When Poverty and Unemployment Are Misdiagnosed . . . The Limits of “Medicine”

“I diagnosed ‘abdominal pain’ when the real problem was hunger,” admits Dr. Laura Gottlieb in a wonderfully candid Op-ed that explains why physicians so often fail to recognize poverty as the true cause of what appears to be a physical disease.

“I confused social issues with medical problems in other patients, too. I mislabeled the hopelessness of long-term unemployment as depression, and the poverty that causes patients to miss pills or appointments as noncompliance. In one older patient, I mistook the inability to read for dementia,” writes Gottlieb who is a Robert Wood Johnson Health and Society Scholar at the University of California, Berkeley, and the University of California, San Francisco. 

“My medical training had not prepared me for this ambush of social circumstance,” Gottlieb adds. “Real-life obstacles had an enormous impact on my patients’ lives, but because I had neither the skills nor the resources for treating them, I ignored the social context of disease altogether.” (Many thanks to HealthBeat reader Dr. Rick Lippin, who called my attention to Gottlieb’s superb Op-ed.)

The patient who suffered from abdominal pain was only 8 years old. “I had known and adored Jeremy's family for several years,” Gottlieb confides. “So when the sandy-haired, good-natured 8-year-old came to see me in my clinic with abdominal pain, I bent over backward to find out why his tummy hurt. I poked and prodded; did tests of his urine, stool and blood; and took X-rays, over the course of several months. When those tests came back normal, I did more. I had trained at a top medical school and gone on to one of the best residencies in my specialty; in Jeremy, I thought I had identified a real clinical mystery. But in the end, the mystery was not a best-seller: It turned out that Jeremy's family couldn't afford to buy food.

“It had never even occurred to me to ask his mother about how much food there was in the house.”
Medical Care vs. Health Care — Broadening the Focus of Family Practice

Gottlieb laments that her medical training at Harvard had not prepared her to identify the “ambush of social circumstances” that makes many of her patients ill.  In a piece published in the Journal of the American Board of Family Medicine, she elaborates:  “As doctors for a low-income, largely uninsured clinic population, my colleagues and I are bombarded daily by the social determinants of health. Our patients lack access to employment and safe housing, suffer violence and discrimination in their communities, and experience hopelessness . . . The evidence continues to mount that these social factors have wide-ranging health effects.”

How can doctors be prepared to recognize the social determinants that, so often, drive disease? In a phone conversation last week Gottlieb suggested that “medical education would benefit from including training in population health,” drawing from fields such as “epidemiology, sociology, public policy and advocacy.”

Health care reform requires more than improving access to doctors and hospitals, Gottlieb argues.  She sees promise in the idea of the “patient-centered medical home” proposed under the new health reform legislation because it promotes the concept of primary health care over primary medical care that, too often, is “isolated to clinical practice”—ordering tests, prescribing drugs, referring a patient to a specialist.  But, she says, the blueprint for medical homes should include more concrete proposals for improving community health.

“Family medicine is well suited  . . . to develop a language and a method for securing the border between clinical and non-clinical frontiers,” Gottlieb adds. “This was the initial promise of family medicine and it is the premise on which the specialty now sits, perched at the intersection of individual, family, and community.”

Ultimately, she suggests, family physicians could begin to bridge the divide between “medicine” and “public health” by recognizing that an individual’s medical problems cannot easily be separated from the community in which she lives. The poor need more than access to medicine; they need jobs, healthy food, and a good education. Without these, their health inevitably will suffer, no matter how many doctors they see. Ideally, Gottlieb suggests, the American Association of Family Practitioners (AAFP) would “encourage widespread continuing education in community health advocacy . . .”  Over time “medical school and residency requirements in advocacy and policymaking” might grow.

“Certainly,” Gottlieb acknowledges, “physicians alone cannot take on the task of bridging the clinical and non-clinical, changing policy and social circumstance while at the same time learning disease and development patterns, formularies, and service guidelines. But” she asks, “can we confine ourselves to what has been traditionally ‘clinical’ with growing evidence that the distinction between clinical and non-clinical is ill conceived?”

In the end, she warns, “We will not be able to pay for universal coverage unless doctors broaden their focus to include the social context:  I spent a lot of our health care dollars looking for reasons for Jeremy's pain. If I had known more about the resources available to Jeremy's family, I might have recognized sooner that his real problem was hunger; it would have been a lot cheaper to connect his family with a food bank than to do a battery of medical tests.”

