Welfare and Wellbeing

I’ve been listening to The Uncertain Hour by Marketplace’s Wealth and Poverty Desk. This season, they’ve taken a deep dive into the United States’ welfare system and the consequences of welfare reform in the 90s.

The podcast provides a great introductory education about American poverty, a topic where opinions are strong and facts are frequently scarce. Interviews with families receiving cash welfare benefits reveal the daily compromises and anxieties which are the lived reality of America’s poor.

Equally disturbing, however, are the interviews with the middle and upper class people who maintain political control of America’s welfare system and the profound contempt for the poor which suffuses their conversations about poverty and welfare.

It’s easy to understand why we have failed to develop a coherent, evidence-based system for addressing poverty in America when you listen to these people and realize that their primary goals are to shame and punish the poor for daring to seek joy or create life, actions that lie at the core of our common humanity.

Two thousand years ago, Jesus of Nazareth pushed back on the prevailing idea that poverty was God’s punishment for sinfulness. Today, in a country where nearly half of the population claims loyalty to his Good News, we remain in this punitive mindset.

I am biased in this conversation because my daily work brings me face-to-face with the suffering that poverty creates, the shorter and sicker lives the poor live out in the midst of abundance. But I truly believe that if our anti-poverty initiatives were crafted by people with direct experience with poverty and designed specifically to promote joy and reduce suffering in our fellow human beings lives that they would be radically different than the systems we have today.

I, Physician. I, Witness.

Richard* comes into my office with low back pain.

He was 27 when he first tweaked his back while loading some tools into his work truck. It had been sore for a week, but nothing a little ibuprofen couldn’t help. Certainly he was glad that he didn’t have to take time off of work. A couple years later, he slipped on some spilled lubricant. Fortunately, he didn’t crack his head, but this time his back hurt so bad that it was three days before he could get out of bed and get back to work.

Even when he was able to pick up a shift again, there was a dull, throbbing pain that stayed with him for weeks. He thought he had healed, but then a couple months later the pain came back after driving four hours out to a work site. He could hardly get out of the truck because of the pain, but he took a couple more ibuprofen and pushed through. At first it flared once a month, then once a week. He started moving slower, avoiding work that would requiring lifting because that would make the pain worse.

Soon enough he was taking ibuprofen every day just to get by. Then, one morning he noticed his urine was bloody. He went to the emergency room and found out that the ibuprofen had been damaging his kidneys. “Acute interstitial nephritis” is what they wrote on the paperwork, though he had no idea what that meant. All he knew was that he couldn’t take the ibuprofen anymore without risking kidney failure.

Without these medications, he couldn’t get through a day of work. He applied for disability, but the application was denied. The letter explaining the denial was incomprehensible to him, but he was sufficiently demoralized to not apply again. His wife had a job as a teacher, so his unemployment wasn’t an immediate disaster, but he felt worthless sending his kids to school and his wife to work while he sat around the house all day in pain.

And so he comes into my office and says, “Doc, I’m in pain.”

This scenario, all too common in my medical practice, is the focus of “Work, worklessness and the political economy of health inequalities” by Clare Bambra. People of low socioeconomic status have fewer job opportunities available to them, and the jobs that they can get have a higher risk of causing workplace injury. To add insult to injury, because these jobs generally require more physical labor, workplace injury is much more likely to disable these workers and expel them from the labor force. Unemployment and underemployment themselves have severe psychosocial and financial consequences and without strong social safety nets, the bottom quickly falls out.

Medical professionals are increasingly coming to grips with the fact that healthcare-based interventions have at best a marginal impact on our communities’ health and quality of life. In the case of Richard, by the time he arrives to my office, pain relievers and physical therapy have very little power to restore his quality of life.

This is the tortured position of the modern physician. Every day we face the consequences of socioeconomic deprivation as borne by the bodies of our patients, and yet the pharmacological and surgical therapies we have at our disposal offer meager relief.

However, this does not mean we are powerless in the face of suffering, because we have two compelling tools at our disposal. The first is social status in a society obsessed with respectability politics. The second is our witness to the true ugliness of socioeconomic inequality.

To proclaim this witness is a political act, one that many physicians are deeply uncomfortable with. However, to deny the witness and stay silent is also a political act. In truth, as soon as we are witnesses to injustice, we lose the option of true neutrality.

It is for this reason that I believe that for every physician-scientist we need a physician-witness. We need a workforce of doctors who can correctly diagnose both the pathophysiology and pathosociology (just making words up now) of a patient’s ill health and intervene on both.

