Police Violence and Public Health

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In the wake of Sandy Hook, the response from physicians, and pediatricians in particular, was astounding. The tragic deaths moved doctors to address gun violence and its health consequences.

But week after week, as black boys who could be my sons and black men who could be my father, are shot and killed by police, doctors remain silent. As a pediatrician, I’m appalled.

We are watching a public health problem unfold in front of us and we aren’t doing anything to stop it.

When someone is involved in a police shooting, they are at risk for injury, disability, and as we’ve seen, death. But those who witness the trauma may also be affected. And if they are children, that effect may follow them into adulthood.

Public police shootings turn neighborhoods into minefields where African-Americans fear suddenly finding themselves in harms-way. Those who escape the line of fire are then victimized by the ever-present fear of harassment, incarceration, injury or death.

Like the trauma experienced by war veterans, living under the threat of unprovoked police violence triggers intense emotional and physical stress, even in moments of relative safety.

The chronic stress that fear generates, may place African-Americans at increased risk for health problems like heart and lung disease, and depression.

If we’re going to understand and address the impact police violence has on community safety and health, particularly for communities of color who are disproportionately victimized, we have to treat it the way we treat all threats to health. That means collecting data to quantify the magnitude of the problem, developing screening guidelines to identify those at risk, training medical staff to refer those at risk of impending danger, and funding interventions that address community violence including police violence.

Tonight, too many parents will tuck their children into bed, only to worry that tomorrow, their curious 10-year-old may be the victim of a police shooting because the combination of a growth spurt and black skin threatened their life. Today, we have to do
more to recognize the worry in our community and prevent those fears from becoming reality.

* This piece was featured on Northern California’s NPR affiliate KQED as a perspectives piece. It airs live on April 29th at 6:43am, 8:43am, and 11:30pm. To hear an audio reading of the piece on KQED’s website, click here.

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Is Civic Engagement the New Frontier of Physician Advocacy?

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We Can Do Better - Improving the Health of the American PeopleThe figure is simple. Health care plays, at best, a minor, and at worst, a relatively inconsequential role in reducing early death in America.

That means, where people live and how they function in their local environment, potentially matters more to their long-term survival than what doctor they go to, or what medicines they are prescribed.

That is a powerful statement about a complex phenomenon – what happens in our communities impacts health in profound and lasting ways. So if health is predominantly determined by community-level factors,* perhaps we should re-design the traditional medical model to place community at the center of health care.

This idea isn’t new, and is probably why Dr. Steven Schroeder aptly titled the article from which this graph was taken, We Can Do Better. One look at the data and it is obvious more can and should be done to address the social, economic, and political drivers of health in this country. But the question of who and how somehow remains.

For many physicians, taking on structural inequality may seem overwhelming or outside their job description. Common retorts I hear are, “This is a social workers job.” Or “This sounds good in theory, but how would it work in practice?” To the first point, the evolution I am alluding to is a systems-wide change in the practice of medicine, such that the way we conceptualize medical care draws upon the skills of an interdisciplinary team of practitioners charged with addressing social determinants of health. So while this vision certainly includes social workers (and public health departments, local government, social service agencies, etc) it also necessarily includes physicians.

To the second point, there is a long history of community-oriented primary care (COPC) theory and practice. It dates back to the 1940s, and the work of giants like Sydney Kark, who created a model of government-funded, community-based, preventative care delivery in South Africa; and Jack Geiger who directed 2 exemplary, community health centers in the Mississippi Delta and Boston, MA in the 1960s. Dr. Geiger’s integrated clinics were the first of their kind and used government funding to pay for community-level health issues, like hunger and housing. Today, there are over 1200 such clinics nationwide serving an estimated 20 million Americans, or 5% of the US population, annually. These clinics are the backbone of the national safety net and the front lines of the medical response to growing inequality.

But as the issues of poverty begin to knock on all of our clinic doors, we can no longer afford to ascribe to the notion that this is the niche work of a minority of physicians.

So where do we begin?

The ballot box.

Data suggests physicians have a relatively low rate of civic participation as compared with professional peers like lawyers and the general population. As local policy informs local resources, the ballot box is the space where physicians find voice to address the pressing needs of our communities, needs that have an undeniable impact on this nation’s health.