I couldn’t agree more. Of course, access to clinical care is critical. While writing HealthBeat, I have been arguing for universal coverage, and the health care reforms that will make it affordable, for nearly four years. At the same time, I realize that the greatest threat to the nation’s health can be summed up in one word: “Poverty.”

In her Op-ed, Gottlieb underlines a fact that many in our multi-billion dollar medical-industrial complex prefer to ignore: “problems of medical care quality and access account for only about 10 percent of avoidable deaths in the United States.” Poverty, by contrast, is directly linked to 45 percent of those needless deaths.

                  The Causes of Premature Death in the U.S.

Dr. Steve Schroeder, Distinguished Professor in Health and Health Care at UCSF, shocked some in his audience when he made this point clear while delivering a memorable Shattuck Lecture before the Massachusetts Medical Society four years ago: “When it comes to reducing early deaths, medical care has a relatively minor role,” Schroeder acknowledged. “Even if the entire U.S. population had access to excellent medical care — which it does not—only a small fraction of these deaths could be prevented.” To illustrate his point, Schroeder offered this pie chart:Shattuck chart1
(For a full discussion of the research behind the chart, and the factors that cause premature deaths, see this Health Affairs article, and this piece from JAMA, both written by JM McGinnins, et. al. 

           Where You Live Can Determine How Long You Live

The chart reveals that “social circumstances” and “environmental exposure” explain 20 percent of premature deaths. When poverty is concentrated in certain neighborhoods, the air itself can be hazardous to your health, with neighborhoods like the Bronx reporting high rates of respiratory disease. In addition, these areas “have high crime rates, with substandard housing, few if any decent medical services nearby, low-quality schools, little recreation, and almost no stores selling wholesome food,” Schroeder observes. “This means that the residents, no matter what their race, income, or education, have little chance to improve their lives and engage in health-promoting behaviors.”

Many blame the poor for being obese, arguing that they foolishly squander money on expensive high calorie “junk food” when they could be preparing less expensive high quality foods. But as Professor Adam Drewnowski, Director of the NIH RoadMap Center for Obesity Research illustrates in the chart below “energy-dense foods cost less; nutrient-rich foods cost more.” Quite simply, high-carb, high-fat foods are much more affordable than fresh fruit, vegetables, fish and other foods that are rich in protein. And nutritious fresh food tends to be even more expensive in grocery stores in poor neighborhoods where pricey items turn over slowly and may spoil before they sell.Energyfood Source: Food Choices and Diet Costs : An Economic Analysis, Adam Drewnowski, Ph.D., Director, NIH RoadMap Center for Obesity Research, Professor of Epidemiology and Medcine, School of Public Health and Community Medicine, University of Washington

Meanwhile, finding a place to exercise in a ghetto can be difficult. “Gyms are too expensive for low-income families; exercising outdoors can be dangerous, and in inner cities, public schools often lack playgrounds and gymnasiums,” Schroeder observes. Public school lunches in poor neighborhoods also tend to be made of ingredients that are cheap and high in fat, carbs and calories.

Until we are willing to raise taxes to pay for school lunches that include lean, ground sirloin, fresh strawberries, and blueberry smoothies, safe outdoor playgrounds, school gymnasiums (and gym teachers),  subsidized green markets, and well-lit, well-policed jogging paths—perhaps we should stop blaming the poor for being overweight.               

      Smoking, Drinking, Drug Use, Poverty and Stress

Behavioral patterns which include smoking, alcoholism and drug use account for another 40 percent of needless deaths. “Smoking is increasingly concentrated in the lower socioeconomic classes,” Schroeder observes “and among those with mental illness or problems with substance abuse . . . Each year tobacco use kills 435,000 Americans, who die up to 15 years earlier than nonsmokers and who often spend their final years ravaged by dyspnea and pain. In addition, smoking among pregnant women is a major contributor to premature births and infant mortality.” (This helps to explain why infant mortality and maternal mortality during childbirth is higher in the U.S. than in other developed countries, even if you focus solely on white children and their mothers.)

What is most frustrating is that we know how to help smokers. As Schroeder points out: “When Kaiser Permanente of northern California implemented a multisystem approach to help smokers quit, the smoking rate dropped from 12.2% to 9.2% in just 3 years.” We have the tools, but we need to train medical students so that they know how to counsel smokers. (Lecturing patients doesn’t work.) Then, primary care doctors should be reimbursed for the time it takes to help patients quit.  Finally, we must fund free smoking cessation programs. (Kaiser discovered that they could quadruple the number of smokers who quit by giving away nicotine patches.) “Given the effects of smoking on health,” Schroeder adds, “the relative inattention to tobacco by those federal and state agencies charged with protecting the public health is baffling and disappointing.”

