The Heart of Medicine
Aside from individual’s lacking access to healthcare, one of the biggest reasons medicine fails to achieve significant health outcomes is that we do not meet individuals where they are at nor do we fully appreciate what’s going on in their lives—not intentionally, per se, but overlooked none the less.
In the midst of diagnosing illness, typing away at our notes, and desperately trying to stay on track, it is easy to lose sight of the person in front of us and the context of their lives.
Yet, according to the World Health Organization (WHO), these circumstances—the conditions and environment where people are born, live, learn, grow, work, play and age—are the bedrock of their health, functioning, quality of life and wellbeing, even going so far as to state that they may be more important than healthcare or lifestyle choices in influencing health outcomes.
It is estimated that the Social Determinants of Health account for 30 to 55 percent of health outcomes.
Not surprisingly, failing to inquire about an individual’s SDoH can lead to any number of assumptions, including, but not limited to, the individual:
knows how to read and write
understands my advice, risks and benefits
can afford medications
has time to exercise
has adequate support from others to meet their goals
has access to food, utilities, shelter and safety
knows how to cook
has a quality grocer nearby
has a livable wage, steady income and benefits
owns a computer and internet-access
has transportation
and so on
Worse, we frequently end our visits with advice like “eat healthier,” “stress less,” “exercise more,” “take your medicines…all fifteen,” or “get more sleep.” Not only are these phrases useless, but assume an individual’s ability to translate their meaning accurately and implement them successfully.
Early out of residency I understood very little about the impact of these Social Determinants of Health—the non-medical factors, influencing a person’s health.
I understood even less about the broader systems and forces shaping those said conditions of daily life—forces not under the control of an individual, yet profoundly impacting their access to health and social resources and opportunities to thrive:
economic policies and systems
social norms and policies
political systems and agendas
But patients have a way of teaching you more than any textbook or lecture. I worked in a small, rural community mid-state Illinois, characterized by endless cornfields, a grocery store on Main Street, and a smattering of outlet stores begging travelers to spend money in the middle of nowhere.
Near the end of my term, a young woman came into the clinic to say goodbye while apologizing for not having a proper gift to show her appreciation—she just didn’t have the money.
She handed me a plastic-wrapped toy and said, “Thank you. This is all I could afford.” She had stopped by McDonald’s for a Happy Meal—her lunch—and saved the toy for me.
Placing the tiny stuffed animal on my dashboard, I realized her gesture exposed a level of poverty I really knew nothing about. One, that in all likelihood, I had rarely taken into account during those two years of seeing her and others.
Later on, while working at a federally qualified health center (FHQC) in Chicago’s inner city, home visits served as ongoing reminders that medicine can only be as successful as the conditions of our patients’ lives—lives we really know very little about unless we have taken the time to ask.
During one such visit, my resident and I were scheduled to see a middle-aged Cuban woman with diabetes, high blood pressure, weight problems, and high cholesterol. With little social support nearby and limited English skills, it was hard for her to get out.
Disheveled buildings, graffiti, broken sidewalks, and a cluttered hallway led up to her third floor one-bedroom apartment. Her kitchen was small with a sparsely filled fridge, a stove, two cabinets and a bookshelf functioning as a make-shift pantry, containing a few canned foods and six to eight Family Size boxes of Corn Flakes neatly organized in a row.
It all made sense.
The image is blazoned in my mind.
Did I really need an explanation why her numbers were not controlled?
Was I really going to suggest walking in the neighborhood when gunshots were heard on a regular basis? Or recommend salmon, fresh fruits and veggies when a grocery store was nowhere in sight?
Medicines were keeping things in check.
She was doing her best.
We were doing our best.
Neither was enough.
In countries at all levels of income, health and illness follow a social gradient: the lower the socioeconomic position, the worse the health.
Social Determinants of Health—What Are They?
Economic Stability: stable income and employment
1 in 10 people in the U.S. live in poverty and directly affects healthy eating, maintaining healthcare, and securing stable housing.
Steady employment, in particular jobs offering a livable wage, sustainable income and benefits, can help reduce the risk of basic needs insecurities.
Certain populations afflicted by chronic medical conditions, disabilities, injuries, and arthritis often struggle the most due to their inability to work consistent hours or perform certain duties
Education Access & Quality: literacy, vocational training, higher education
Individuals with higher education and training are often healthier and live longer.
Children from low-income families or living with the stress of discrimination are more likely to struggle with math and reading, less likely to graduate from highschool or attend college.
The stress of living in poverty can affect a child’s brain development, impact their learning, focus and academic achievement.
Lower education not only reduces the likelihood of getting a well-paying and stable job as adults, but is associated with an increased risk of developing chronic medical conditions, like heart disease, diabetes and depression.
Healthcare Access & Quality: health coverage, access to providers, inclusivity, cultural and language sensitivity, quality care
1 in 10 U.S. citizens do not have healthcare insurance.
Without insurance, individuals are less likely to have a primary care provider, participate in preventive measures, like cancer screening and finding disease early.
Without insurance, individuals are unable to afford treatment and regular follow-up visits for optimal management of chronic medical conditions.
Getting sick is one of our greatest liabilities, even if we have insurance—bankruptcy is often one sickness away
Neighborhood & Built Environment: sidewalks, parks, bike lanes, safety, building maintenance, transportation / traffic, internet / utilities, pollution, grocery stores and amenities
Appearance, upkeep, safety where people live, learn, grow, work is paramount to well-being.
Many live in areas of increased violence and volatility, unsafe air and water quality, noise pollution, heavy traffic, poorly regulated buildings or lack of pest control.
Populations most vulnerable are frequently racial and ethnic minorities and low-income families and individuals.
Social & Community Context: quality of friends, coworkers, family and community, exposure to discrimination / stress, access to social services
Positive support systems and healthy relationships at all levels are critical in how we experience stress, face obstacles and difficulties, reduce isolation, vulnerability, loneliness, and helplessness, and feel empowered—or not.
Having access to social services must be available to face the challenges outside of one’s control, such as losing a job, a pandemic, disasters, domestic violence, abandonment, mental health problems, including assistance with legal services or identifying resources and help.
We will continue putting proverbial ace-wraps and LARGE bandages on the medical conditions crushing our society until the foundations of well-being are stabilized and the systems, dictating the policies surrounding them, are rebuilt to support a healthy, vibrant community rather than garner votes, privilege, party favors, tax-breaks, and power.
We can do better, must do better.
Elections are coming up, vote for change that matters.
Notes & References:
World Health Organization. “Social Determinants of Health.” www.who.int https://www.who.int/health-topics/social-determinants-of-health#tab=tab_1
U.S. Dept of Health and Human Services. Healthy People 2030. “Social Determinants of Health.” www.health.govhttps://health.gov/healthypeople/priority-areas/social-determinants-health