When we forget health’s basic needs …
When someone can’t afford stable housing or nutritious food, his health suffers and healthcare costs rise — for all of us. If our country is serious about improving health, meeting human needs will need to be the foundation of healthcare.
After finishing my medical training, I worked at the Tom Waddell Clinic in San Francisco’s Tenderloin. The clinic was free for everyone with no questions asked. In the winter, homeless patients would drop in, telling the nurse they had pneumonia. What most wanted was a note for a week in a residential hotel.
At Tom Waddell, I learned that poverty was physical. I saw how poverty hurt and how it got under the skin. I remember a man who couldn’t get his asthma under control. He had a regular job, understood his disease and took his medications religiously. He had already figured out that his damp basement room was causing him to use up his inhalers. But, he didn’t want me to send a city housing inspector to look for habitability violations. He needed his home.
Statistically, poverty is the single biggest cause of poor health in the United States. One-third of poor working-age adults have two or more chronic conditions — double the proportion of the non-poor, and rates for avoidable stays in hospitals are highest in poor neighborhoods. These facts shouldn’t surprise anyone. If a diabetic can’t afford a prescribed diet, she is going to have trouble controlling her diabetes. If a parent is struggling to pay the rent year after year, the stress eventually makes it to the heart.
We expect doctors to achieve the same standards of care for all their patients. Keeping every patient’s blood pressure and blood sugar in check has now become a mark of medical quality. But how does a doctor manage the patient with unpaid bills, an eviction notice, or a violent neighborhood? Four out of five primary care doctors say that unmet basic needs, like substandard housing, poor nutrition, the lack of economic opportunity, and social isolation, make health worse for Americans. These doctors, even the most compassionate, are unequipped to provide their patients’ what they lack.
Ideally, comprehensive health care begins by helping people meet their most fundamental human needs. But we haven’t designed or funded our health care system to care for people in a whole, integrated way. We have made a durable national commitment to pay the cost of treating sickness, but we have yet to establish a standard of living for health.
Some are trying to change how the healthcare system operates. Approaches, like “hot-spotting” show that social and environmental conditions can explain why a minority of chronically ill people — so-called “super-utilizers” — account for a disproportionately large share of healthcare spending. Indeed, programs that work in teams to help patients solve medical and non-medical needs simultaneously can reduce avoidable hospitalizations and costs. New York City’s supportive housing program, which creates stable living situations for people with chronic medical conditions, saves the city more than $10,000 per person. Some forward thinking hospitals are paying for home-delivery of meals as a way of preventing hospital admissions.
But even at its best, healthcare’s approach to addressing unmet human needs will be reactive — acting only after deprivation has caused harm. Today, the social institutions charged with meeting human needs are operating in separate silos disconnected from their health impacts. As Elizabeth Bradley and Lauren Taylor have pointed out, many other countries see health and social needs as interdependent; these countries spend more on social services than we do but save on health care and have better health performance as a result.
Medical spending will reach $3.2 trillion in the U.S. this year — about $10,000 per person — and is expected to reach $5.4 trillion in 2024. On another side of the social ledger, child poverty remains at 23%; about 50 million families are food insecure; and over a quarter of working renters spend more than half their income on housing. While policy makers routinely blame soaring drug costs, unnecessary medical procedures, and rising chronic disease for health care spending, there is silence about the effects of hunger and unstable housing.
Why do we fail to make such obvious connections? Is our inattention cultural, explained by a historical aversion to helping the poor? Or is it institutional — a function of the fragmentation of our sick-care system from other human welfare institutions?
Perhaps, there is simply no business case for addressing the deeper social roots of disease. Redistributing resources from symptomatic medical treatments to pay for preventative social services, even if cost-effective from a broader social perspective, is not in the interest of the healthcare industry’s bottom line. As one healthcare administrator confided: “We don’t save any money by keeping people out of the hospital.” And healthcare leaders can easily argue that managing poverty is a problem for other institutions to handle.
IF MEDICINE IS TO FULFILL HER GREAT TASK, THEN SHE MUST ENTER THE POLITICAL AND SOCIAL LIFE. DO WE NOT ALWAYS FIND THE DISEASES OF THE POPULACE TRACEABLE TO DEFECTS IN SOCIETY — DR. RUDOLF VIRCHOW, 1821–1902
But the failure to connect the dots affects all of us. The poor suffer worse health, and we all have fewer resources to spend on the good stuff — parks, schools, and better neighborhoods.
It’s past time for a full accounting of poverty’s impacts on disease and for a movement to invest in the community and economic foundations of health. The solutions do not require any great advancement in technology or bio-medical science. We need a simple commitment to a decent standard of living; a stronger social safety net; and a re-imagination of health care as a team enterprise supporting the whole person. Doctors, who see the physical consequences of poverty daily, would be especially powerful witnesses for this movement.
It’s true that our current politics, markets, and institutions hardly favor such changes. But unless we make them, we’ll be paying a sick care system to treat suffering that could have been more cheaply avoided.
Rajiv Bhatia, MD is a physician and health scientist working to make basic human needs the foundation for population health improvement. Principal at the Civic Engine, he supports innovation within public, private, and civil society organizations.