Why do low-income Americans smoke? We know that depression and other forms of mental illness are strongly linked to poor physical health, as well as self-destructive behavior such as excessive drinking and smoking. Schroeder explains: “At least 50 percent of the 2 million Americans with severe mental illness abuse illicit drugs or alcohol, compared to 15 percent of the general population, according to the Alcohol, Drug Abuse, and Mental Health Administration."

What is the link between poverty and mental illness? “Studies have linked poor health to the constant stress of a lower-class existencea lack of control over one's life circumstances, increased social isolation, and the anxiety brought about by a subjective feeling of being of low social status (all of which can be compounded by racism)” Schroeder reported in a NEJM study titled “Class – The Ignored Determinant of the Nation’s Health.”

Some would blame the poor for compounding their problems by drinking or using drugs. But the poor are more vulnerable to self-destructive behavior for reasons that are not hard to understand. Imagine that you are a mother with two children, working full time and earning less than $17,000 a year, married to a man who is unemployed, extremely frustrated and often angry. You spend many sleepless nights worrying about the future. And when you toss and turn, you think about the fact that the inner-city public school your seven-year-old attends has not yet taught him how to read.

If you found yourself trapped in that box, what would you do? Self-medicating with alcohol, cigarettes, or drugs is a very human response to the anxiety, rage and depression that any one of us would feel if we had so little control over our lives. This woman can’t force someone to hire her husband. She doesn’t have the power to make her son’s school provide the Special-Ed class that the reading specialist says he needs. The school system is cutting back. And she doesn’t know how to break through her son’s learning disability and teach him herself.

Children Who Grow Up in Poverty Will Die Sooner—Even If They Do Everything Right

Although some children manage to break out of poverty, the scars of a stressful childhood trapped in an inner city—or mired in rural poverty—often never heal. Research by the Pittsburgh Mind-Body Center shows that early childhood experiences of stress and poverty leave permanent damage,  increasing the odds that those children will develop chronic diseases as adults–whether or not they have a poor diet, don’t exercise, drink in excess, or smoke later on in life.

Cardiovascular disease provides a case in point. If a child grows up poor, her cardiovascular health is more likely to be compromised  when she grows up “regardless of how successful she becomes and how much she achieves on her own as an adult.” Ultimately, a child who lives in an impoverished home where the adults are upset and unpredictable is sensitized to stress at a very early age.  Moreover, Schroeder explains, “stress appears to trigger a neuroendocrinologic response that is beneficial in the short term but over the long run can weaken the body's resistance to illness.”

                  More and More American Children Go Hungry

Hunger at an early age weakens the body, and Jeremy’s plight is far from rare. In the U.S., more than 20 percent of our children live in poverty (up from 16 percent in 2000)—a larger share than in any other developed country in the world. Meanwhile, It is estimated that over 36 million Americans (close to 24  million adults and over 12 million children)  reside in households that have limited access to an adequate  supply of food, due to lack of money. These families represent over 11 percent of all homes.

Who are the poor? According to a report released by the Census Bureau in September of 2010 most are not new immigrants. The vast majority (nearly 88 percent) are native-born. Over 40 percent are non-Hispanic whites. From 2008 to 2009, the number of non-Hispanic whites living in poverty climbed from 17 million to 18.5 million.

Meanwhile, children are sinking deeper into abject poverty: In 2009 9.3 percent of all children lived in homes with total income below one half of their poverty threshold—up from 8.5 percent in 2008. A family’s poverty threshold varies depending on the size of the household: for example, today a family of four with income of less than $22,350 a year is considered “poor.” If that household’s total income is “below one half of their poverty threshold,” this means that the family is living on less than—often much less than—$11,175 a year. These are the children who are going to bed hungry.

But wait a minute, how can this be?  We still have food stamps, don’t we? Yes, though the program is now known as SNAP (Supplemental Nutrition Assistance Program). And, as it turns out, “nutritional” is something of a euphemism: Nationwide, the average SNAP beneficiary received $125.31 per month in fiscal year 2009, reports The Nation’s Melanie Mason. “If food stamps constitute a person’s entire food budget—as often happens . . . that translates to just under $1.40 per meal,” she explains. “If you’re looking to buy something that will satiate you for $1.40, you probably won’t be buying broccoli.”

