To close out my first week of medical school, the class was treated to a talk by a stuffy but soft-spoken lecturer on the relationship between poverty, education, and poor population health. “Social determinants of health,” he labeled them, a clunky and unwieldy term if ever I’d heard one. In those days, audiovisual aids consisted of an overhead projector for black-and-white transparencies. And boy did that talk have transparencies. Chart upon chart of statistic upon statistic. Between the heat and hum of the projector, and the monotone of the man in front of it, the session was little more than a sedative for most of us. Challenging us to think twice before placing our faith in the biological approach to medicine? This was the wrong guy giving the wrong talk to the wrong audience. We were future be doctors: white coats, stethoscopes, saving lives! Who was this statistician to tell us what mattered to a person’s health?
Years later, social determinants of health crept back into my professional life when I started training in public health. This time, however, I had a few years’ experience as a family doctor under my belt, with a good sense of what was and wasn’t relevant to the patient in front of me. Skeptical though I was, it didn’t take long for me to discover that all this talk of social determinants actually matters more at the level of the individual than it does for the population as a whole.
Don’t believe me?
Imagine two men in their late 30s that live across the street from one another, both in good health with no family history of major illness. Daniel is a mid-level municipal administrator. His wife is a nurse at the local hospital, they have two children in grade school, and own their home. Both Daniel and his wife grew up in town, and they enjoy a wide circle of friends as well as their respective families.
Danko rents the basement in the house across the street from Daniel. He is former Bosnian refugee, but now earns money as a laborer in a local warehouse and performing odd jobs for his landlady. His wife cleans houses part-time. They are staying afloat with their basic expenses but that’s about it.
Early one morning in February, Daniel and Danko each find themselves facing a foot of snow outside their doors, and grab their shovels to clear their respective driveways. The temperature’s been up and down, so the snow is much heavier to move than expected. Both Daniel and Danko feel sharp twinges in their lower backs after moving particularly heavy loads of snow. It turns out they’ve both suffered herniation of the L4-L5 lumbar disc. The identical injury, with identical symptoms, in medically identical men.
Nevertheless, they will end up having radically different paths through the health care system, with radically different outcomes, for reasons having nothing to do with medical science.
Daniel calls in sick, and ends up needing to take the following week off. He taps his workplace benefits for massage treatments and a consult with a physiotherapist. He sees his doctor who prescribes some anti-inflammatories and refers Daniel for an MRI. His wife pulls some strings to get the appointment moved up, and in the meantime, Daniel undergoes an ergonomic assessment at his office, with mild modification of his workspace and duties.
Some months later, he hasn’t improved with conservative management. He asks for a referral to the spine surgeon whose son plays on the same baseball team as his. He undergoes surgery to remove the herniated disc down the road, which requires him to go on short-term disability for a brief period. Two years after the initial injury, he’s had to give up his men’s pickup league and take lessons to adapt his golf swing, but otherwise, life and work are fine.
Danko can’t take time off, because he’s only paid when he shows up. The injury happened at home, so Workman’s Compensation won’t pitch in for physio or massage. He sees his doctor and gets prescribed the same anti-inflammatories, but they don’t help much since Danko’s job is almost all lifting, carrying, and bending. He’s prescribed codeine which upset his stomach, and Vicodin a few weeks later.
After a month of trying to muddle through, Danko is forced to quit work. He applies for welfare, and his wife looks aggressively for more houses to clean. Nevertheless, Danko’s income isn’t completely replaced despite his wife’s best efforts. Danko grows increasingly stressed and depressed, watching his sense of self-worth evaporate along with his inability to support his family. His doctor eventually refers him for an MRI, which is booked for six months down the road. With the positive MRI findings, Danko is referred to the spine surgeons’ group practice, with the appointment after a year’s wait.
When the day of the consult finally arrives, Danko struggles to relate the severity of his symptoms to the surgeon in his broken, incomplete English. The surgeon is “unimpressed with the overall picture” and thinks Danko would benefit from anti-depressants and weight loss more than an operation. Danko returns to his family doctor despondent. He goes through several trials of medication, ultimately ending up on high-dose Oxycontin. He applies to a disability program with the help of his doctor, but the initial application is declined. Two years after the initial injury, Danko and his wife are destitute, desperate, and bogged down in an appeal of the disability application through legal aid. They have no prospects for anything resembling the middle-class life their neighbors across the street enjoy.
We’ve all been conditioned to believe that medical science is the answer to what ails us. Our health is impaired by some sort of disease, and whatever treatment we use will fix the problem with the same odds of success. What I hoped to illustrate here is that nothing could be further from the truth. It’s job security, income, social capital (i.e., friends, family, and connections), language and ethnicity — those darn old social determinants — that matter most to a person’s health. And if you think one sorry ex-refugee suffers this way, just imagine how these things play out across an entire population.
Where’s a stuffy, soft-spoken statistician when you need one?
Franklin Warsh is a family physician.
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