affect health and well-being in measurable ways. In an all-volunteer military that has been engaged in the longest war fought by volunteers in our Nation’s history (17 years this autumn), people often join for the benefits and opportunities. But they stay for the sense of purpose.

Service in the active duty military largely eliminates the potential negative impact of the social determinants of health by providing education, employment, housing, healthcare and purpose and reminds us that these disparities can be overcome. But the military is not for everyone. And we only need so many on active duty.

There should be additional ways for all young American men and women – particularly those from underserved areas – to serve their country and reap the same benefits.

Perhaps that is an effort worthy of our National leadership.

Chuck Callahan Henry V 4.3 – Lead from the Front https://henryv43.wordpress.com/