Fresh vegetables, fruit, fish and lean meats are too expensive for most families on SNAP.  To make their food stamps last the month, they fill their grocery carts with canned vegetables, and large bags of carbohydrates (pasta, rice, beans, potatoes, cereals and bread) to stretch the ground chuck, chicken, eggs, and milk that represent all the protein that they can afford. And yes, they also buy cookies and other sweet treats; as the chart above reveals, “desserts” and “sugar” show up on the left-hand side of the chart as “energy-rich foods that cost less.”

Mason reports that a lucky but “tiny fraction” of those on SNAP are hooked up with local Farmer’s Markets that match a  certain amount of money from a customer’s SNAP benefits, assistance that essentially doubles the customer’s purchasing power. These local markets are selling the relatively inexpensive fruit and vegetables that kids need, and customers are not forced to pay the high transportation costs that are built into prices at grocery stores. In some cities, growers bring the produce to poor neighborhoods, and sell it from the back of a truck.

   “If Medicine Is to Fulfill Her Great Task . . .”

This is the type of program that the family doctors Gottlieb describes as “perched at the intersection of individual, family, and community,” might well support. Imagine a physician appearing on the local evening news as a community health  advocate; rather than touting some new cure for cancer, he might introduce viewers to a farmer’s market that is involved in the project, and urge that community leaders draw more markets into the program.

Local efforts to fight hunger are desperately needed, because in Washington things seem to be going in the opposite direction. Budget Committee Chairman Paul Ryan (R-Wis.) wants to slash SNAP by 20 percent or $127 billion through the year 2021. This would dismantle SNAP’s essential structure and impose astonishing limitations on those who receive such help: Recipients must either be working or be enrolled in a job training program, and there would be time limits on how long one could receive assistance. According to an April 11, 2011 report issued by the Washington, D.C.-based Center on Budget and Policy Priorities, implementation of the proposed Ryan budget plan would result in dropping more than 8 million of the 44 million Americans currently enrolled in SNAP from the program. According to the Center, most of these families include children, seniors or people with disabilities, and 93 percent are living below the federal poverty line. Professional organizations representing pediatricians, family physicians and other might want to comment on this proposal.

“With more and more Americans forced to enroll in SNAP— a nearly 12.1 percent increase from January 2010 to January 2011 alone — it’s absolutely clear that the food stamp program has prevented massive hunger in America,” observes the online Jewish Journal.

Meanwhile, conservatives across the nation are threatening to whack school breakfast and lunch program. In New Jersey, Governor Chris Christie already has eliminated the school breakfast program for poor children.

This isn’t just a political problem, Gottlieb argues, it’s a health problem. She quotes Rudolf Virchow, the father of modern pathology: “If medicine is to fulfill her great task, then she must enter the political and social life.”  And she ends her Op-ed with a call to action:  “It is time to ask all health care professionals to put aside the debate about whether social problems fall within their domain and just ask them to think about what's good for the nation's health.”

                          But Won’t the Poor Always Be With Us?

Schroeder raises the inevitable question about poverty: “Aren't class gradients a fixture of all societies? And if so, can they ever be diminished?”

He answers his own question: “The fact is that nations differ greatly in their degree of social inequality and that— even in the United States — earning potential and tax policies have fluctuated over time, resulting in a narrowing or widening of class differences.”

When it comes to childhood poverty, the U.S. is an outlier. While more than one-fifth of American children live below the poverty threshold, in Germany, France, Switzerland, Austria, and Denmark, fewer than one-tenth of all children endure the stress of living in homes where there isn’t enough money.  And in recent years, the situation in the U.S. has grown worse. Over the past decade the share of American children living in households defined as “poor” climbed from 16 percent to 20 percent. 

In earlier decades, as Schroeder points out, the U.S. used tax policies and social programs to narrow the gaps between rich and poor. In the 1960s, this country declared a “war on poverty.” Many Americans don’t recall that war; even fewer remember how well it worked.  But as this chart from a 2010 Census Bureau report shows, as a result of legislation passed in the 1960s, the share of seniors living somewhere below the poverty line plummeted from roughly 30 percent in 1965 to just over 15 percent in the early 1970s.


