HSS Case Study: 51-year-old Man with Diabetes

00:01 So now that we have seen the importance of the structural and social determinants of health, let's come back to San Francisco, my hometown.

00:12 As I shared the life expectancy across seven miles of the city, from the Bayview-hunters Point neighborhood to the Outer Sunset neighborhood goes from 77 years to 85 years. The Bayview-hunters Point neighborhood is more polluted, has more people of color, and has higher rates of asthma and ER visits per capita. Let's explore some of the structures that have contributed to the health outcomes and the difference in mortality that we're seeing across zip codes in the city of San Francisco.

00:51 This is another map of San Francisco from the 1930s.

00:56 It is what was called a residential safety map to guide investment across neighborhoods, and this was done across the nation from the 1930s to the 1960s.

01:08 So federal agencies raided neighborhoods based on favorable or detrimental influences.

01:18 Now, the factors that made something detrimental might be things you expect, like the terrain, the type of buildings, the age of the buildings.

01:29 But they also included factors such as the threat of infiltration of foreign born black or lower grade populations.

01:41 So there was xenophobia and racism built in to this seemingly objective rating of neighborhoods for investment purposes.

01:53 This was called redlining.

01:56 So let's talk about the effects of redlining on health.

02:01 The redlining of black neighborhoods from the 1930s to the 1960s led to rejections for home loans. And what happens when you don't invest in a community? Houses deteriorate. Businesses close.

02:15 Individuals cannot build wealth.

02:17 And that leads to some of the outcomes we see today.

02:20 With higher rates of poverty, increased chronic medical conditions, shorter lifespans and social vulnerability.

02:29 If we lay the redlining map from the 1930s of San Francisco over the life expectancy today, we can see that the Bayview-hunters point neighborhood was a redlined neighborhood and the Outer Sunset was not.

02:46 And that has an impact on the health outcomes that we see in our patients today.

02:52 It is incumbent upon us to understand the structures and the history in place that are contributing to the health outcomes that we see today.

03:01 When we talk about health disparities, it might be easy to see that, to say that poverty and inequality are leading to these health disparities.

03:11 And really, we need to take a step back further and understand that there are policies, economic systems and social hierarchies like racism, and place these larger structures that are causing and contributing to the health disparities that we see today.

03:28 I'd like to turn to a case discussion, and this is an opportunity for you to start thinking about social determinants and structures that are in place.

03:39 Manny is a 51 year old man with a history of type two diabetes on insulin.

03:45 He gets hospitalized with pneumonia and his blood sugar is noted to be high at 469.

03:52 His A1c check during this hospital admission is 8.7, which is increased from 6.8 just one year ago.

04:04 Taking this at face value, we might say, well, diabetes control relies on regular monitoring of your blood sugar, medication adherence to insulin, and follow-up lab testing with your doctor.

04:19 So I might adjust his medication and schedule him for some more appointments.

04:26 I'm going to give you a little bit more information so that we can understand the social context. Manny grew up in New York City with parents who immigrated from the Dominican Republic and worked in a hotel.

04:40 He completed high school.

04:42 He works two part time jobs, one at a grocery store and the other at a restaurant. He was living in a rent-controlled apartment in New York City, but eight months ago received an eviction notice from his landlord because she was going to move back into her apartment.

04:59 He was unable to find an apartment within his budget, and now he's staying with friends who live outside of the city while he figures out his living situation. He's using public transportation to get to work.

05:10 He was previously taking his insulin regularly four times a day, but has not prioritized his health amid his life upheaval.

05:18 Let's pause for a moment.

05:20 I'd like for you to write down some ideas of how many social situations could be contributing to his current health status.

05:34 We can see that it won't be as simple as prescribing insulin or scheduling more appointments to help Manny achieve better control of his diabetes and improve his health. Let's identify some of the social determinants and the structures that underlie the social determinants that Manny is seeing the effects of.

05:59 So Manny came to us with poor diabetes control and he was hospitalized for pneumonia. This green box here is often the only thing that we will see in the clinic or in the hospital setting, And we may make decisions only based on this information. However, we understand a lot more about Manny.

06:21 He completed high school.

06:24 He works part-time jobs.

06:25 He lives in a rent-controlled New York City apartment.

06:29 He was recently evicted, and his housing is unstable as he lives with his friends. He lives far from work right now, and he's taking public transportation, and he's missing his doctor's appointments.

06:41 Now, let's take a look at the structures underlying Manny's social situation.

06:49 We can see that he's completed high school.

06:52 We know that racism and racialized, low-wage labor markets contributed to the opportunities that his parents had when they immigrated to the US.

07:03 The lack of generational wealth in Manny's family and potential lack of support to continue higher education may have led to his completion of high school without further education. This now contributes to the job opportunities that he has due to his educational status. And in the United States, the health care system ties your health care access to your work for the majority of the working population, as insurance is provided through work, and so many may be in jobs that don't provide him with health insurance, thereby limiting his access to health care.

07:43 His living situation he lives in a rent-controlled New York City apartment and he is able to be evicted, leading to unstable housing.

07:53 This is due to city and federal policies that have contributed to gentrification and displacement of populations in cities.

08:01 He's now living with friends far from work, so he's dependent on the public transport system not only to get to work, but to get to his doctor's appointments, which could contribute to missing his doctor's appointment.

08:14 And insulin is a medication that needs to be refrigerated.

08:18 We've already talked about the cost being a factor, potentially based on his insurance status, but he may not have easy refrigeration access based on his current living status, or if his insulin is dosed four times a day.

08:31 He may not be able to go back and forth if he's living far from work.

08:36 So then, when he's hospitalized for pneumonia and he has poor diabetes control, we can see that it's not just about medication, non-adherence or missing doctor's appointments or missing his insulin.

08:50 There are a lot of reasons that contribute to this.

08:53 I'll pause for a moment so that you can think about a couple of interventions that you might take as his physician or his healthcare provider to help Manny achieve optimal health. Now, if I were seeing Manny in the emergency room or in my clinic after his hospitalization, I would certainly think about the easy things like, let's optimize your healthcare appointments and make sure that you have prescriptions for your insulin.

09:30 But I might also think about things like consolidating his insulin regimen so that he doesn't have to take it four times a day, and that might help him adhere to the medications. I would connect him to the housing advocate or the social worker in my clinic to see what housing options he might have.

09:48 We might think about telehealth appointments so that he wouldn't have to think about transportation to and from his doctor's appointments.

09:57 So there are lots of things that I might think about beyond just the medications to address his health care status.

10:05 And these are the things that we all need to be doing as healthcare providers and as physicians for our patients to be thinking more broadly beyond just the individual health behaviors, but rather also on the social and structural determinants of health.