The future of medicine requires physicians confront the impacts of concentrated poverty, a tiered education system with gaps big enough for entire communities to fall through, immigration and population displacement, and racial and gender discrimination, among other indicators of health. Still, the traditional physician role and our current training paradigms largely ignore these modern threats to health and wellness. So in the absence of a clear system-wide charge, vote in a way that makes a difference.

If community health centers are the backbone of the social safety net, voting is the backbone of physician advocacy.

Civic participation is the new frontier for physicians to combat the effects of poverty and inequality on health in enduring ways. It is how we can reach beyond the limits of our clinical role to engage the issues that matter to our patients and our communities.

Visit Vote411.org to find a polling place near you, trouble shoot election-day problems, and find a state-specific voter guides.

Definitions used in this piece:

* Community-level factors are things like where you live, how safe your neighborhood is, if you have a park within walking distance of your house, or if the property values in your neighborhood are high enough that your local public school is well-funded and thus if you are of school-age, you are more likely to go to college as a result of living in that neighborhood. These community-level factors are intimately related to the choices people make or their “behavioral patterns” (as referred to in the pie chart above). For example, if your neighborhood is relatively safe and there is a park within walking distance of your house, you may be more likely raise your child in a lifestyle that promotes and values physical activity, a known method to prevent obesity. Conversely, if you live in a neighborhood that does not have a grocery store that sells affordable fresh produce, you may be more likely to eat processed food, and more likely to battle obesity and related health conditions.

For more on how community level factors or structural inequality affects health, check out my piece on structural inequality here. If you are an educator thinking about teaching these topics, check out my piece on teaching structural inequality here. This piece also includes the syllabus and reference guide I use when teaching on this topic.

Teaching Structural Competency and the Perils of Pretending

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Earlier this year, I started teaching a course to first year pediatric residents at Stanford. In it, I challenge the trainees to identify the structural contexts in which patients and families make choices that may impact their health and well-being. Termed structural competency, the goal is to enable young physicians to understand and confront stigma and inequality as key determinants of health. We talk about educational attainment and health literacy, socioeconomic status and health access, social norms and health practices, institutional discrimination and health disparities, and the built environment and health behaviors. Together, we examine the fragile balance between resources and health, recognizing that local forces that manipulate resources effectively legislate health, by structuring choice and opportunity.

To illustrate these fundamental connections, it is often necessary to convert what otherwise exist as invisible forces in society into accessible, clinically-relevant language. This allows us to conceptualize the structural framework in which patients’ live, work, and play, within a medical model. It shrinks what seems like a diffuse and disconnected system of local policies and institutions into tangible drivers of health and disease that require socially-informed, clinical interventions. It transforms inequality, a sociopolitical phenomenon, into a silent but active participant in the clinical encounter. This makes addressing local infrastructure a central component of any community-centered, health promotion strategy.

But as we expand our purview beyond the exam room and encourage young physicians to adopt a global approach to clinical medicine, we must be very careful not to succumb to, what I will call, “the perils of pretending.” Here, there are 3 common pitfalls that warrant discussion.

1. The Poverty Simulator. In any educational endeavor, experience is perhaps, the greatest teacher. Without experiencing poverty first-hand, it may be difficult for residents to understand the challenges families living in poverty face when seeking medical care or selecting medical treatments.

One such simulator offers “players” a chance to live on a low-income budget. Other programs ask residents to navigate public transit to various appointments. At Stanford, I ask the residents to live on the average food stamp budget for a week. These self-reflective exercises are meant to influence learner attitudes about inequality and build empathy among providers as they realize what it takes to survive under certain conditions.

The problem with poverty simulators is that the process of pretending to be poor unfairly and inaccurately reduces the daily struggle of living in poverty to a series of poor choices, no pun intended. The “game” motif insinuates that some choices are superior to others while completely obscuring the larger network of policies and institutions that concentrate disadvantage and manipulate choice in low-income communities.

For example, if you live in a food desert, the choice to eat fresh produce is constrained by the proximity of those resources to your home. This “trade-off” requires bargaining between necessities and results in a loss either way. Buying cheaper food in your neighborhood may have adverse health consequences and expending the time and money to obtain healthy food on a fixed income makes other necessities unaffordable. This zero-sum reality profoundly limits choice.