As Bambra’s work argues, we need to target our socioeconomic interventions not just on individuals but on the socioeconomic systems in which those individuals operate. For Richard, this means not only referring him to a medical-legal partner so that he can get access to the disability payments that he’s entitled to (individual intervention), but also political action for safer working environments and more equitable economic opportunity (systems intervention).

This is not a trivial task, which is why I believe that we need training in the correct diagnosis of pathosociology as part of our medical training. We need to create training opportunities for physician-witnesses that begin during pre-medical education. We need to recruit students with a talent for witness into medicine, recognizing that these talents are more often found in students who themselves were raised in the midst of social and economic inequality. We need to ally ourselves with non-medical folk with talent for witness and use our voices to amplify theirs. We need to use our social privilege as doctors to speak truth to those in power who are slaves to respectability politics and would not get the message otherwise.

There is work here for all of us, and its a labor that is necessary if we are to truly work for the health and well-being of our patients.

*To protect patient privacy, this narrative is an amalgamation of several different patients’ stories.

Our Police, Ourselves

Last week, the National Bureau of Economic Research (NBER) published a working paper by economist Roland Fryer on how police use violent force on civilians based on the race of those civilians.

Because police departments are not obliged to provide detailed encounter summaries in response to Freedom of Information Act requests and there is no standardized reporting of police use of force, Fryer’s team used a non-random sample of urban police departments with whom they were able to make contacts. Most of these departments were voluntarily a part of President Obama’s Police Data Initiative, a reform initiative focused on police accountability. In the methods section, Fryer is explicit about the bias that this selection introduces to the study and the limits it places upon its generalizability.

From these data sets, Fryer makes some interesting observations:

New York City Stop-And-Frisk Data

  • In New York, Black people are 17% more likely to experience police violence during a police stop compared to Whites. Hispanic people are 12% more likely.
  • This disparity was present across all use of force categories [(1) hands, (2) force to a wall, (3) handcuffs, (4) draw weapon, (5) push to the ground, (6) point a weapon, (7) pepper spray or (8) strike with a baton].

Police-Public Contact Survey (PCPS)

  • The PCPS is a nationally representative survey of civilians on their encounters with the police.
  • In the PCPS data set, Black people were 2.7 times more likely to report use of force by police and Hispanic people were 1.7 times more likely after accounting for demographic and encounter characteristics.
  • “Strikingly, both the black and Hispanic coefficients are statistically similar across these income levels suggesting that higher income minorities do not price themselves out of police use of force”

Houston Officer-Involved Shooting (OIS) Data

  • This was the result that has made the headlines. In Houston, police were no more likely to shoot a Black person during a police encounter than a White person.
  • Unlike in much of the press surrounding this research, in the paper itself Fryer is explicit about the limited scope of its conclusion: “To be clear, the empirical thought experiment here is that a police officer arrives at a scene and decides whether or not to use lethal force. Our estimates suggest that this decision is not correlated with the race of the suspect. This does not, however, rule out the possibility that there are important racial differences in whether or not these police-civilian interactions occur at all.”

This study joins a growing body of literature focused on racial bias in policing. These studies are reliant on the lay press for data which introduces its own set of biases, but unfortunately such weak data is what we’re stuck with until we get mandatory reporting of all police shootings.

These results do no necessarily conflict with Fryer’s result when you consider that Black people are more likely to be stopped by police than white people.

In other words, even if there is an equal chance of a police officer pulling the trigger during an encounter with a Black or White person, because Black people are stopped by police more often, they are shot by police more often.

I think this is an important conclusion to think about because it moves the narrative away from focusing solely on police shootings to a bigger picture view of how policing reflects broader social perceptions of Black criminality and suspiciousness.

Better de-escalation training can reduce the overall number of people killed by the police and by extension the number of Black people killed by police. Implicit bias training can reduce the excess targeting of Black communities which leads to excess Black deaths at the hands of police. These are great harm-reduction steps that we can take right now that will literally save lives.

However, affirming that Black Lives Matter means taking a step beyond reactive politics toward an understanding that police attitudes and behaviors are not anomalous, but a reflection of the society in which they operate. Police reforms are important, but so is rooting out and addressing the racial biases present in my own life and in my immediate community.

If this is something that you’re interested in as well, check out this curriculum on race and racism or this guide to developing a positive White identity through anti-racist action. And of course, feel free to chat with me about it. I’m @hkalodimos on Twitter.

