Social Determinants of Health (SDH)
One of the most neglected social determinants of health is access to adequate transportation. While housing, education, social inequality (as reflected by the Gini coefficient), and income are widely recognized as important factors of well-being, it is striking that the public health discourse on transportation has overwhelmingly emphasized the negative aspects. These include crashes, injury, mortality, pollution, lack of exercise, and noise. A worthy public health emphasis on active mobility through walking and cycling may have also overshadowed the central role of transportation as driver or passenger in an automobile for the majority of the US population who do not have access to effective public transportation or who have compromised personal mobility. Recent evidence points to the negative consequences of restricted personal vehicle transportation on an individual’s independence, emotional and social well-being, and life expectancy.
The public health bias towards the negative aspects of transportation issues, particularly driving, has led to observed disengagement of physicians and other clinicians in assessing and promoting medical fitness to drive and a failure to consider the transportation needs of patients when accessing health care services . For those clinicians who do address fitness to drive, few supports exist. At the federal level, a standard for fitness to drive exists only for commercial drivers (Federal Motor Carrier Safety Administration 49 CFR Part 391). At the state level, regulations vary regarding medical standards for fitness to drive and requirements for mandatory reporting of impairment. Seventeen states lack medical advisory boards to guide these regulations, and thirteen states lack internal medical units to review medical evaluations and/or need for re-examination of referred drivers . States without such medical support systems rely on individual physician opinion about fitness to drive and driving impairment despite a general lack of physician knowledge of medical fitness-to-drive guidelines .
Lack of consistent Standards. California DMV Guidelines. However many states do not have standards or guidelines.
It is not surprising, therefore, that there has been little dialogue between the field of health care and the main disciplines involved in transportation, such as transportation planners and engineers. However, the beginnings of a rapprochement between the fields have begun, through an emerging focus on the impact of disease and disabilities on transportation mobility and driving safety. This emerging scientific foundation should replace stereotypes, opinions, and anecdotes, and should guide evidence-based transportation counseling for older drivers, young drivers, and those with medical conditions and disabilities.