To avoid this pitfall, it is important to be clear about the purpose of the exercise, which is to acknowledge that resource limitations have health consequences. The lesson is that poverty is not a deficiency of ingenuity or the manifestation of good or bad choices. There are no “right” choices when selecting between food and medicine. So if poverty is the result of eroding urban infrastructure and imbalanced resource allocation and is associated with poor health outcomes, then building infrastructure is a health intervention.

2. The Absence of Clinical Models. While the associations between social determinants of health and poor health outcomes are well-documented, we lack comprehensive, evidenced-based clinical models for addressing complex trauma and chronic stress, physiologically significant exposures that are the downstream sequelae of poverty and inequality. Short of co-locating same-day necessities in medical clinics, like food pantries or legal assistance, there are few models to describe how physicians in particular and the medical system at large, should engage the sociopolitical drivers of health through clinical work.

In the absence of these models, some physicians pretend there is nothing that can be done, or worst yet, that these issues are not “medical.”

The problem is that we are complacent in our current clinical practice. Stagnated by the dearth of evidence and overwhelmed by the magnitude of the issue, we simply avoid it. We fail to universally screen patients for social determinants of health because we don’t know where to refer them. We refuse to inquire about these issues because we essentially lack confidence in our ability or aptitude to address them.

The solution here is to do it any way. Just as all politics are local, so too will be the formation and dissemination of novel clinical models that address these issues. So we must encourage our trainees to identify the most pressing needs in their communities and trial socially-savvy interventions in their continuity clinics. This is quality improvement at its best.

3. The Conflation of Race and Risk. When seeking to address the “cultural” influences in a clinical encounter, it can be easy to minimize “culture,” to the readily identifiable traits in the visit. Here, “culture” becomes a monolithic, static archetype we project onto patients based on our unconscious bias about their physical attributes, like ethnicity, nationality, or language.

When we do this, we are pretending that socially-assigned attributes, like race, are a proxy for risk. We track patterns of disease prevalence by these attributes and over time, come to associate the attribute with the disease. This logical fallacy then informs clinical practice and leads clinicians make inaccurate assumptions about certain patient populations, their relationship with disease, and the efficacy of certain medications to address their complaints (remember BiDil?).

The solution is to replace cultural competence with structural competence and educate young providers to interrogate the local context in which patients live, the resources at their disposal, and the networks they rely on to make medical decisions. We must of course, when doing this, not turn a blind eye to the ways in which local policies and historical discrimination produce predictable patterns of disease in certain communities. These patterns may make it seem as if the risk factor is easily recognized in the exam room (race, nationality) as opposed to the real risk factor that lives in our communities – structural inequality.

As medicine advances to address inequality as an important driver of health, we must be thoughtful about the way we educate our trainees to tackle this new frontier in primary care. While there will be pitfalls along way, if we tread carefully and together, we can transform the future of medicine in powerful and meaningful ways.

* Update: To learn more about my course, please check out the syllabus and reference guide I have shared below.

Rhea’s Stanford Course Details

Rhea’s Stanford Course Resources

Who’s Hungry?

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It is no secret that growing income inequality is one of the major issues facing the nation today. Close to 50 million Americans, or 1 in 6, live in poverty and 1 in 3 children are now projected to live in poverty at some point in their lifetime. But did you know, up to 1 in 3 kids in San Francisco may go to bed hungry tonight?

As the price of housing transforms our city into one of the most expensive in the country, the national income gap seems to have landed on our doorstep. And while this topic has garnered robust media attention and local public debate, the focus on poverty remains cursory, at best. Here, the housing crisis is literally changing the face of the city, and yet it is hard to identify who is most affected by the fickle pendulum of the economy and it is easy to make affordable housing the center of the conversation.

But the impact of poverty extends from the most recognizable needs in our community to one of the least – hunger. So let’s talk about it. Who’s hungry in our city?

Meet Lani. Lani’s grandmother originally came to San Francisco from Samoa in the late 1970s and her family has lived and worked in the Bay Area ever since. Like many of us, she dreams of owning a home in the city one day, but like a growing population of San Franciscans, her immediate need is food for her family.

