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Poverty is misery. It saps nutrients, because the poor may trade sustenance for cheap calories to stave off hunger. It precludes restorative sleep, given the demands of staying alive in the elements of the streets, the noisy crowded quarters, or the grueling hours of a second job. Poverty challenges the most basic levels of safety, security, hygiene, mental health, and the overall well-being of the lives of the almost 50 million Americans and billions worldwide in its grasp.
The socioeconomic gradient is one of the most pervasive and enduring trends in health. Found in nearly every disease entity, from cardiovascular to autoimmune disease, the gradient exists across and within nations.1 The gradient has confounded generations of physicians, whose training and turn of mind typically stop at the clinic door. After all, how far can physicians go? We cannot ensure that our patients keep the home stocked with nutritious foods or can escape nasty pollutants, much less prevent their future homelessness, can we?
Well, it turns out we can. Kangovi and colleagues2 report on an innovative community health worker (CHW) program in which members of an urban Philadelphia low-income community, after brief training, are deployed to help guide patients from their community to a more healthful life. With the CHW’s help, intervention patients, compared with randomly allocated usual-care controls, were more likely to make it to their follow-up appointments and had better communication with the medical teams as well as improved mental health function and agency. Perhaps most important in this era of accountable care, although the 30-day readmission rate was similar between groups, among readmitted patients, the intervention group had less than half the rate of multiple events within that window (15.2% vs 40.0%; P = .03).
Although the evidence for disease-specific effects of CHWs is fairly robust, data on their general place within health systems are rare, and the cost-savings piece is even harder to establish.3 In part, this is because cost savings are generally harder to demonstrate, particularly when the costs and benefits accrue to different sectors of society or the economy. For example, if a nutrition program supported by a health maintenance organization results only in fewer sick days and improved physical function among its members, but not in decreased use of medical care, its benefits would accrue to the members and their employers while the bill comes to the health maintenance organization. Therefore, despite being a success, the program would have trouble demonstrating its cost-effectiveness to the health maintenance organization.
This report is among the best evidence so far in support of what some are now calling upstream medicine, a term based on a common parable about children rushing down a river toward a waterfall. Rather than exhaust all resources to snag the children as they pass, it seems only reasonable to send a party upstream to see who is throwing them in the river in the first place. Upstream medicine is gaining momentum, exemplified by the online community HealthBegins (http://healthbegins.ning.com/), now home to more than 650 “upstreamists” from medicine, public health, community organizing, urban planning, and dozens of other fields.
In truth, most CHW efforts in the country remain firmly rooted within the medical model, such as chronic disease management, injury prevention, and immunization. But engaging with people in the community is bound to lead us to the parts of their lives that are well upstream of, for example, their medication adherence. Part of the appeal of the approach in the study by Kangovi et al is that patients and CHWs worked together to find aspects of the patients’ lives that, with help, could improve their sense of well-being. Such efforts will naturally lead upstream. Finding a comfortable social activity, identifying a food pantry, creating a budget for food—these interventions are not typically identified with medical care, but they lead to a measureable improvement in medical care.
Of course, public health efforts are, by definition, upstream from the medical encounter, but these are typically focused at the population level and have been historically at arm’s length from the health care that transpires in a physician’s office or hospital room. As a widely cited commentary4(p131) on social epidemiology observed, in the public health community, “the dominant approach to health care has been to ignore or dismiss it.” Nonetheless, public health has made substantial progress in understanding the role of social factors in health, and the upstream medicine movement is poised to apply many of the findings to patient care.
During the past 5 years, in an effort to find patient-centered applications for innovations from the laboratory, the National Institutes of Health5 has spent more than $2 billion funding its Clinical and Translational Science Awards. The collaborative publishes thousands of scientific papers annually: in 2010, more than 1000 each on genetics, metabolism, and physiology. Meanwhile, a quieter revolution in translational science is rolling out.
For more than 50 years, epidemiologists have chipped away at the opaque relationships between how we live—our behaviors, our social milieu—and how we feel—our health. Known sometimes as social determinants of health, this constellation of social phenomena can embrace housing, diet (including food insecurity), employment, income, race and ethnicity, social networks, neighborhood context, and many other features of our patients’ lives. Social isolation, for example, has a clear independent association with early mortality.6
For as much detail as epidemiologists and social scientists have provided about these relationships, there remains a wide gulf between what we know about social determinants and what we have been able to achieve with our patients given that knowledge. The CHW movement is a central part of the effort to apply the evidence generated by epidemiologists to patient-centered outcomes. However, in many other quiet corners of the medical care system, further efforts are found. For example, Health Leads (https://healthleadsusa.org/), a help desk to guide patients toward resolving health-related social needs, launched in Boston in 1996, now operates in more than 15 hospitals nationally.
Another iteration, medical-legal partnerships, provides legal services for poor patients facing eviction, termination of benefits, and many other threats to their well-being. According to the National Center for Medical Legal Partnership, 250 hospitals and clinics now feature formal articulations with legal services or law schools. These collaborations sometimes begin as revenue-generating operations for hospitals by appealing Medicaid and Medicare denials, but typically evolve to cover a wide range of services meant to “improve health outcomes by alleviating legal stressors.”7(p3)
Hybrids of these 2 models are emerging. At Highland Hospital in Oakland, California, patients visiting our emergency department can consult with a Highland Health Advocate, a volunteer college student who has access to lawyers, social workers, and specialized web-based tools to help patients navigate their care at Highland, their legal needs, and many of the obstacles facing low- and moderate-income patients. It is plausible that, by mitigating selected hardships of poverty and disadvantage, the pervasive socioeconomic gradient can be bent.
A secure place to socialize with other elders, a nearby food pantry, and a ride to the office of the medical home: with hospital-based medical care as the central cost driver in American medicine, these are opportunities for keeping patients out of the hospital, which is a central focus of cost control and health reform. If CHWs helping patients with these basic demands can prevent a cascade of hospital admissions and can improve patients’ health and well-being at the same time, we should all start looking up the river.
Corresponding Author: Harrison J. Alter, MD, MS, Department of Emergency Medicine, Alameda Health System, Highland Hospital, 1411 E 31st St, Oakland, CA 94602 (email@example.com).
Published Online: February 10, 2014. doi:10.1001/jamainternmed.2013.13302.
Conflict of Interest Disclosures: None reported.
Alter HJ. Social Determinants of Health: From Bench to Bedside. JAMA Intern Med. 2014;174(4):543–545. doi:10.1001/jamainternmed.2013.13302
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