What’s really making Americans sick?

Many countries enjoy better health than the US because they have made different choices in how healthcare is delivered.

A patient receives treatment during the
According to the Institute of Medicine report, countries enjoy better health when they don't treat health in isolation - but also support with policies and practices in related fields like education, housing and justice [AFP]

Tears fell quietly down my patient’s face. I was explaining that, given her continuing and worrisome high blood pressure, we were going to increase her medications. But Sylvia’s concerns were not the same as mine. She explained that her grandson had been shot and killed two weeks ago. “He was a good boy,” she said. “My heart is broken.”

Doctors are not trained to respond to a statement like that. When your patient’s heart is broken from sadness, when her body hurts from the emotional and physical toll of stress, what should a doctor do next? Write a prescription for more blood pressure medicine? Tell her to eat less salt and lose some weight? This is what the US medical system has trained me to do – but it is not working.

In January, the Institute of Medicine released, “US Health in International Perspective: Shorter Lives, Poorer Health”. The report confirms that Americans have been dying at younger ages than people in almost all other developed countries. Americans have worse health than our counterparts in other wealthy nations – even though the US spends far more per person on health care.

The IOM report used large studies and data sets to investigate why the US is falling behind. But let’s consider another source of evidence: Patients are speaking and telling their stories. They have the answers, and possibly the solutions – if, doctors, health care leaders and elected officials can learn to listen.

The phrase “patient-centred medicine” often gets tossed around in healthcare – and too often, is used to mean that the doctor gives the patient the treatment he or she wants. But I would argue that, more profoundly, patient-centred medicine also means listening to what patients are saying about what is making them sick.

Psychological factors

What I hear from my patients is that illness is not merely the end result of individual biology and behaviour. What people experience when they are ill is usually something far more complex, deeply interconnected with their daily lives. 

 Discussing US health care reform

Health and illness are rooted in people’s social, emotional, physical and economic environments. Last month, a study by researchers from Pittsburgh found that African Americans who live in more segregated counties are more likely to die from lung cancer than those who live in less segregated counties, even after accounting for common explanations such as smoking, education and income.

The IOM report details countless studies that link social, psychological and environmental factors to Americans’ poor health. Yet our leaders, policymakers and healthcare system have not offered an effective response.

That’s partly because science doesn’t completely understand how these daily life experiences are linked to biology. As a scientist, I find that frustrating. But as a primary care physician, I hear and witness from my patients how things like job insecurity, unsafe neighbourhoods, lack of opportunity, being undocumented, loneliness and stress – which scientists would call “non-biological and non-behavioural factors” – all profoundly affect their health.

Hearing about my patient’s broken heart helps me see that emotions have clear physical manifestations, that stress can affect blood pressure, and that gun violence has health consequences beyond the loss of one life. Most important, it helps me understand that the solutions to Americans’ poor health are not going to be found solely within healthcare.

Sylvia’s high blood pressure is clearly an important health threat that must be treated. But I cannot treat her blood pressure without acknowledging her broken heart. We talked about her loss, how it must be affecting her body and how she could ease her grief.

She said that she could find solace in her family and also her church. I encouraged her to spend more time with her other grandchildren and to attend her church luncheon that she had been missing.

We agreed to wait a few weeks before increasing her blood pressure medicine. While this approach can feel overwhelming – I am after all, a doctor trained to treat medical problems, not provide an ear for social and personal problems – it is only by listening to the patient about what is making her sick that I can help her genuinely get well.

Expanding healthcare access

To improve our nation’s health, we can keep doing more of what we have been doing, much of which is certainly needed: expanding healthcare access, making sure people take their medications and implementing effective interventions in the healthcare setting. But more of the same is not going to be enough.

According to the IOM report, countries enjoy better health when they don’t treat health in isolation – but also support their healthcare goals with policies and practices in such related fields as education, labour, housing, justice and environment.

For example, countries that guarantee paid family leave for new parents have much higher rates of breast feeding – which may be one reason their infant mortality rates are lower than those in the US. By contrast, the US rarely coordinates our health goals with our other public policies.

Consider that science has shown us that Americans desperately need to eat more plant-based foods – fruits, vegetables, beans, linked to lower weights and better health – and fewer animal-based foods, linked to obesity, diabetes, heart disease and cancers. And yet, US agricultural policies subsidise the cheap production of meat and dairy – but not fruits, vegetables and beans.

Occasionally our system does successfully look beyond the disease to treat the person who is getting the diseases. Consider that under Secretary Eric Shinseki, the Veterans Administration (VA), which is largely focused on veterans’ health, launched a programme to reduce and eradicate veterans’ homelessness

“High blood pressure begins in childhood and is driven by low birth weight, duration of breast feeding and body mass index.”

What does that have to do with health? The VA can treat homeless veterans’ drug-resistant skin infections, bronchitis, frostbite, or depression as if they were independent diseases – but only by ignoring the fact that the person underneath those illnesses is getting them because he or she has no place to live. You cannot effectively treat illnesses if a person does not have a home. 

But the VA healthcare system has a financial incentive to look at genuine prevention rather than just billable prescriptions and tests. That’s not true of the US healthcare system at large, which offers disproportionately high financial rewards for those who develop and use technologies and medications for individual diseases – and no comparable reward for preventing illness or for addressing the root causes of poor health.

Improving social factors 

Sylvia’s high blood pressure originates in a complex set of social, biological and behavioural factors. Effective strategies for improving her health could include a neighbourhood free from gun violence, strengthening her network of family and friends, and a doctor who has time to listen to her story and to let her grieve and rest before writing the next prescription.

In formulating a response to the vexing problem of high blood pressure, our leaders might even consider the latest evidence: that high blood pressure begins in childhood and is driven by low birth weight, duration of breast feeding and body mass index.

I’m not saying that better social and public policies alone can solve America’s health problems – but neither can we solve our health problems by pouring more money into new technologies and pills. And sometimes, as with my patient Sylvia, solutions will need to involve families, friends and neighbours.

These prescriptions are not trivial, but they are essential if we want to stop the downward spiral of Americans’ health. Many countries enjoy better health than the US because they have made different choices in how healthcare is delivered, how health is integrated with other public policies and in how they choose to care for each other.

There is no reason that Americans cannot achieve better health by learning from what other countries have done, coordinating key policies and sectors with our overarching health goals, and improving the social factors that determine health and well-being.

You can follow Namratha on Twitter @NammiKan

Dr Namratha Kandula is a general internist and Assistant Professor at Northwestern University’s Feinberg School of Medicine. She is also a Public Voices fellow with the OpEd Project. Her research, on the social and cultural determinants of health, has appeared in the American Journal of Public Health.