I love community health. I love talking about it and thinking about it. The idea of empowering communities to improve their own health and impart social change just makes me feel happy inside. I initially started writing this post thinking it was going to be this great, uplifting write up about the need for dynamic, innovative policy that promotes and maximizes social capital in community health programs, and how such policies could act as a vehicle for vulnerable populations to achieve political and economic parity on a wide-scale and even improve health outcomes over time.
It all sounded good in theory…
I remember a patient I saw in clinic a few months ago, Mrs. A. When I met her she was a morbidly obese woman who was trying to get approved for a gastric bypass procedure. She was also a recovering crack addict. The surgeons had placed her on a very strict diet leading up to the surgery. This was standard protocol, but it put Mrs. A in the position of trying to overcome a crack addiction and a food addiction at the same time. On top of all of this, she was also struggling with depression (not to mention CHF, COPD, and a host of other chronic illnesses). During the visit, I asked her about the status her support system. She told me that she had none because she had intentionally isolated herself. The majority of her meaningful relationships in life were based on a shared crack addiction. We both agreed that re-visiting those relationships was a bad idea and that finding some new friends would be best, but when she asked me how to do that, I didn’t have an immediate answer. The standard responses didn’t apply. She was wheelchair bound, she didn’t live in a great neighborhood, and there really wasn’t much for her to do there besides smoke crack and go to the corner store. She wasn’t confident that she could even develop new relationships based on shared interests that were productive and healthy. She didn’t know where to start.
Social capital isn’t some magic cure-all. To start, for many people, linking up with others in their immediate social, cultural and geographical vicinity would be harmful to themselves and/or their communities. Gangs are made up of people who form amazingly strong bonds with one another and then use the acquired social capital to terrorize their communities. Other members of the community are often forced to intentionally isolate themselves out of pure self-preservation, similar to what Mrs. A chose to do. There is also a matter of concentrated disadvantage, which is intimately related to the social, economic, and geographic isolation of vulnerable populations. Even if one isolated individual was able to link up with their community in a positive way, the social capital of the community would be inherently weak. Isolation can come in layers.
A recent NPR article on the current face of poverty touches upon the issue briefly. These days its not odd for a family sitting well below the poverty line to have an iPad, a cellphone, or a flat screen television in the home. But poverty is about more than just the lack of material wealth. As a case manager interviewed in the article stated: “…if you’re poor, you’re poor in every avenue: emotionally, supportwise, familywise.”
So what is the solution? I don’t know. But I do think clinicians educating themselves on the realities of what their patients are facing is a start. I’ve also challenged myself to have more meaningful interactions with my patients, to develop relationships that are less paternalistic, but more nurturing and also informative. Though I cannot change the relationships my patients have with their families and communities, I can try to ensure that our relationships are productive, nurturing, and beneficial to the patient. I’m also going to change the way that I look at physician advocacy. I had always leaned toward the community partnership approach, which encourages communities to identify and develop solutions for their own problems. However, I’m starting to wonder if a more active approach on behalf of physician advocates and other healthcare providers might be beneficial. In this manner, having a more visible and outspoken ally in the form of a physician advocate could help strengthen the perception and visibility of the community’s social capital to outside investors and lawmakers, giving it a bit more weight.
And this is where I will end for now.
Thoughts? Share with me in the comments!
The Minority Health Review 