Winter 2014

Wide-Angle Healing

U.S. medicine needs to take a step back and consider patient complaints from a broad social perspective if it is ever going to get better at delivering optimal health

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Illustration: Brian Stauffer

It was an unseasonably warm spring day in South-Central Los Angeles in 2011. Veronica, a 33-year-old woman, sat in my exam room, her head in her hands. Her otherwise tall and formidable figure was slouched over in pain. This was not the first time she had felt this way. For more than a year her headaches had come and gone. And each time, the pain would ripple through her life, disrupting her family and work. This episode was no different. She had missed about seven days of work as an office manager at an auto parts dealer in the past month. 

We have to see past the imagined boundaries of the clinic walls and the role of the clinician. Then we’ll see that health care can be better.

Veronica’s employer, who was understanding, would see her in pain and insist that she leave early and seek help. But the headaches kept coming, straining her relationships at work. Her home life started to suffer. It was hard for her to sleep. Veronica often had to call on her elderly mother to care for her two sons when she needed to visit the doctor or simply rest. At her sons’ school activities, Veronica was often unable to focus. Usually a stoic woman, she considered herself unflappable in the face of adversity. But these days, she admitted, she was fatigued and often irritable. 

Three weeks earlier, Veronica had gone to a local emergency room to seek relief. After a battery of tests, a doctor prescribed her some pain medications. Then she gave Veronica instructions to return to the emergency room if the pain worsened or persisted. The medicines helped for a short while, but they often left her drowsy and unfocused. The pain persisted. So, following instructions, she returned twice more to a local emergency room. All told, she underwent at least a dozen blood tests, two CT scans and a spinal tap. But for Veronica, each visit to the emergency room ended the same way: She was told her test results were “normal,” sent home with more pain medication and advised to seek a primary-care physician. 

When I met Veronica, she was exasperated. A $1,200 bill for her first hospital visit had arrived at her home. At work, her boss was growing concerned. Veronica was concerned about losing her job. Without a steady income, she worried about paying the rent, roughly $850 per month. She fought back tears as she described the toll this was taking on her family. 

And she grimaced often. On top of everything else, Veronica was still in pain.

Her story is far too typical in our health-care system. Her experience has become commonplace, not just in low-income neighborhoods but in middle-class and more affluent communities as well. Access to quality care is a problem. And even when care is available, it is often poorly coordinated, expensive and stressful.

When Veronica came to our clinic, though, we did things slightly differently.

The clerk checked Veronica in. The medical assistant recorded vital signs and collected standard information about her health. This is a typical process for many clinics. But then the medical assistant ran down a simple checklist, asking Veronica a few routine, evidence-based questions about her housing. Veronica indicated that her apartment had some problems with mold, water leaks and roaches. These answers went into her chart, along with other important data. I briefly reviewed the chart and opened the door to greet her.

Knowing where Veronica lived made a world of difference. I asked her to tell me more about her home and her headaches. She lived with her sons in a two-bedroom, ground-floor apartment in South Los Angeles, not far from the clinic. Veronica insisted that she kept her home as clean as possible, but persistent leaks had led to chronically damp, moldy conditions and the roach infestation. Her landlord hadn’t helped, and she couldn’t afford to move. As she talked, I followed up with more questions and began a targeted physical exam. 

Within 15 minutes, I felt pretty confident in my diagnosis: Veronica had migraines related to chronic nasal allergies and sinus congestion. These conditions are often caused or made worse by dampness, mold, roaches and other markers of substandard housing. I asked about her sons’ health. Her eldest was under a pediatrician’s care for severe asthma, another health problem often related to bad housing. I explained my concerns and prescribed her medicines to help with the symptoms. Then I referred her to a program run by our clinic in partnership with two local organizations to help make her housing healthier. One of the partners was a tenants’ rights advocacy group long active in South Los Angeles. The other was a community development agency that created affordable housing and trained residents to become community health workers.

Within a few days, a community health worker from our clinic visited Veronica. She taught her new techniques for controlling dampness in her home. Then, with the help of our partners, she helped Veronica contact the landlord, this time with a doctor’s note and information about local housing codes that the landlord was obligated to meet. 

Veronica came back to the clinic a few months later for a routine follow-up visit. She hadn’t been to the emergency room. Her home was healthier. Her allergies lingered but had improved, and her headaches were gone. Her son’s asthma was less active. Veronica and her family had gotten better.

Symptoms vs. Causes

To improve Veronica’s headache, the health-care system had to address where she lived. Why did Veronica go so long before she got that type of care? Did she have to suffer as long as she did? The great irony is that many of the health-care professionals who had cared for her provided what is generally considered adequate care. On each occasion, doctors and nurses initiated a diagnostic workup involving expensive machines and procedures. They prescribed medications to help relieve her pain and instructed her to seek further evaluation if required.

The problem, of course, is that the current standard of care isn’t working. Instead of addressing the cause of disease, health care in the U.S. has long focused on just treating its symptoms. We fixate on the headache and ignore the home. Once upon a time, interacting with patients in their homes and communities seemed like an obvious, integral part of doctoring. But in the last century or so, the culture of medicine has largely been shaped by an exuberant overemphasis on the biologic and molecular phenomena of disease. Improving the social conditions that shape health has become an afterthought.

In the last century or so, the culture of medicine has largely been shaped by an exuberant overemphasis on the biologic and molecular phenomena of disease.