 

Affirming the Value of Black Lives

In the wake of Alton Sterling and Philandro Castile’s untimely deaths at the hands of police, there is renewed focus on how we might remake our society into one which upholds and affirms the value of Black Lives. As healthcare providers, life’s value is not an abstraction, but a concrete goal toward which we strive every day. Every therapy we prescribe or perform is rooted in the value of life and our mission to preserve and prolong it.

Because of this, there is currently a lively discourse amongst physicians and other healthcare professionals about how we might respond to this epidemic of violence. I’m collecting some of these approaches in this post mostly in order to organize my thoughts, but I also want them to be available to anyone who is looking for a way to take action against the systemic racism which leads those who are labeled Black in this country to have a greater burden of illness.

If you have anything that you think I should add to this list, please let me know! Specifically, I want to know of any groups or individuals which are helping organize people around specific interventions.

Personal Interventions

Educate yourself

Change begins with you, right? A Letter to Our Patients on Racism is a great statement on how medical providers can meaningfully commit to anti-racism. While you’re at it, here are some great reading lists to better inform yourself of the causes and consequences of racism in American society:

If you have privilege, be an ally to those without it

At some point, I will pick and choose from these lists to make a shorter more manageable doc, but for now here are some resources that I frequently draw upon.

Speak to your friends, family, and coworkers

Discussing race is difficult, but important. Here are some tips to make the conversation productive.

  • Connect before you correct. Always start the conversation by centering on your connection with the person and acknowledgement of their good qualities. At the very least, most people have good intentions.
  • Spend more time listening than speaking. Monologues do not change minds. Spend time early in the conversation coming to understand not only what a person’s beliefs are, but what experiences they’ve had that have informed those beliefs.
  • Respond to the person, not to the straw man. When listening to someone, consider the most generous interpretation of their words and respond to that.
  • Do not try to “win” the conversation. The purpose of this conversation is not to embarrass the other person or force them to admit they are racist. It’s to come to a better understanding of each other’s points of view. If you are approaching the conversation with malice, you better believe that the other person is going to shut down.

Law Enforcement Interventions

Advocate for comprehensive police reform

  • Summary: No single intervention is going to fix all the problems with our current law enforcement system, however, Campaign Zero has put together a thoughtful list of reforms which when taken together promote and more just and peaceful society.
  • What you can do: Read over their reform proposals and then use the Take Action Tool on their website to speak with your local representatives about the laws being considered in your state or to advocate for the reforms you feel most passionate about. If you’re feeling generous, you should donate here!

Promote police implicit bias training

Promote Crisis Intervention Teams

  • Summary: Crisis Intervention Teams are focused on safely and appropriately responding to people experiencing a mental health crisis without resorting to violence. While not directly addressing the issue of racism in policing, it is a reform effort to making law enforcement more humane and community-oriented.
  • What you can do: The National Alliance on Mental Illness has a page dedicated to how you can help establish a Crisis Intervention Team in your city. As before you can also contact your city council person and advocate for this intervention.

Make law enforcement-related deaths a notifiable condition 

  • Summary: By mandating reporting of these deaths, researchers will be able to gather more accurate public health data about patterns in this type of violence. Dr. Nancy Krieger has been the most vocal advocate of this approach and you can read her full argument in PLoS Medicine (Open Access).
  • What you can do: I’m not aware of any formal organizing around this issue, but you can contact the APHA or your medical society and advocate for this approach.

Healthcare Interventions

Commit to and promote the practice of trauma-informed care

  • Summary: Patients that have been traumatized by police violence, repeated racist encounters, or other events are often at higher risk of illness. Trauma-informed care is a practice of acknowledging past traumas and helping patients heal while avoiding re-traumatizing them.
  • What you can do: The Substance Abuse and Mental Health Services Administration has some great resources here, but to really engage you will likely have to seek out local training for your physician group.

Ensure hospital staff is trained in de-escalation strategies

  • Summary: The recent shooting of Alan Pean while he was hospitalized for a manic episode brought national attention to hospital security staff that is often unprepared to safely manage agitated patients.
  • What you can do: Find out what policies your hospital has for managing agitated patients and if they haven’t instituted de-escalation training for security personnel, advocate for it.

Physician-Activist Groups To Join or Follow

BLM

 

Unintended Pregnancy: Common Ground in the Abortion Debate

Screen Shot 2016-03-13 at 4.27.03 PMThis chart is a big deal because unintended pregnancy is a big deal.

