Opinion

VIEWPOINT
Social Determinants of Health in the Digital Age
Determining the Source Code for Nurture
Freddy Abnousi, MD, The scope and types of data available in social net- of Health and initiatives by the MacArthur and Robert
MBA, MSc works represent growing potential resources for deci- Wood Johnson Foundations.4-6 From a research per-
Facebook Inc, Menlo phering and addressing the social determinants of health. spective, numerous studies have shown associations be-
Park, California; and
Between 2005 and 2018, the use of social media among tween social determinants of health and life expectancy.7
Stanford University
School of Medicine, individuals in the United States increased from 5% to While these studies reflect the overall importance of so-
Stanford, California. 69%.1 In 2016, the Pew Research Center found that Face- cial determinants of health in relation to health out-
book was the most popular platform, used by 68% of the comes, an important limitation of current research on
John S. Rumsfeld, MD, US population (76% of whom visited the site daily, en- social determinants of health is that many of the iden-
PhD
gaging for nearly an hour a day), followed by Insta- tified factors, such as income and education, cannot eas-
American College
of Cardiology, gram, Pinterest, LinkedIn, and Twitter.1 Social media user ily be changed.8 This is in part because of a lack of granu-
Washington, DC; profiles represent archives of people’s activities and con- larity in understanding the person and his/her
and Department of nections, curated in real time. Furthermore, the rela- community, compounded by the potential flaws intro-
Medicine, University
of Colorado School of tionships between and among users are dynamic social duced by survey self-reported social/behavioral vari-
Medicine, Denver. network structures that intertwine people, places, and ables as opposed to observed factors. Access to infor-
their interests.2 This information has the potential to im- mation that captures the habits, behaviors, and networks
Harlan M. Krumholz, prove understanding of the social determinants of health of individuals has been limited in the existing body of
MD, SM
in a deeper way than prior data sources have ever al- work as these parameters relate to health outcomes. As
Departments
of Medicine, lowed, and, in turn, identify novel targets that could such, it is not surprising that actionable variables con-
Epidemiology, and meaningfully influence health outcomes. tinue to be elusive.
Public Health, Yale Remarkable advances in medical science, clinical Better approaches are needed for accessing infor-
School of Medicine,
care, and therapeutics over the last 60 years have es- mation about observed habits, behaviors, and net-
New Haven,
Connecticut; and tablished the current understanding of the “nature” side works to foundationally understand their relationship
Center for Outcomes of disease. The “nurture” components of disease also with health and health outcomes. Despite the exponen-
Research and have been explored, revealing strong associations be- tial increase in the role of social media in the daily life of
Evaluation, Yale
New Haven Hospital, tween social support and health outcomes. However, individuals around the world over the last decade, most
New Haven, prior investigations into social determinants have of- studies have not directly evaluated social variables from
Connecticut. ten been limited by self-reported information based on social network sources in relation to clinical outcomes.
Evaluating social network data in
combination with increasingly available
[Data from social media] has the potential digitalhealthcaredata(suchasfromlarge,
national clinical registry programs or elec-
to improve understanding of the social
tronic health records) could lead to novel,
determinants of health in a deeper way more nuanced understanding of social
than prior data sources have ever allowed and behavioral variables that account for
the interplay of the individual and the net-
reductionist instruments with standardized responses. work in relation to health outcomes. These may trans-
Moreover, social determinants are complex, and entail form the traditionally held social determinants of health,
networks and behaviors that are best revealed by what including education, income, housing, and community, to
actually occurs in life, rather than the perception of these encompass a more granular tech-influenced definition,
complex relationships. Individual and network data avail- ranging from simple factors, such as numbers of online
able within social platforms therefore have the poten- friends, to complex social biomarkers, such as timing, fre-
tial to elucidate the understanding of social determi- quency, content, and patterns of posts and degree of in-
nants of health and could offer measurable, actionable tegration with online communities. With data related to
insights into how disease can be prevented. To date, only millions of users, network effects may amplify the total
limited direct links between medical and complex so- range of patterns and associations.
cial network data have been made. The promise of this kind of research endeavor not
The roots of interest in social determinants of only involves its scale, but also involves the richness of
Corresponding health can be traced back in part to the World Health possible connections that can be explored with ma-
Author: Freddy Organization (WHO), which, in 1946, notably defined chine learning and other evolving “big data” method-
Abnousi, MD, MBA, health as “complete physical, mental, and social ologies. Given that users interact daily with these plat-
MSc, Facebook Inc,
well-being.”3 Since then, a number of national and in- forms, the potential for intervention may exceed the
1 Hacker Way,
Menlo Park, CA 94025 ternational efforts have increased awareness of the field, immutable nature of the social factors that have been
(abnousi@fb.com). such as the WHO’s Commission on Social Determinants explored to date. For example, could suicidal ideation