The War on Poverty began officially with LBJ’s State of the Union address in 1964. In the years that followed, small business loan programs, rural programs, migrant worker programs, remedial education projects, and local health care centers sprang up. In just two years, major legislation was passed including:  the Civil Rights Act (1964), the Food Stamp Act (1964), the Elementary and Secondary Education Act (1965), the Higher Education Act (1965), and, of course,  the Social Security amendments creating Medicare/Medicaid (1965) which would made such a difference for seniors.

But the war on poverty also helped kids: the share of the nation’s children trapped in poor households tumbled from roughly 23 percent in 1965 to 15 percent during the Carter years. President Nixon had kept the social programs going. But at the beginning of the1980s, the Reagan administration argued that government was too big. Social programs were cut back, and the percent of children living in poverty began to rise. As the chart shows, in the late 1990s, children began to catch some breaks, but the past decade has taken a disproportionate toll on low income families, and today the child poverty rate has  once again jumped to well over 20 percent.

                                     Another Turning Point?

The passage of the Affordable Care Act signals that many in Washington believe that the time has come for government to once again turn its attention to social programs. The ACA strengthens Medicare, reducing the cost of prescription drugs while making preventive care free; it expands Medicaid, doubles the capacity of community clinics, and provides $2 billion for the National Health Service Corps over a five year period, reviving a program that will fund the education of thousands of  new primary care physicians willing to “go where no one else will go.” Ten years from now we might look back on passage of the ACA and see it as the first step—however small—toward a new war on poverty.

Not everyone agrees, of course, that government should be striving to narrow the gaps between the haves and the have not’s.  Reformers face a fierce war of ideas.

The division between liberals and conservatives on this issue comes down to a matter of political philosophy. As Schroeder puts it: “One reason the United States does poorly in international health comparisons may be that we value entrepreneurialism over egalitarianism. Our willingness to tolerate large gaps in income, total wealth, educational quality, and housing has unintended health consequences. Until we are willing to confront this reality, our performance on measures of health will suffer.”

Here Schroeder is referring to the fact that, even though the United States spends more on health care than any other nation in the world, when it is compared to other developed countries it ranks poorly on nearly every measure of health status including life expectancy at birth, life expectancy at age 65, infant mortality and maternal mortality. “It is remarkable how complacent the public and the medical profession are in their acceptance of these unfavorable comparisons,” Schroeder adds. “One reason for the complacency may be the rationalization that the United States is more ethnically heterogeneous than the nations at the top of the rankings . .  . But even when comparisons are limited to white Americans, our performance is dismal.”

Schroeder suggests that if we wish to improve the nation’s health “we must focus on the poor . . . because the biggest gains in population health will come from attention to the less well off.”  To that end, he argues, we need to recognize “that social policies involving basic aspects of life and well-being (e.g., education, taxation, transportation, and housing) have important health consequences. Just as the construction of new buildings now requires environmental-impact analyses, taxation policies could be subjected to health-impact analyses.”

But we rarely discuss public health. Instead, our pundits and policy-makers talk almost exclusively about the need for more medical care. “To the extent that the United States has a health strategy, its focus is on the development of new medical technologies and support for basic biomedical research,” says Schroeder. “We already lead the world in the per capita use of most diagnostic and therapeutic medical technologies, and we have recently doubled the budget for the National Institutes of Health. But these popular achievements are unlikely to improve our relative performance on health. It is arguable that the status quo is an accurate expression of the national political will — a relentless search for better health among the middle and upper classes.”

It is worth remembering that Schroeder delivered the Shattuck lecture in 2007; back then, few would have predicted that Congress would pass health reform legislation in 2010. Moreover, as Schroeder noted “though the Department of Health and Human Services periodically produces admirable population health goals — most recently, the Healthy People 2010 objectives— no government department or agency has the responsibility and authority to meet these goals and the importance of achieving them has yet to penetrate the political process.” 

Today, that may be changing. Gottlieb points to the creation of the National Prevention, Health Promotion, and Public Health Council as “the most promising thing I see in the health reform bill.” Like Schroeder, she believes that concern about the population’s health should not be limited to the Department of Health and Human Services; public policy regarding education, taxation and transportation also impacts  our health. With that in mind, the Council brings together the heads of some 17 government departments and agencies including: the Department of Agriculture, the Dept. of Education, the Federal Trade Commission, the Department of Transportation, the Department of Labor, the Environmental Protection Agency, the Office of National Drug Control Policy, the Department of House and Urban Development and the Office of Management and Budget. The Council’s over-arching goal is to integrate health criteria into planning and decision making across multiple sectors, whether enhancing cross-sector collaboration in community planning and design or promoting affordable, accessible, safe and healthy housing .

