by Marie Crandall, MD, MPH, FACS
Living in Detroit as a child, I learned that if your water got turned off, you just went down to the city Water Board, paid $10, and got your water turned back on. When I started high school in the early 1980s, our family moved to Northern Michigan. It was there I met folks who didn’t have running water. I have countless memories of stumbling out past snow-covered woodpiles to drafty outhouses, then pumping ice cold water over my hands before returning to not terribly public health-focused high school parties. Seeing both urban and rural poverty and the ensuing late-diagnoses of cancer, alcohol-induced car crashes, and gunshot wounds that ruined lives absolutely influenced the course of my life and my career.
The crushing effects of poverty are pervasive and have a tremendous impact on health disparities, as income and race have been found to predict outcomes in nearly every kind of illness, from trauma to appendicitis to cancer, though we are only just beginning to understand the mechanisms. However, programs that improve housing stability and access to healthcare and healthy food choices have been shown to improve ALL health outcomes for children, underscoring the principles of the social determinants of health. If we can address some of the nutrition, education, and health issues of children living in poverty, we may be able to narrow the gap of subsequent health outcomes disparities. Likewise, if issues of homelessness and substance abuse could be more comprehensively addressed, there is evidence to suggest that Emergency Room visits and healthcare expenditures can be reduced.
Injury is the leading cause of death of all Americans ages one through 45. Gunshot wounds take the lives of 30,000 Americans every year. There is an epidemic of violence and endemic acceptability of violence in our communities with African American and Latino youth suffering a disproportionate amount of gun violence in the United States. Simply providing excellent trauma care is not enough. Programs like CeaseFire/CureViolence in Chicago and Safe Streets in Baltimore are necessary adjuncts to address the underlying root causes of handgun violence. Ensuring safe access to schools, improving educational and earning potential for underprivileged youth, and teaching conflict resolution skills as alternatives to violence are essential to preventing the loss of life that takes such a heavy toll on our disadvantaged communities.
Fear of flying is one of the most common phobias in America, affecting nearly 40 million people. Yet if you ask any group of people if they know someone who has been killed in a commercial aviation crash, almost no one will raise their hand. However, most people have no fear at all of getting behind the wheel of a car, even when intoxicated, though nearly 30% of Americans have lost someone in a motor vehicle crash. However, there are things you can do to make your ride safer, like wearing a seatbelt, which reduces the risk of death for a similar velocity crash by up to 80%. Many researchers have found that people of color are less likely to use a seatbelt; this disparity is completely eliminated in states with primary seatbelt laws. These data suggest that primary prevention can be effective in some cases to decrease racial disparities in health outcomes.
So, what does all this mean? I believe that by recognizing the disparities around you, affecting your families, friends, and communities, and by striving consistently to acknowledge and eliminate them, you will be a better clinician and global citizen. Your role may include public health work, competent clinical care, health policy, and/or advocacy. But a holistic worldview, with an understanding of the social determinants of health that affect all of us, is essential to the comprehensive care of your patients.
What health disparities have you witnessed in your community or during your travels? What efforts have you made (or wish to make) to transform the world into a better, healthier place? Leave your comments below!