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 Opinion Viewpoint

be identified at the individual and network level with enough ad-
vance warning and accuracy to stage a peer-driven intervention?
What if risk-factor prediction models used to identify patients at
high risk for opioid addiction could be refined sufficiently for phy-
sicians to reliably use these models as a means to revise care man-
agement plans? Could individuals at the highest risk for cardiovas-
cular mortality be identified, and then families and close networks
be tasked with responsibilities for each other using the networks to
facilitate increased social integration and, thereby, reduce mortal-
ity? These data could also provide novel markers of early disease,
as suggested by assessing keystroke patterns as a precursor for
Parkinson disease.9
However, along with significant potential for benefit, this kind
of research also harbors potential risk and clear challenges. As was
done for the Human Genome Project, the first step will be to estab-
lish the legal and ethical framework for this endeavor. Social net-
work data raise unique challenges to deidentification beyond the
typical demographic identifiers. For example, when an individual
posts a simple phrase, the exact composition of words used can be-
come a form of identification in its own right; developing the tech-
niques to deidentify this kind of data will require thoughtful ap-
proaches. In addition, a combination of physical and software-
driven isolation needs to tightly control access to the data.
Concurrently, investment in research towards the creation of
“synthetic data sets” (ie, data sets that maintain associations but
have the original data removed) may serve to advance security and
privacy for the next iteration of this research.
The United States and many other countries are in national dia-
logues about privacy and whether data collected for personal rea-
sons can be used in aggregate to advance knowledge in meaning-
ful ways. The prospect of social media data propelling research into
social determinants of health should serve to stimulate the devel-
opment of methods that respect individuals, seek consent when-
ever possible, and always protect security and privacy in the quest
to learn more about how best to promote health.
Once acceptable privacy and security standards have been es-
tablished, the next step will be to forge the public and private part-
nerships necessary to link social media data with clinical and health
outcomes. A number of additional steps will be required between
this point and data analysis, and even once accomplished, the find-
ings will be retrospective and associative. Nonetheless, embarking
on the earliest stage of harnessing social network data is necessary
to determine if those data hold the promise to advance understand-
ing of social determinants of health in a truly novel way. When com-
bined with deep, powerful, and interactive social tools, perhaps it
will be possible to rewrite the source code for nurture.

ARTICLE INFORMATION
Published Online: December 20, 2018.
doi:10.1001/jama.2018.19763
Conflict of Interest Disclosures: Dr Abnousi is the
Head of Healthcare - Research at Facebook Inc.
Dr Krumholz reports contract work for the Centers
for Medicare & Medicaid Services, grants through
Yale from the US Food and Drug Administration,
Medtronic, and Johnson & Johnson, serving as the
chair of the Cardiac Scientific Advisory Board at
United Health, the Life Sciences Board at IBM
Watson Health, the advisory board at Element
Science, the Physical Advisory Board on Aetna,
and is the founder of Hugo. Dr Rumsfeld reports
no conflicts of interest to disclose.
REFERENCES
1. Pew Research Center. Social media fact sheet.
The Pew Research Center website. http://www
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Accessed February 13, 2018.
2. Facebook: sharing it all. The Economist. https:
//www.economist.com/blogs/babbage/2011/09
/facebook Published September 23, 2018. Accessed
February 14, 2018.
3. Irwin A, Scali E. Action on the social
determinants of health: a historical perspective.
Glob Public Health. 2007;2(3):235-256. doi:10.1080
/17441690601106304
4. Marmot M, Friel S, Bell R, Houweling TA, Taylor S,
Commission on Social Determinants of Health.
Closing the gap in a generation: health equity
through action on the social determinants of
health. Lancet. 2008;372(9650):1661-1669. doi:10
.1016/S0140-6736(08)61690-6
5. MacArthur Foundation. Research network on
socioeconomic status and health. The MacArthur
Foundation website. https://www.macfound.org
/networks/research-network-on-socioeconomic
-status-health/details. Accessed March 1, 2018.
6. Robert Wood Johnson Foundation. RWJF
commission to build a healthier America.
The Robert Wood Johnson Foundation website.
https://www.rwjf.org/en/how-we-work/grants
-explorer/featured-programs/rwjf-commission-to
-build-a-healthier-america.html. Accessed
March 1, 2018.
7. Chetty R, Stepner M, Abraham S, et al. The
association between income and life expectancy in
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(16):1750-1766. doi:10.1001/jama.2016.4226
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social determinants of health: what works? PLoS One.
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9. Giancardo L, Sánchez-Ferro A, Arroyo-Gallego T,
et al. Computer keyboard interaction as an indicator
of early Parkinson’s disease. Sci Rep. 2016;6:34468.
doi:10.1038/srep34468

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