It is too early to tell just how proactive this new Council will be. Will it actually generate a conversation about how changes in tax policy and income distribution over the past 30 years have affected the health of low-income and middle-income families? Could it lead to a national discussion about air quality in our poorest neighborhoods, or the health hazards in public schools invested with cockroaches and mice?

Today, as Gottlieb points out, the health reform movement focuses primarily on medicine, not health.  Even when a relatively small amount of money is earmarked for a social program, “when push comes to shove, it is often the first thing to go.”

In her Op-ed, Gottlieb expresses her disappointment that in June, Secretary of Health and Human Services Kathleen Sebelius announced that $250 million originally designated for dealing with the social issues that cause problems like Jeremy's would instead be used to train more primary-care doctors. “Given dramatic and worsening shortages in the primary-care medical workforce, these efforts to increase access are laudable,” Gottlieb concedes. “But if we think that increasing access to doctors will solve America's health care problems, we will have not only missed the rescue boat but also put holes in the raft we jumped on.

“There's a strong argument that these millions directed toward the health care workforce would be better spent on community programs that directly address the avoidable social factors that either make people sick or sicker than they could be.  Because the Obama administration is not likely to find more money in the midst of the recession, we need to train these new doctors to deal with the problems we seen in the clinic. There are several important reasons that this new workforce – and the old one – should increase its skills to tackle the social factors that affect health.”

                Should Doctors Speak Up For Those Who Have No Voice?

Schroeder agrees that physicians can no longer ignore the web of adverse circumstances that affect their neediest and sickest patients. In the U.S., “the disadvantaged are less well represented in the political sphere here than in most other developed countries, which often have an active labor movement and robust labor parties,” he notes. This, he argues, is one reason why doctors should step forward. “In the absence of a strong political voice from the less fortunate themselves, it is incumbent on health care professionals, especially physicians, to become champions for population health. This sense of purpose resonates with our deepest professional values and is the reason why many chose medicine as a profession.”

Schroeder is not alone. It might surprise some to learn that in 1957 The American Medical Association added a charge to participate in activities tending to improve the health and well-being of the community to the AMA Principles of Medical Ethics.  In 2001, the AMA went a step further adding an obligation to support “access to medical care for all people.” That year, the organization's Declaration of Professional Responsibility,  included “an oath by which 21st century physicians can uphold … ideals that, throughout history, have inspired individuals to enter medicine.” The Declaration enjoins physicians to “advocate for social, economic and political changes that ameliorate suffering and contribute to human well-being.”

Not everyone embraces the idea of the physician-advocate. In March, Dr. Thomas Huddle, a professor of medicine at the University of Alabama Birmingham School of Medicine spoke out strongly against the concept in a “Perspective” published in Academic Medicine, the Journal of the Association of American Medical Colleges. “Advocacy is  finding its way into discussions of medical training and even into requirements of the Accreditation Council for Graduate Medical Education” (ACGME) Huddle complains. “The pediatrics residency review committee now requires pediatrics training programs to provide ‘structured educational experiences’ … which prepare them [residents] for the role of advocate for the health of children within the community.”

Even worse, from his point of view, “The ethical statements of the AMA and the Project on Medical Professionalism imply a requirement for a specifically political commitment from physicians and for political activity. This requirement is consistent with the definition of advocacy" recently proffered by Dr. Mark Earnest and colleagues at the University of Colorado, who describe it as “action taken by a physician to promote those social, economic, educational, and political changes that ameliorate the suffering and threats to human health and well-being.”

But Huddle claims, “this attempt at incorporating political responsibilities into professional norms is relatively recent” and “has not so far been strikingly successful.” He admits that “various professional organizations have recently declared a duty to advocate to be part of medical professionalism and physicians may acknowledge such a duty when responding to surveys,” but he insists: “most physicians do not engage in advocacy activities.” In fact, “they engage in other community and political activities less often than do others with similar levels of income. In a 2004 survey, just 25% of U.S. physicians claimed to engage in political activity on local health issues beyond voting. Medical trainees may not even acknowledge social justice or advocacy to be among their professional responsibilities,” Huddle concludes, with some satisfaction, citing a 2007 study which appeared in Medical Education.

