Making the Connection
EFFECTS OF ENVIRONMENTAL AND SOCIAL FACTORS.The New Physician
Candy was hard to come by growing up. We rarely had any at home, and as kids we didn’t have the money to buy it for ourselves. But on Sundays, if we timed it right, we could count on one of the elderly women in our neighborhood to press a peppermint or butterscotch into our hands. I naively assumed they carried the candy to make us neighborhood children happy. I learned later that the candy wasn’t just a treat. It was the women’s “medicine” to control their blood glucose levels. A quick candy could be just enough to stabilize their blood sugar, keeping their diabetes in check.
Looking back on the neighborhood where I grew up—an underserved, predominantly black community a little more than an hour southwest of Chicago—diabetes was a common complaint. The prevalence of hypertension and heart disease was equally worrisome, mirroring other communities with a similar demographic and socioeconomic makeup.
Although I didn’t realize the connection between environment and health until much later, when I did, it cemented my desire to become a physician. I began to understand that health care is a way of life, encompassing more than what goes on inside a hospital.
To better understand this association, I worked as a research analyst studying impoverished, inner-city communities during college. My clinical research showed me how patients’ socioeconomic conditions affected their health and subsequent care. I also learned how these patients understood their care, as well as how they responded to particular physicians, and I began to recognize the barriers to care they faced. Many of these residents attributed their health problems to environmental and social factors, but because they were poor and uneducated, they were unable to address, much less correct, the threats to good health. Coupled with the violence, crime and discrimination that plagued their neighborhoods, their health problems only increased.
These situational factors typically lie beyond the clinical scope of medicine, but I wanted to address all health problems, beginning with a patient’s living conditions. I quickly noticed that such health-damaging behaviors as smoking and poor nutrition were more prevalent in impoverished communities and that traditionally clinicians ignored them.
Public health and outreach organizations that attempt to address these health inequalities have succeeded by using a much wider range of activities and interventions than primary care physicians. One example is Project Brotherhood, a program in the Woodlawn community of Chicago. Dr. Eric Whitaker, a former American Medical Student Association president and the current director of the Illinois Department of Public Health, built a model to deliver care to an underserved population of black men. When these men were asked what they wanted from a health-care system, they said they wanted to be respected, for without respect they didn’t feel they had access to treatment. So Whitaker began to address their health-care needs at the social level. He started clinics offering the men free haircuts and food, and, if they wanted, time with a doctor. And the men began to gather. Some came just for the haircuts or the food, but others listened to Whitaker’s informal health education sessions and sought health care.
Since the clinic opened in 1998, doctors have held sessions on anger management, diabetes, hypertension, AIDS and cancer. While receiving medical attention, the men also get help with work skills and have access to computers.
Since college, I have worked in health-policy consulting and health-care delivery systems. Looking at the bigger picture of medicine, I am more aware of the health problems that handicap underprivileged populations like those in my own childhood neighborhood. It has shown me firsthand how such policy and prevention initiatives as screening programs, needle exchanges and counseling sessions can address a community’s multiple and debilitating health problems.
An example of the need to incorporate public-health efforts with medicine is apparent with a disease like diabetes. Care includes medical management as well as lifestyle and prevention aspects. Diabetics need attentive medical care to control their disease and prevent complications. To ensure they have access to this care, many will need to overcome the logistical barriers of financing and transporting themselves, as well as finding child care or even a translator. Community-health centers and home visits help, and such public-health strategies as population-based screening can detect diseases early on.
Considering the biological insignificance race, ethnicity and socioeconomic status have on disease makes the strong correlation between poor communities and health problems very troubling. I believe the unraveling of this connection is critical to combating the health problems of minority communities.
At some point in the future, I hope I can say that my patients are second and third generations of my earlier patients. I hope that as a community, we can reduce the incidence of diabetes and hypertension through preventive medicine, education and better lifestyle choices. Luckily, I have been able to work with public-health organizations, pharmaceutical providers and other outreach efforts to provide some medications for the indigent with these diseases, but there is so much more to do. Ultimately, we as clinicians need to understand patients’ cultural and socioeconomic environments as much as their medical complaints in order to provide holistic and effective care.
Jay Bhatt is a third-year at the Philadelphia College of Osteopathic Medicine. He received his M.P.H. from the University of Illinois at Chicago. Direct comments about this article to firstname.lastname@example.org.