I met William on a busy Friday morning during our homeless outreach clinic. He waited patiently while I saw the patients before him and fielded questions. He greeted me with a firm handshake asked if I could helphim with getting his medications. He told me he’d had a sent placed in hisheart 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 hedecided 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 there had been a miscommunication and there wasn’t an openbed at the shelter so he joined the XX other Atlanta’s sleeping under bridges,in parking garages, and other places not meant for 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 ableto get medication,” he explains with a smile that seems too large for his leanframe. “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 together 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 whileand having medications but I keep thinking how his situations so clearlyillustrates 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 myclinic 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 from13 years in Atlanta to XX to XX. Dissected at a neighborhood level, thesedifferences become even more staggering with 20 to 30 year life expectancy gaps between neighborhoods in the same city. These years about 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 unreimbursed 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 lowers when the bottoms rugs fall out.
So where do we start? The more we understand to role of social determinants in creating health inequity, the more overwhelming theproblem 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 onlyhas a very limited ability to decrease preventable deaths. Start screening for social determinants of health using a sterilized tool or develop your own basedon needs assessment data from your community. Build relationships with local food producers, case workers, outreach programs, pastors, and others provinghelp with housing, food access, and other resources. When we leave the healthcare bubble for a more inclusive view of health, we can prevent the diseases wespend our days treating.
If you are an employer, consider pathways for employee advancement and job control. If you are involved in urban planning or realestate, increase affordable housing options and add affordable units in all ofyour projects. As an individual, consider attending community meetings orrunning for local offices. Volunteer at an under-resourced school and shop inways that support local businesses and food growers. Adovcate for health in allpolicies, using health equity as a means of evaluating all 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 building 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 ofoverwhelming health disparities, do something because we can and because millions of small actions can create significant change.
We created this website as a place to share ideas and best practices. We invite you to contribute. Contact Us and tell us about your workand resources in the area of SDOH and health equity.
Let’s make healthy neighborhoods.