And that’s the irony. When clinicians ignore the home—or any of the other factors that shape our health—their treatments are often less effective. In clinics and hospitals across the nation, we repeatedly miss precious opportunities to understand and improve people’s health in the context of their social and physical environments. These opportunities are often obscured by the transactions of pills and bills that have come to define the health-care experience for many patients and providers. For patients like Veronica, the medical system fails to reduce suffering because it simply doesn’t collect the right data or equip providers with the right tools to address the factors that shape our health where it begins. 

This disconnect is striking, especially when one considers the forces that determine how healthy we are as a society. As the New England Journal of Medicine reported in 2007, medical care accounts for only about 10 percent of the variation we see in health outcomes. 

When we think about what really shapes our health, medical care is just one relatively minor force. Experts often think of five general health-defining forces: genes and biology, behavior, medical services, social environment (the ways in which we relate to each another) and physical environment. The latter two, often referred to together as the social determinants of health, are significantly more powerful drivers of wellness than is medical care. 

The social determinants are shaped by the power and resources that people have, all of which are influenced by the policy choices we make as a society. These policies, in turn, influence the behaviors and choices you and I make every day. For instance, a growing body of research indicates that how close people live to affordable, healthy food outlets or safe, green parks plays a role in their choices to eat healthily or to exercise. 

I would argue that the future of health care depends on growing and supporting more of what I call “upstreamists.” These are the rare innovators on the front lines of health care who see that health (like sickness) is more than a chemical equation that can be balanced with pills and procedures administered within clinic walls. They see, rather, that health begins in our everyday lives, in the places where we live, work, eat and play.

Upstreamists are the rare innovators on the front lines of health care who see that health (like sickness) is more than a chemical equation that can be balanced with pills and procedures administered within clinic walls.

The nature-vs.-nurture debate can no longer be viewed as a battle between equals. The impact of nurture—in the form of the social and environmental settings that surround us—is far more powerful than we’ve ever imagined. These are the forces that shape or distort our genes, our behaviors and the landscape of opportunity in our communities. 

Our current standard of care often ignores these forces. This lack of attention leads to missed opportunities to effectively alleviate suffering and can sometimes even contribute to more suffering. Think of the costs for Veronica. While bouncing in and out of the health-care system, Veronica stacked up major opportunity costs. Instead of spending time at work or with her family, she spent days in a hospital or clinic looking for help. The direct economic costs were just as bad. Just one of her three emergency room visits resulted in a bill roughly equivalent to one month’s rent.

Then, ironically, this experience with the health-care system took its own toll on her health. Each time a hospital or a clinic discharged her with nothing more than pain medicine, the system unwittingly sent Veronica—without adequate warning, protection or tools—back to her home, the place where her illness first started. Besides Veronica, I’ve cared for many other individuals who suffered health problems caused or worsened by factors in their home, work or school. In each case, these patients had received care from clinics for weeks, months and even years, only to have the social or environmental context of their disease ignored. It’s like mistakenly and repeatedly sending someone suffering from radiation exposure back to a home near the site of a nuclear power plant meltdown, without protection or help. 

Expensive and Ineffective

I would suggest that the current standard of care itself is simply unacceptable, from a moral and an economic perspective. No matter how you look at the performance of our medical system, what has come to pass as the standard of care is far from cost-effective. In the U.S, health-care spending represents 18 percent of our gross domestic product. That comes to about $8,000 per person every year, more than any other nation has ever spent on health care. 

But the return on that investment is pretty poor. Among all nations, the U.S. ranks 37th in health status. In fact, Americans—both rich and poor, minority or not—are experiencing a widening health disadvantage compared with citizens of other wealthy nations. The Institute of Medicine, established in 1970 as the health arm of the National Academy of Sciences, recently completed an exhaustive 405-page review of this gap. The authors put it plainly: Comparing the U.S. with 16 other wealthy nations, they say, “we uncovered a strikingly consistent and pervasive pattern of higher mortality and inferior health in the United States, beginning at birth.” 

Recent changes in the law have made health care more accessible and affordable for millions of Americans. The Patient Protection and Affordable Care Act of 2010, aka Obamacare, will increase the number of insured Americans by around 27 million by 2017 through a combination of mandates, tax credits and subsidies to employers and individuals. One of the law’s lesser-known benefits is a major national expansion of community health centers like the one I worked in when I met Veronica. Up to 20 million additional Americans will access care at these sites in the next few years. Many clinicians, including me, have welcomed and even championed these reforms, knowing that far too many people have lacked access to health care for far too long. 

But the major problem with the current standard of care still looms large. In a 2011 survey, the Robert Wood Johnson Foundation found that four out of five doctors in America believed that their patients’ social problems—those social determinants of health—were as important as their physical health problems. But only about one in five doctors felt confident in their ability to help patients with social ills.

The good news is that it’s a problem with a solution. I called Veronica recently to see how she was doing. It had been nearly a year and a half since her first visit with me. Her allergies and migraines were under control, less frequent and less severe. Many of the problems at home had abated, but she was still working to get the landlord to make additional repairs. 

To reach the solution, though, we must first acknow-ledge the shortcomings of our own assumptions about the nature of the problem itself. We have to see past the imagined boundaries of the clinic walls and the role of the clinician. Then we’ll see that health care can be better. And it will take the upstreamists to get us there.

Rishi Manchanda is the founder and president of HealthBegins, a Los Angeles-based startup focused on improving care for patients with medical and social needs. This article is adapted from The Upstream Doctors: Medical Innovators Track Sickness to Its Source (TED Books, 2013), available as an e-book from Amazon, Barnes & Noble and Apple Books. The title was selected as a Common Reading Book, to be read and discussed by the first-year medical school class at Tufts, and culminated in the author’s visit to campus in Fall 2014.

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