What Plays the Primary Role in Health Outcomes?

“It’s funny how you switched careers. You went to medical school but now you’re doing public health,” one of my professors lightly remarked to the Associate Dean at the public health school I am now attending. The Dean politely brushed off the comment but in many ways it elucidated the current tensions in our health care system. Why is improving the well-being of an individual considered so distinct from improving the well-being of a population? Why are demarcations established between healing a person and healing the surrounding environment?

Mounting evidence demonstrates that a patient’s health outcome has largely been decided for him or her before the patient even enters the clinic. One’s health is predominantly impacted by socioeconomic determinants of health, such as poor housing, food insecurity, and unemployment; medical care itself affects only 10-15% of patient outcomes.ⁱ Ignoring these factors often results in doctors merely putting a bandage on a biomedical manifestation of greater social ills. With population health now highlighted as part of the Affordable Care Act’s triple aim, more health care organizations are seeking to address socioeconomic and environmental factors to improve the health of local communities.^{ii iii} We are in a very exciting time right now with respect to redefining the boundaries of health and the role that providers can play in promoting community health.

In the midst of such enthusiasm and innovation in the health sector, I’m incredibly blessed to have had the opportunity to take this year off from medical school to pursue my MPH. Although it has only been a month since I started, I’ve already seen social justice act as the framework for much of our public health coursework. This is vastly different from various medical schools where curricula are criticized for not adequately addressing issues related to health disparities or social accountability.^iv In these cases, such lack of attention in medical instruction is unacceptable when it is linked to worse patient outcomes, with individual patient-provider interactions contributing to the significant health inequity we see today in our nation.^{v vi}

Recognizing the ramifications of insufficient training on social medicine, my classmate. Robert Rock, and I were compelled to create a “U.S. Health Justice” course last year. We sought to use the course as a means of initiating a larger movement to change institutional culture regarding the role of social justice in medicine. ^vii And it was that wonderful experience with galvanizing community leaders and faculty, developing reflection sessions and workshops, and engaging in thoughtful dialogue with peers, which reinforced my desire to pursue an MPH.

I intend to take courses this year with a focus on epidemiology and mental health. My research experiences coupled with some great mentors in medical school have recently pushed me to seriously consider psychiatry despite it not being in my top three careers interests when I started medical school. While I have yet to do my clinical rotations, I’m increasingly discerning how many of my previous clinical and research experiences point to psychiatry as a really good fit for my intentions to do health justice work in the future. The mentally ill continue to be significantly marginalized and are still underserved in our healthcare system.^viii Much psychopathology can be traced back to trauma and adversity, which can disproportionately affect those from disadvantaged backgrounds. ^{ix x}

Alongside my burgeoning interest in mental health, I have also become further interested in health policy as a means of addressing structural causes of health inequity in this nation. While I have done community outreach and organization work in the past, I’m eager to learn more about how large-scale public policy interventions can improve health outcomes within historically marginalized populations. I envision doing epidemiology research in order to explicate major public health concerns and generate the necessary evidence to support policy proposals.

Former Health and Human Services Secretary Tommy Thompson asserted in a recent interview: “Be bold. You have an opportunity like you’ve never had before. The health care system has got to be changed. It can be built upon in the ACA”.^xi It is an exciting time indeed. I envision this year to be a very insightful one as I think more deeply about what my role as a health justice advocate can look like in the future.

i. The Case For More Active Policy Attention To Health Promotion J. Michael McGinnis, Pamela Williams-Russo, and James R. Knickman. Health Aff March 2002 21:278-93; doi:10.1377/hlthaff.21.2.78
ii. http://www.academyhealth.org/files/AH2013pophealth.pdf
iii. www.aafp.org/news/health-of-the-public/20150804populationhealth.html#.VcNliQ78WpM.twitter
iv. The necessity of social medicine in medical education. Westerhaus M, Finnegan A, Haidar M, Kleinman A, Mukherjee J, Farmer P.
Acad Med. 2015 May;90(5):565-8. doi: 10.1097/ACM.0000000000000571.
v. Med Care. 2002 Jan;40(1 Suppl):I140-51. Research on the provider contribution to race/ethnicity disparities in medical care. van Ryn M1.
vi. J Gen Intern Med. 2003 Feb;18(2):146-52. Racial and ethnic disparities in the use of health services: bias, preferences, or poor communication? Ashton CM1, Haidet P, Paterniti DA, Collins TC, Gordon HS, O’Malley K, Petersen LA, Sharf BF, Suarez-Almazor ME, Wray NP, Street RL Jr.
vii. Rehman, T., *Rock, R. (2015). Advocating for Greater Exposure to Domestic Health Disparities in Medical Education. American Medical Student Research Journal. Retrieved from http://amsrj.org/index.php?journal=amsrj&page=article&op=view&path %5B%5D=258&path%5B%5D=97
viii. http://whqlibdoc.who.int/publications/2010/9789241563949_eng.pdf?ua=1
ix. Kessler, R. C., McLaughlin, K. A., Green, J. G., Gruber, M. J., Sampson, N. A., Zaslavsky, A. M., … Williams, D. R. (2010). Childhood adversities and adult psychopathology in the WHO World Mental Health Surveys. The British Journal of Psychiatry, 197(5), 378–385. doi:10.1192/bjp.bp.110.080499
x. Epidemiology. 2015 Sep;26(5):681-9. doi: 10.1097/EDE.0000000000000350.
To Treat or to Prevent?: Reducing the Population Burden of Violence-related Post-traumaticStress Disorder. Cerdá M1, Tracy M, Keyes KM, Galea S.
xi. Judy Woodruff Reflections Of Five Former HHS Secretaries Health Affairs, 34, no.8 (2015):1269-1272