The physical and emotional stress of unintended pregnancy is reason enough to desire its reduction. However, it’s also notable that unintended pregnancy is associated with inadequate prenatal care, smoking and drinking during pregnancy, and giving birth to premature or low birth-weight infants. Thus, by creating conditions in which a women can choose if and when she becomes pregnant, you can improve the health and well-being of both women and children.

Because of this, the National Survey of Family Growth has been a frequent cause for consternation among public health-minded folks as it has previously shown an unintended pregnancy rate that just wouldn’t budge. Results from 2001 allowed for some hope when there was a modest decline in the rate, but when 2008 results showed an increased rate of unintended pregnancy, those hopes were dashed.

Two weeks ago, the New England Journal of Medicine published the latest data on unintended pregnancy in the United States showing a 18% decline in the rate of unintended pregnancy between 2008 and 2011 to an all-time-low of 45 unintended pregnancies for every 1000 women between the ages of 15 and 44. This is still far too many unintended pregnancies, but it’s progress.

tThe report also contains lots of interesting information about the use of abortion in the United States. The percentage of unintended pregnancies that ended in abortion ticked up slightly from 40% to 42%. However, because the rate of unintended pregnancy dropped over this same time period the abortion rate actually decreased from 19.4 to 16.9 per 1000 women aged 15-44 between 2008 and 2011. 

I really can’t emphasize enough how important it is to recognize that one of the most effective tools we have for reducing the rate of abortion is to reduce the rate at which women need abortions by providing effective and affordable birth control to all women who desire it. In these times when political common ground is scarce, this strikes me as an area where people with different value systems can agree on a policy that would be a win for everyone.

Finally, the report also emphasizes a fact that I believe doesn’t get enough play which is that abortion is incredibly common amongst all types of women. Amongst Catholic women, 48% of unintended pregnancies end in abortion. Evangelical Christians, the religious group which utilizes abortion the least, still terminate 32% of their unintended pregnancies. Although people from these groups are often fighting to restrict access to abortion, there is a deep irony to the fact that this is a procedure that they themselves use at roughly the same frequency as the general population.

Even if it is ironic, it is not surprising. After all, abortion is a safe procedure which allows women to be in control of whether or when they raise a child. Of course women from all walks of life avail themselves of it.

Facts to take with you:

  1. 45% of all pregnancies are unintended
  2. 42% of unintended pregnancies end in abortion
  3. 21% of all pregnancies end in abortion
  4. 1 in 3 women will have an abortion at some point in their life

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Behavior change and patient empowerment

(The following is a response to an event co-hosted by NEJM Catalyst and LDI CHIBE on “Patient Engagement: Behavioral Strategies for Better Health.” It has been cross-posted to the Leonard Davis Institute’s Health PolicySense blog)

As a medical student going into primary care, I value health behavior change not only as a disease prevention strategy, but as a way of empowering patients. In many areas of our health care system, we ask our patients to be passive recipients of care: to take their pills obligingly, get their colonoscopies on the appointed date, and to consent to the surgeries we recommend. In health behaviors such as diet and exercise, patients are instead active promoters of their own wellbeing.

This altered power balance in which the patient has control and the provider has only influence can make health care practitioners who are used to being in charge feel deeply uncomfortable. However, with a third of all premature deaths in America attributable to health behaviors, there is tremendous opportunity here to better our nation’s health by partnering with patients to promote more healthy behaviors.

Continue reading “Behavior change and patient empowerment”

A Brief Intervention for Behavior Change

This essay is based on a talk I gave to medical students and faculty at the Perelman School of Medicine at the University of Pennsylvania on how physicians can help patients achieve behavior change.

Developing instincts

heart_attackThis image is enough for most of you in the audience to start building your differential diagnosis. When this older gentleman shows up in your emergency department sweating profusely and complaining of chest pain, you’re going to instinctively reach for an aspirin and an EKG.

Much of our medical training is focused on these kinds of situations where procedural memory helps us act quickly and effectively. This is important because when we’re in a time limited and stressful situation, it can be difficult to think clearly and so we need to develop good instincts.

Yet let me turn the clock back twenty years, well before his coronary arteries are overrun with plaque. What happens when this same patient shows up to your outpatient practice and during a routine exam you find out that he smokes a pack of cigarettes a day?

You’ve got 5 minutes until you see your next patient. Once again, you’re time limited and stressed. What do you do? Are you still ready to act?

Continue reading “A Brief Intervention for Behavior Change”