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.
The lecture HSS Case Study: 51-year-old Man with Diabetes by Megha Garg, MD, MPH is from the course Health System Science: Introduction.
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