I met William* on a busy Friday morning during our homeless outreach clinic. He waited patiently while I saw the patients before him. He greeted me with a firm handshake and asked if I could help him with getting his medications. He told me he’d had a stent placed in his heart four weeks ago.
“It’s actually my fourth heart surgery, “ he tells me. He was sleeping outside when he started having chest pain. After a few days he decided he couldn’t ignore it anymore and walked into the ER. He was hospitalized immediately and taken into surgery. At discharge, the hospital provided two weeks of medication and transported him to a local shelter. When he arrived, he found out there had been a miscommunication and there wasn’t an open bed at the shelter so he joined the 3,000+ Atlanta residents sleeping under bridges, in parking garages, and other places not meant for human habitation. After a week he was able to get into an emergency shelter down the street from the clinic.
“They told me about you guys and I thought I might be able to get medication,” he explains with a smile that seems too large for his lean frame. “I know I need to be taking them.” He doesn’t know the names or dosages of his medication but he remembers what they were for and we piece together a medication list:
“I’m on something to make the stent work.” He needs a blood thinner.
“I’m supposed to take something for blood pressure.” He needs at least two blood pressure medications.
“I’m on something for cholesterol.” He needs a statin to prevent another heart attack.
He is gracious and upbeat about staying inside for a while and having medications but I keep thinking about how his situation so clearly illustrates the brokenness of our health care and social services systems. This man is one clot away from death and without consistent medication he will be back in the emergency room with another heart attack. Our understanding of social determinants of health suggests his path to heart disease started in childhood. As a black man living in America he’s undoubtedly experienced racism. He provided a history of growing up in poverty and experiencing abuse. He started smoking at a young age, a rational response to chronic stress. This stress along with smoking, genetic factors and lack of access to preventive health care resulted in four heart surgeries by the age of 50 and an ever-decreasing life expectancy.
His story is unfortunately not particularly unique at my clinic or anywhere else in the U.S. Zip code is a very strong predictor of life expectancy. Life expectancy between poorer and wealthier zip codes ranges from 13 years in Atlanta to 9 years in New York to 20 years in Philadelphia. Dissected at a neighborhood (census tract) level, these differences become even more staggering with 20 to 30 year life expectancy gaps between neighborhoods in the same city, some just blocks apart. These years amount to lost friendship, productivity, experience, and growth. It’s also a loss to society as a whole. Each time William ends up in the hospital that hospital looses money. The cost of his care is passed on in increasing health care costs. When poverty, unemployment, oppression, racism, lack of education, and other social determinants shorten lifespans as a society we loose years of production, ingenuity, and advancement. Even the top of the socioeconomic ladder suffers when the bottoms rugs fall out.
So where do we start? The more we understand the role of social determinants in creating health inequity, the more overwhelming the problem becomes. However, when we understand that all aspects of society impact health status it also means that all of our decisions and actions have the power to improve the health of our nation.
If you are in health care, recognize that medical care only has a very limited ability to decrease preventable deaths. Start screening for social determinants of health using a verified tool or develop your own based on needs assessment data from your community. Build relationships with local food producers, case workers, outreach programs, pastors, and others providing helps with housing, food access, and other resources. When we leave the health care bubble for a more inclusive view of health, we can prevent the diseases we spend our days treating.
If you are an employer, consider pathways for employee advancement and job control. If you are involved in urban planning or real-estate, increase affordable housing options and add affordable units in all of your projects. As an individual, consider attending community meetings or running for local offices. Volunteer at an under-resourced school and shop in ways that support local businesses and food growers. Advocate for health in all policies, using health equity as a means of evaluating those policies. Local action improves neighborhood health, which decreases the life expectancy gap.
William leaves with a handful of bottles of medicine. It’s a small step toward preventing another hospitalization. We also talked about options to stop smoking and build a consistent medical record of follow up visits for a strong disability case. It’s small steps for only one person but there are hundreds like him in my clinic every week, and every day is an opportunity for impact. The same is true for our neighborhoods. In the face of overwhelming health disparities, do something because we can and because millions of small actions can create significant change.