Lani is a 35-year-old working mother of 2 and the only employed adult in her household. Her husband was a construction worker who, because of poor health, is physically unable to work. And after losing her mother in 2008, she and her husband became legal guardians to her younger siblings. That means, it’s all up to Lani to make ends meet.

As a high school graduate, she’s worked in food and cleaning services, but with the downturn in the economy, consistent work has been hard to find. In 2012, she became a certified nursing assistant and found a part-time position that offered $14 an hour but no benefits. She took it.

All 6 members of her household live in a government subsidized apartment in Hunter’s Point and yet because of her new income they recently found out they no longer qualify for food stamps or CalWorks. Struggling to get by without any additional aid, they rely on food from her church to make it to the end of the week. Sometimes, that is only a bag of rice and a can of vegetables. Her kids, aged 6 and 7, are just starting primary school. Without the free breakfast and lunch they receive there, she says she “probably wouldn’t be able to find something nutritious for them to eat at home.”

Hunger is a problem. But the issue here is more complex than the physical sensations of inadequate caloric intake. The more insidious challenge facing family’s like Lani’s is food insecurity, or limited or uncertain access to the resources to buy, store, and prepare the nutritious and culturally appropriate food necessary to support a healthy lifestyle.

According to the 2013 San Francisco Food Security Task Force’s annual report, 1 in 4 San Francisco residents live at or below 200% of the federal poverty level. For a family of 4, that’s about an income $47,100 per year. These low-income families make up a quarter of the city’s residents are the most likely to be food insecure. But the population we seldom recognize, despite having similarly high rates of food insecurity, is our city’s children.

For these communities, food insecurity is literally changing their lives. There is mounting scientific evidence showing that food insecurity is related to poor health outcomes like increased risk of adult chronic disease including diabetes and heart disease, and in children, increased risk of obesity and learning and behavior problems. And recent data from San Francisco General Hospital’s Community to Clinic Linkage Program, indicates almost half of the patients seeking urgent care at our county hospital are food insecure.

This is a public health problem and it sits at the intersection of income inequality and poverty in every city in America, including our own. In December 2013, the San Francisco Board of Supervisors issued a charge to local legislators and community organizations, to eliminate food insecurity in San Francisco by 2020. In collaboration with the San Francisco Food Security Task Force, help address this important issue!

Here are some things you can do today:

  • Support your local food bank by making a monetary donation, hosting a food drive, or donating food. The most needed items are: tuna, canned meat, peanut butter, soup, chili, beans, cereal, canned fruit and vegetables, and granola bars. Visit the SF-Marin Food Bank website to learn more.
  • Of all the students in the San Francisco Unified School District (SFUSD), 60% qualify for free or reduced priced meals, but less than half of those who are eligible are enrolled to receive this benefit. If you know of a child who may qualify, go the SFUSD website to apply now!
  • As summer approaches, even fewer low-come students have access to nutritious food. Know of a child who may need food over the summer? Go to the Department of Children, Youth, and Families website to find out how to enroll them in the After School Snack and Summer Meal Programs.
  • If you are a medical provider, start universally screening all of your patients for food insecurity. Here is a quick, validated tool you can use. If they screen positive, call 211 to connect them to food services!
  • Contact your state representative to support AB-2385. This bill would create the Market Match Program to provide additional income to recipients of programs like food stamps, to purchase food at farmer’s markets. A similar measure is being considered for San Francisco. Want to learn more? Visit the California Legislature website.
  • Join your local pediatricians and the American Academy of Pediatrics at Supervisor John Avalos’ Office in City Hall Room 244 to view a free photo exhibit entitled “Who’s Hungry? You Can’t Tell by Looking!” This exhibit captures the faces of local children to raise awareness of this often invisible need.

National rates of poverty are the highest they have been in decades and they impact our city in unique ways. But when you ask Lani what she wants for her kids, she doesn’t talk about eliminating financial stress or putting food on the table. She simply says, “I want them to become someone.” Healthy food and snacks are the building blocks to “become someone.” If recognizing the problem starts with asking the right questions, perhaps it is time we all asked, “Who’s Hungry?”