In December 2019, Mrs. H, a 49-year-old Hispanic woman, presented to the Riverside Free Clinic to establish care. She told me in broken English that the doctor she had been seeing dropped her from his care for being noncompliant. A glance at her chart revealed that she had metabolic syndrome: obesity, Type 2 diabetes, hypertension and hyperlipidemia. Mrs. H admitted to eating a diet heavy in rice and meat but lacking in fruits and vegetables, not exercising, not tracking her blood sugar and not taking her medications consistently. I initially came to the same conclusion as her previous physician: she was a noncompliant patient who is not willing to make the effort to improve her health. However, learning more about her story made me question this label.
Mrs. H lives in a predominantly Hispanic, low-income neighborhood of Riverside. She shares a two-bedroom apartment with her husband, their youngest daughter and their son’s two children. Her grandchildren became her dependents after their father joined a gang and neglected them. Mrs. H and her husband emigrated from Honduras 30 years ago, and she never finished high school.
Mr. H works as a painter, and Mrs. H cleaned houses until she had to stay home and care for her grandchildren. She enjoys cooking traditional dishes and sowing clothes. She would like to exercise more but she does not feel safe walking in her neighborhood, and there are no parks in her community. Since staying home with the children, she has gained weight and become increasingly stressed about her family’s finances. She struggles to buy enough food for everyone and the cheapest options are never healthy. Other than a liquor store, a McDonald’s is the only food source in her neighborhood. Mrs. H is not content with her current state of health and wants to live a healthier, longer life for her children and grandchildren, but she only takes her medications when she can afford to pay for them and hasn’t checked her blood sugar since she ran out of test needles months ago. As she is both unemployed and uninsured, she cuts costs wherever possible to be able to afford to pay to see the physician out-of-pocket.
An individuals’ health is the result of numerous factors; in fact, clinical care only determines 20% of health outcomes. Health behaviors such as getting enough exercise and adhering to medication constitute about 30%, while the strongest determinants, accounting for about 50%, are social and economic factors, including physical environment. A patient’s abbreviated “social history” focuses on select behaviors and only provides a glimpse of their true social environment. Thus, to trace the social and political root causes of illness, it is important to understand the socio-ecological model of health: public policy shapes communities, which influences organizational, interpersonal and individual factors.
In The Social Medicine Reader, the authors define social determinants of health as those conditions which structure the roles and health opportunities of a defined, organized group. Consider Mrs. H, for example: Hispanics in Riverside County are less likely to engage in physical exercise three or more times a week. This may be due to lack of parks and safe streets for walking in many minority neighborhoods. Additionally, low educational status and poor finances reduces a person’s lifespan by up to 13 years. Simply the zip code in which one resides can make a difference of up to 30 years of life.
In addition to social determinants, there are structural determinants of health which are harder to see. Social structures are durable, patterned arrangements which create statuses and roles, each with their own opportunities and vulnerabilities. Structural Violence occurs when these structures inhibit individuals from meeting their basic needs. This includes institutional neglect of low-income neighborhoods such as Mrs. H’s, where streetlamps don’t get repaired, parks are not built and grocery stores do not franchise. Structural violence is thus the underlying driver of the social correlates with health, or put another way, “the structural determinants of the social determinants of health.”
Similarly, exposure to biological risks, such as air pollution from a nearby highway, but also the presence of violence or inaccessibility of food, are often determined by a person’s position in society. Mrs. H and her neighbors do not have disposable income to spend at stores, the education to attain better jobs, the political standing to demand change or the legal protection to do so; all of these factors make them vulnerable to structural violence and increase their risk of chronic disease while decreasing their access to quality healthcare, or even being deemed “deserving” of the best care.
Victims of structural violence are often blamed for their own affliction. Mrs. H, for example, was dismissed by her physician as “noncompliant” and thus not worthy of his time and effort. The label “noncompliant” codes a patient as unwilling to better his or her health. This disregards the socioeconomic and structural factors influencing their behaviors and instead places undue blame on their cultural beliefs and practices, further alienating vulnerable populations. Patients are too often shamed by care teams for behaviors which are out of their control. This, in turn, discourages them from sharing the challenges which lead to their perceived noncompliance.
How can physicians avoid this dilemma and better care for the health of structurally-vulnerable patients? First, it is important to create a welcoming, understanding environment where the patient feels safe to talk about his or her obstacles to a healthy lifestyle. This can be achieved by simple gestures such as providing magazines in different languages and displaying visuals including diverse people and cultures in the waiting area, employing staff from a variety of cultural, ethnic and gender identities in addition to having translators available. Structural humility is equally important: providers must recognize that clinical care is only a small factor in a patient’s health outcome and that communities have their own expertise and resources to resist structural violence. When possible, providers should employ diverse resources when providing care, encouraging such practices as peer-to-peer interviewing and coaching or patient-led support groups. Furthermore, contributing to population health management by writing to local officials, participating in the development of health policy for academic or private institutions or becoming involved with policy-focused organizations such as the American Medical Association can address the health of entire marginalized populations as opposed to individual patients.
After learning more about Mrs. H’s story, I set her up with free medication refills from our pharmacy and ordered lab tests to track her progress. As we had seen, however, those were not all the tools she needed. Fortunately, the free clinic has more than simply medical resources available: first, I referred her to our clinic’s diabetes management committee, which provides free glucose-testing supplies, additional education and support groups. Next, I connected her with the nutrition committee, which offers nutrition education, meal plans and healthy, affordable recipes. Finally, I recommended she visit a stress-management meeting in the basement of the church where the clinic is held. And perhaps most important of all, I encouraged her to become her own advocate and join a group of her peers in becoming politically-engaged in her community.
Mrs. H’s story is just one of millions of Americans who have become victims of structural violence and suffered from the social determinants of health. With a clearer understanding of the complex factors that contribute to patients’ health outcomes, I now aim to reunite the erroneously separated domains of medicine and social sciences.
Classical “case studies,” like that of Mrs. H, simultaneously teach healthcare providers about the art of clinical diagnosis and the social forces which underlie the patient’s ailment. This instructive approach shows how social determinants and dynamics play a prominent role in the clinical afflictions of many of our patients. That relationship should be a central piece in medical education, clinical practice and health system planning.