Gottlieb has written a letter responding to Huddle’s article; in our phone conversation she told me that it will appear in Academic Medicine in September. I look forward to reading it. She also left me with this final thought: “In an ideal world—far from where we are—public health would be the umbrella program and medicine would be one sub-specialty. Instead, we’ve created the opposite structure.” 

I wonder where readers stand on this issue.  Should physicians stick to “medicine”?

11 thoughts on “When Poverty and Unemployment Are Misdiagnosed . . . The Limits of “Medicine”

  1. I was trained as a medical doctor. I started practicing emergency medicine. I moved to health information systems for US doctors then to international public health.
    I view this career path as moving up form the bottom (last resort medicine) to the top of an idealized health system (“ounce of prevention”) with a focus on the value of information at all levels.
    I agree that the greatest determinants of health are social, environmental and behavioral with a small contribution from curative medicine. I think doctors do a good job considering the limits of medical care and it would be good for them to consider the wider causes of ill health. However, these are social problems that require political solutions and I am not sure doctors have much power to influence or interest in these causes.

  2. I read your post then wandered onto AHIP’s website. In their advocacy/issues section, “health care costs” caught my eye. While I did not read the content (I believe I have in the past), the thought came: “I’m sure the impact of long-term poverty is not included.” The social and economical factors need to be diagnosed, not just by doctors, but by the industry.

  3. Many if not most physicians seem to me to be quite politically conservative. Getting involved in social policies where society tries to better and help less fortunate citizens is not where conservative ideology generally excels. Indeed, conservatives seem to blame the victims of poverty for their own poverty more than not. Therefore if most physicians are politically conservative, it may well be asking a great deal from them to change their political ideology, even though social status and social improvement is likely a major determinant of health which is in the physician profession realm.

  4. Mark, Rachel, NG
    Mark– an interesting career path — int’l public health is a field where so much needs to be done.
    In our society many people respect and trust doctors. This is why I think that, if they want to, they can have a real influence on social problems in their communities. People would listen to that young doctor on the local evening news.
    Yes poverty is very costly in terms of lost productivity. When people don’t get a good education in our public schools, we lose out in global competition. When sickness, alcoholism, and depression keep people home from work, we are less productive.
    The poor don’t live as long as the rest of us (they die about 6 years sooner, on average) so they don’t need medical care for as many years after the age of 65. But that savings is wiped out by the loss in terms of human capital. And that doesn’t even “count” the human suffering caused by poverty.
    YOu are right that many doctors are politically conservative. When I was writing Money-Driven Medicine, one specialist told me that if you went into the doctors’ lounge in most hospitals, you would find the television tuned to FOX news, not CNN.
    This makes sense insofar as wealtheir people tend to be more conservative–many are focused on conserving their wealth, keeping taxes low, etc. which means that they are less likely to favor public programs to help the poor, govt’ safety nets, etc.
    And doctors–even those at the lower end of the physician income ladder– are “wealthy” compared to the average American.
    On the other hand, medicine is about helping people, and the Hippocratic oath is about putting the interests of others ahead of your own.
    So a fair number of doctors are liberals/progressives.
    I’ve been told that political views among physicians tend to break down by income. Those that earn less (family physiicians, pediatricians, geriatricians, palliative care specialists, primary care doctors) are more likely to be liberals, while those who make the highest salaries (orthopedists, oncologists, surgeons, radiologists) cardiologists are more likely to be conservative.
    There’s also an element of self-selection here: people who choose family pracice or pediatrics tend to be more interested in “helping people.” Some proceduralists are less focused on the whole person, more focused on the body part– the heart, the knee– and the science behind what they do.
    But of course, these are gross generalizations. I know individual oncologists, radiologists and surgeons who are extremely liberal.
    And I can think of at least one primary care doctor who is very conservative. Years ago, when “managed care” came to N.Y. he warned me that it would drive down doctors’ salaries, and as a result, “the sort of people who go to med school will no longer be the most ambitious, or the most intelligent. Instead, they’ll be the sort of people who become teachers!” he said with great disgust.
    (Although he was a primary care doc, he made a very good income in a wealthy neighborhood; he didn’t take any insurance and gave his patients what, today, we would call “concierge care.”

  5. I am a pediatrician that sees Medicaid patients in a poor urban area.
    I will say that obesity is a MUCH larger problem than kids going hungry.
    For every child I see in clinic that is underweight and doesnt get enough food, there are at least 50 kids who are obese.
    I’m not saying that kids going hungry no longer happens in the USA, I’m just saying that its rare compared to kids being overweight, even when both groups of kids are poor.

