A pediatrician uses a light to peer inside a young boy's mouth as she examines him at a free clinic for the poor and uninsured.
A pediatrician examines a young boy at a free clinic for the poor and uninsured in Los Angeles. Damian Dovarganes/AP

Poor health isn’t just a result of individual choice. A program at Washington University in St. Louis teaches first-year medical students how the city’s environment shapes well-being.

Last year, Griffin Plattner’s medical school orientation included more than tours of hospital corridors and lecture halls. Plattner, a student at Washington University in St. Louis, visited a former African-American hospital and public housing complex, and other sites in low-income neighborhoods, and listened to lectures about the city’s history of racism and segregation.

The university has offered the tour for more than 15 years, and its goal is to help future doctors understand the various circumstances of some of their patients’ lives in order to treat them more effectively and with more empathy. When the program began in 1999, it was voluntary, and about 20 students signed up; now all 130 students participate before they even step into a classroom.

“I found it really thought-provoking,” Plattner says. “I had never thought about how environmental factors such as the adequacy, timing, and location of public transportation affect people’s health.”

Will Ross, a kidney specialist and the associate dean for diversity at the university, has run the program since its inception. He says the idea is not for students to see “how specimens are operating” and then return to the sterile environment of the medical school, but to take what they learn about the social determinants of health—a neighborhood’s abundance or dearth of green spaces, grocery stores, and bus or subway lines, or an individual’s income level and housing situation—and apply it in treatment.

Ross says that when students see these factors at play, they are better equipped to understand why some patients can’t easily adhere to a medical plan. “The idea that the patient is non-compliant—that they don’t really care about their health—is a mentality that has unfortunately affected too many of us in the medical environment for too long,” he says. The reality is that such patients face obstacles that prevent them from following a treatment plan: a lack of insurance to cover visits and medication, a lack of access to a car or public transportation to make their appointments, a lack of nearby stores to buy fresh, healthy food.

“Changing the mindset that it’s the individual’s fault means that doctors will ask meaningful questions about what’s going on in patients’ lives,” Ross says. “The patient then trusts the doctor more and works with them to follow their treatment.” The would-be doctors are also trained to connect patients in need with social services, such as programs that provide prescriptions at minimal cost or give free rides to medical appointments.

The Washington University program is emblematic of a shift in the field of public health over the past two decades, from a focus on how an individual’s personal choices affect their well-being to how factors in their environment shape those choices.

Judy Lubin, an adjunct professor in the Department of Sociology and Criminology at Howard University, says that current research shows that over 50 percent of a community’s health is determined by social factors. For instance, recent studies stress that one’s neighborhood is a strong determinant of well-being. The difference in life expectancy between St. Louis’s wealthiest and poorest zip codes is at least 12 years.

Lubin notes that this environment-centered way of thinking has roots in the advent of public health more than a century ago, when officials focused on improving residents’ environment through sanitation to stop the spread of communicable diseases. Scholars of color, particularly black scholars, have also long recognized the strong link between environment and health. W.E.B. DuBois, for example, chronicled the social factors that led to the ill health of African Americans in a Philadelphia neighborhood in 1899’s The Philadelphia Negro.

Yet for much of the twentieth century, many public health leaders emphasized individual control over well-being. A fixation on diet, exercise, and other life choices made good health the result of virtue and poor health a personal failing. While an individual’s choices certainly play a role in their health, Lubin says that understanding patients’ social contexts is critical to advancing the medical profession.

Washington University isn’t the only sign of such change. Ross says the majority of medical schools are engaged in some form of service learning and community engagement. The University of Texas at Austin, for instance, has a health disparities team that works to identify and reduce health inequity in the city. In 2015, the MCAT began to include questions on how social inequality can affect the health of a patient. Lubin teaches sociology to pre-med students at Howard and prepares them for these questions.

And in New York City, a medical center in Bedford Stuyvesant, a neighborhood with a high rate of premature deaths from illnesses like diabetes and hypertension, started an initiative last year—Prescribe-a-Bike—in which doctors recommend bike rides and give patients a free helmet and 12-month bikeshare membership. As the city’s Deputy Health Commissioner Dr. Aletha Maybank told WYNC, “Health alone is not just about the behaviors that people have, but people do things and choose behaviors based on what they have access to in their neighborhoods.”

Do initiatives like the ones at Wash U and in Bed Stuy actually change behaviors of doctors and patients long-term? It’s hard to say. Prescribe-a-Bike is still gathering data, and Ross says he and his colleagues are conducting research on the orientation program. But there’s some evidence to suggest that the shift in zeitgeist is changing how doctors approach patients. Medical school graduation questionnaires, for example, show that an increasing number of future doctors are interested in providing care across cultural barriers and working in disadvantaged areas.

Lubin says she hopes knowledge of health’s social determinants spurs doctors to do even more than change their approach to individual patients’ treatment. “It’s a call to action,” she says, “I implore my students, ‘When you’re a physician in a position of power and privilege, ask yourself how can you change policy to improve the conditions of these communities.’”  

This article is part of our project, “The Diagnosis,” which is supported by a grant from the Robert Wood Johnson Foundation.

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