“Promise me he won’t die here,” my patient’s daughter begged me. In her eyes was a fear born of familiarity: She’d seen too many of her family and neighbors die in a hospital. Just last year, her mother was admitted to the intensive care unit and never left. Now her 70-year-old father, whom I’ll call Ray, was in the same place, lying in a bed with his eyes unfocused and his speech confused. Ray would die here, and I could do nothing to stop that from happening. His life was never mine to save. It had been lost much earlier to the destructive grind of the impoverished, embattled neighborhood where he lived.
Ray lived in East Harlem, N.Y., for a half-century. During that time he saw his neighborhood deteriorate under pressure of failed public policies. Super block public housing isolated poor neighbors — almost all of them black and Latino — from the richer, whiter city around them. The political clout of wealthier neighborhoods unwilling to host drug treatment facilities turned East Harlem into New York City’s methadone capital. Violent crime increased. For decades, Ray couldn’t find work — or safety. Over time, he grew isolated, eating meals of cheap takeout on his couch while watching TV. The salty food and inactivity left him with diabetes, swollen limbs, and ultimately heart failure.
His neighborhood helped create the conditions that killed him, and they continue to take their toll on the children and grandchildren Ray left behind.
But it doesn’t have to be that way in East Harlem or any other neighborhood in America. There are ways to make neighborhoods places where healthy lives are built, not ground down.
Had Ray been born 10 blocks south of East Harlem, in Manhattan’s Upper East Side, his life and death would have been very different. There’s a 10-year difference in life expectancy between residents of the Upper East Side and East Harlem. In other neighborhoods across the country, the gap is even larger. According to the Institute for Health Metrics and Evaluation a boy born in Bolivar, Miss., can expect to live 67 years. Born the same day in Fairfax, Va., he would expect to live 15 years longer. Such disparities reflect differences in the resources and infrastructures available in different communities. To address these inequities, health care systems must be understood as just one part of the complex, integrated community systems needed to support health.
During this chaotic period of health care reform in America, doctors like me are waking up to a reality we have long ignored: To save lives, it simply isn’t enough to provide the best clinical care we can. As we transition from fee-for-service care to population health management, we must do more than “bend the cost curve” and provide health care more efficiently. We must look beyond the walls of our health centers and hospitals and into the communities where people live their daily lives.
Rather than focusing on clinical diagnoses and treatments, we need to collaborate with community leaders and organizations providing social services, making ourselves part of the neighborhoods we serve.
Many hospitals and clinics are already experimenting with innovative approaches that link the clinic to the neighborhood. Nationally, the 100 Million Healthier Lives network brings together community-based organizations providing everything from mental health supports to transportation assistance to learn from each other about how to successfully collaborate with hospitals to build health in their communities. In Dallas, Parkland Health and Hospital System is developing an electronic data system that lets doctors and social service organizations coordinate care for the people they both serve. Instead of telling a patient to eat more vegetables, a physician can send a note to the food bank across the street, informing the staff of the patient’s dietary needs. In New York, City Health Works matches low-income patients with complex chronic conditions with health coaches who help them find motivation and support systems to navigate daily life.
If Ray had been able to work with a health coach, he would have had someone to visit him at home, use behavioral psychology to help him meet his challenges head-on, and use mobile communications technologies to share information with me and other members of his care team about why he struggled to control his diabetes.
These programs represent a new generation of collaborative efforts to push back against the premise that the circumstances of a person’s daily life are not the concern of health care providers. As health systems take on financial responsibility for population health, using advances in analytics and mobile technologies to implement adaptable care models will be essential for building healthier communities.
That work isn’t easy. But if we truly believe that the neighborhood in which you are born shouldn’t limit your prospects for good health, it is the work we must pursue. If health care providers, community-based professionals and leaders, and policy makers embrace this new spirit of collaborative innovation, it is still possible for Ray’s grandchildren in East Harlem to represent the healthiest generation of Americans we have ever known.
Prabhjot Singh, MD, is the director of the Arnhold Institute for Global Health and chair of the Department of Health System Design and Global Health at Mount Sinai Health System, and author of “Dying and Living in the Neighborhood: A Street-Level View of America’s Healthcare Promise” (Johns Hopkins University Press, 2016).
I agree & then some. Our real issue is our marketized culture, our thinking that individualism trumps solidarity, our being owned by corporate interests. And anyway, this is not really a doctor issue, though too quickly it ends up in our basket because in the US anything health is reflexly dumped in the inbox of docs, who somehow are supposed to fix it all, which is not only wrong, but impossible. We are trained to identify & treat disease, and that training takes a lot of time & experience before we can safely do that. Social determinants of health are a societal issue, and unfortunately our national assumptions & responses have got us to where we are now. Dumping on docs is a waste of time & a distraction from what has to be the real focus–the social & political will to treat each other better.
“Rather than focusing on clinical diagnoses and treatments, we need to collaborate with community leaders and organizations providing social services, making ourselves part of the neighborhoods we serve.”
I could not agree more, this entire read makes me think of Illich’s “Medical Nemesis”. A very strong bioethical critique of medical practice in America.
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