Module 3: Social and Environmental Determinants of Health

Interestingly, during a dermatology rotation in New Orleans, I saw many patients at the University Medical Center experiencing homelessness who were also on biologics for their psoriasis, atopic dermatitis or other skin conditions. Since they didn't have reliable refrigeration but needed these medications ofr quality of life, the medical center had a program where the pharmacy would keep their medications refrigerated for them so that they could come every time it was due and get their injection. At my home institution in Oregon (and a friend's private practice clinic in Washington), where this demographic is not frequently seen, this practice was unheard of. I think about this often as a great example of how local circumstances have a large impact on practice.

UMC also saw a lot of incarcerated patients. Unfortunately, access to timely and appropriate medical care is hard to come by in the prison system, so these patients would come in with fungating tumors, long past the time where resection would be curative.

I've had the unique opportunity to care for the lower-income/homeless population that lived on the island of Galveston, TX at a local clinic. In this clinic, we dealt with the "island tourism" culture which invested its money into what brought business to the island. Consequently, the majority of the resources/businesses were located away from the lower-socioeconomic areas resulting in food deserts, transportation issues, and less areas where shelter could be sought. Unfortunately, this resulted in poor nutrition habits, inconsistency showing up to clinic, and frequent loss of medications/poor adherence.

Cyclone Idai, and other natural disasters alike, offer governments and communities a rare opportunity rebuild in ways that wouldn't be possible otherwise. The destruction can allow for more robust infrastructure that can be one step toward both equity on a day-to-day basis for residents of communities impacted, but also can prepare communities for future natural disasters to hopefully lessen the impact on the vulnerable. Building stronger communication systems in these communities impacted can serve as both day-to-day communication improvements allowing these underserved communities the opportunity to be more involved and informed, but also give earlier/wider warnings for incoming threats.

Communication is a great point - both pre-disaster and post-disaster. And it helps address one of the most immediate concerns regarding safety. Bolstering communication efforts can be extremely effective in helping families prepare for a natural disaster. Communication is also invaluable after a natural disaster occurs; and can help families be reunited, informed of nearby relief aid, and reassured that a safety plan is in effect.

2. Previously, I had the opportunity to work briefly with the Indian Health Services in New Mexico. There were a number of social determinants that stood out (i.e. stress, addiction, lack of access to fresh produce/food desert, limited opportunities for employment) and one of the main ways these determinants were analyzed by the providers was in looking at early impacts of these factors via ACE scoring. The native community we served had evidence of higher than national ACE scores, not to mention that often many of those factors that created early stressors became chronic stressors as adults (i.e. domestic violence, neglect) and had more long term impacts related to health (correlated with obesity, substance use disorder, depression, heart disease and fatal CV events). Furthermore, as the ACE scoring system has expanded over the years to include the impact of systemic racism, institutionalized discrimination and oppression, it is easy to recognize how these scores would range higher for this community and therefore contribute directly to both social and environmental determinants of health. 

A very difficult situation to begin with and when you consider that health care is run as a business, it is often hard to convince large organizations (and small) to spend money and change practice for those that aren't adding to revenue. 

During the summer between my first and second years of medical school, I was fortunate to embark on a medical volunteer trip to Rupin Valley, India for three weeks during which we hiked through the Himalayas and set up daily clinics in small mountain villages we encountered. With assistance from translators, we would announce that our clinic was available that day, and by the end of the day we would triage about 100 patients. Our ability to help our patients was limited based on what medications or supplies we could carry with us, among other things. Some of these villages were more developed than others, but most did not have electricity or sound infrastructure and ALL of them were at least 2 hours (by car) away from a city with a hospital. The locals did not have cars, so people travelled hours to days on foot (while sick!) to get to a hospital if needed, or simply just stayed in their native village. After our clinic days, we were able to help transport a few of the sickest patients to the closest city to receive medical care above what we could provide. Multiple family members lived in the same room, increasing risk of spreading communicable disease. Medical literacy was poor, even with assistance of a translator, and schooling was mostly done at home or only up until children were old enough to help with work/farming. There was even a monsoon that caused roadslides/mudslides that prevented us from returning to larger cities for days. There were many social determinants of health at play here: economic instability (relied mostly on farming and self-sustenance, not many other jobs available), limited access to health care (from physical distance and not knowing what resources were available to them), education access (which was satisfactory in larger villages but very limited to absent in smaller, more remote villages), and infrastructure (often made their own homes out of available materials which were not always very structurally sound and no health care buildings in which to provide care - we set up canvas tents that we brought with us). There did seem to be a good sense of family and community support, as everyone worked together to sustain their family and greater village community, and they did eat healthily for the most part. Their food source relied heavily on the land, though, which put them at risk for disaster during natural events like monsoons or floods.