Several years ago, the World Health Organization’s (WHO) Commission on Social Determinants of Health (SDH) put out a publication with a title that asked a poignant question: “Why treat people’s illnesses without changing what makes them sick in the first place?”
There have been multiple times over the years when I have asked myself the same question — sometimes several times a day. Here are two hypothetical patients, Melvin and Mildred whose hospital course can illustrate why disparate health outcomes among our patients make many clinicians ask that same question the WHO asked above.
Melvin is 47, lives in a temporary housing with three other people, he is admitted to the hospital, for foot infection, for the third time. He has poorly controlled diabetes, hypertension and coronary vascular disease. He doesn’t know all his medications, smokes, has a ninth grade education, does odd jobs, is estranged from a female partner and his two adult daughters. In the hospital he has minimal interaction with the care team.
Mildred is 75, has hypertension, osteoarthritis and Chronic Myeloid Leukemia who is admitted to the hospital after a fall. She is a retired accountant, widowed, lives in her own home, has a daughter who is a college professor and a son who is a registered nurse and her medical power of attorney. She has four grandkids to whom she is very attached, drinks a glass of wine occasionally, no tobacco use, goes to a bridge club once a week, enjoys gardening. Her children are actively involved in her treatment and discharge planning and frequently interact with the clinical team for updates on her course.
Incidentally, both Melvin and Mildred test positive for the SARS-CoV-2 virus during their hospitalization. At the time of hospital discharge, they are both told to isolate themselves for 10 days.
During discharge planning, Mildred and her family made an informed consent for her to get outpatient physical rehab, and decided to move her to an assisted living facility where she can still be close to her grandchildren and maintain her independence. She is to follow up with her already established primary care doctor and oncologist at the end of her isolation date.
On the day of discharge Melvin is told that unless his diabetes is better controlled, he will likely lose his foot, unless he stops drinking his liver will fail, and that he has very high risk for heart attack and stroke due to his hypertension, diabetes, smoking and drinking. He is given a list of centers for alcohol rehab, a follow up appointment for a wound care clinic, a 10-day course of antibiotic for the foot infection in addition to refills of seven other medications. He is told to follow up with a new primary care doctor in 10 days at a local clinic after completing his isolation days.
It doesn’t take a medical or public health degree to speculate the disparate post discharge outlook for these two people, despite each getting the “standard of care” for their respective medical needs. Melvin is one of thousands of socially disenfranchised patients who go through the medical system repeatedly with predictable poor health outcomes. This is because most of what determines health is determined by social circumstances. Social disenfranchisement is not just economic depravity, it is also lack of social capital-which is the essential network of “relationships among people who live and work in a particular society, enabling that society to function effectively”. Socially disenfranchised patients, often live segregated with other socially disenfranchised people. They are caught in a vicious circle of poverty and poor social capital that worsen their health status that further impoverishes them which makes them sicker which disenfranchises them even further. This wheel keeps turning, pulling in many more nearby into its orbit until whole communities are trapped.
That poverty and ill-health are inextricably intertwined is an accepted fact, the question is, who is responsible to address this public health hazard? Pre-pandemic, there was less consternation over this association and doctors could focus on providing the “standard of care” to every patient equally who came through their doors. In caring for a patient like Melvin, a physician would dutifully enumerate to Melvin the dire consequences of neglecting his health, and Melvin would dutifully listen. He would get treated for foot infection get some education and some social resources for outpatient follow up and the doctor would move on to the next patient. At some deep level, both Melvin and his doctor would sense the odds are stacked up against Melvin to stay healthy but they would go through the motions nonetheless. As sure as the sun rises on the east patients like Melvin are frequently readmitted, often for the same problem or from complications of the same problem. When Melvin comes back, he would be labeled as “non-compliant” who didn’t take personal responsibility for his health. He would receive the “standard of care” once again and then get discharged, and the doctor would move on to the next patient. This is a classic case of “medical futility in the face of social dysfunction.” And this is common. And this is very expensive.
In the time of this pandemic, Melvin’s adherence to discharge recommendations against COVID-19 is a serious public health matter of national and international magnitude. Who should then intervene on behalf of disenfranchised patients and their communities whose socio-economic standing does not afford them the luxury of following some key public health recommendations? A time has come when this question can no longer be ignored by health systems. If health systems are to be relevant in solving such complex population-based problems the only way forward is through forming a multi-sectoral collaborative, where affected communities are also given a seat at the table.
Logic dictates that our attempt to deliver equitable healthcare to all people without addressing the SDH that thwart these efforts is ineffective at best. In the time of COVID-19 while the SDH are top of mind, we should ask ourselves the same question the World Health Organization asked, paraphrased: Why don’t we work more to change what makes people sick?
The COVID-19 pandemic will someday become part of our dark history, but disenfranchised communities will be here for generations to come. They will remain major targets for subsequent public health calamities and they will remain vulnerable to disparate health outcomes– unless we invest in their social wellbeing today.
Sosena Kebede MD is the Chief Medical Officer for Community Health Services, Inc./ Hartford.