  6. Dr. Rick, Diana
    Dr. Rick–
    Thank you.
    As you may or may not know, the producer/director of the documentary “Unnatural Causes” is the distributor of the film based on my book “Money-Driven Medicine.”
    “Unnatural Causes” is an extraordinarily fine documentary.
    I urge readeres to go to the website, read it, and order the film
    I have been meaning to write about Unnatal Causes, but was a l little shy about doing it when they were actively promoting Money-Driven Medicine (concerned about
    seeming conflict-of-interest. In fact, I don’t make any money from the film, but most people wouldn’t know this.)
    You have reminded me that I really should write about Unnatural Causes now.
    First, I’m very glad to hear from a doctor who is seeing Medicaid patients in an areas where you are much needed. Congratulations.
    I hear what you are saying, and totally believe you.
    But aren’t some (perhaps many?) of the obese kids also undernourished?
    In other words, they could be getting plenty of carbs & calories, but not enough nutritious food?

  7. One thing about Diana’s post and your comment, not to put either of you down for what are basically true statements.
    It is possible for obese people to not only be malnourished — and a lot of poor obese people and some not so poor are — but it is also possible for them to suffer from hunger.
    In particular, many poor people live through cycles of extreme destitution — sometimes on a weekly, bi-weekly, or monthly basis when paychecks and benefits run out with time left till they are replenished, and sometimes on other cycles related to seasonal work, job losses, exhaustion of benefits, failure to keep benefit registration current, and so on.
    Just because a person is obese does not mean they are not hungry, and a question of when and what patients last ate is often an appropriate one in dealing with issues like weakness, abdominal pain, headache,insomnia, anxiety, depression, and so on.
    As a radiologist administering contrast material, I regularly asked patients when they last ate and what they ate, and was often surprised at the number of people who answered by saying it had been days since they ate — one group that was particularly effected was mothers who were going hungry at the end of financial cycles in order to keep their kids fed.
    Diana is correct in that starvation is rare in the US, but hunger is by no means rare, and sometimes effects people who seem well-nourished or obese.

  8. Pat S.–
    Yes, what you say makes sense. I also have read that when poor people do have food, they tend to eat as much as they can– the body’s natural response to uncertainty as to when it will be fed again.
    This also would lead to obesity among people who sometimes go hungry.

  9. I think Dr. Gottlieb makes some wonderful points, and highlights an important problem.
    I also think she is overlooking a solution that is already available to assist her in identifying just the kinds of patients she worries about.
    Nurses ALREADY practice in a holistic fashion. Asking just these kinds of questions has been part of our training for decades. We are in a perfect position to assist physicians in identifying these patients, and helping form a plan of care to pull in interdisciplinary resources to find practical solutions.
    So, why aren’t we?
    The answer lies in the dilution of nursing practice that has been going on for the past 20 years or so. You see, nurses are expensive. Because we are expensive, many physicians really don’t use nurses much in their office practices. They might have one RN or LPN who manages the medical assistants . . . maybe. But that nurse is so busy, she doesn’t have the time to ask the right questions to identify these patients, nor to formulate a nursing plan of care even if she did identify them. It is not within the scope of practice for medical assistants to do this.
    (BTW, docs, it really makes me grind my teeth when I visit a doctor and he refers to his medical assistant as a “nurse.” She is NOT a nurse!)
    It’s not any better in the hospitals. Standard admission forms do ask a lot of these questions: how far through school did you get; how many steps to get into your home, etc . . . questions could be added to address nutrition.
    But as the admission process becomes ever more complicated and involved, staff nurses have less and less time to do it properly. So many hospitals employ “admission nurses” whose sole job is to do the admission paperwork . . . but the staff nurse is the one who actually performs the care. This leads to a disconnect. Problems may not be communicated well or overlooked. We would need to improve the admissions process so that other disciplines like dietary and social work can get involved when the admissions nurse identifies these issues, and not leave it up to the staff nurse . . . or for the staff nurse to be able to request a consult and not wait on the physician if SHE is the one who identifies the problem.
    And don’t think for a minute that physicians can’t get involved politically, as physicians are VERY effective in the political arena when they want to be: take a good hard look at the history of the AMA for proof. Lack of interest really seems to be the problem, or a pervasive believe that medicine is not in some way a social science (how it can not be I don’t understand since we inherently are dealing with people).
    Just my two cents.

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