By Sohini Bandy
Social determinants of health have a profound effect on physical health. Societal issues, such as poverty, unemployment, housing insecurity, stigma, bias, racism, trauma, and lack of education, fuel health inequalities that affect the most vulnerable people in our society. As a medical student, working with homeless patients at Healthcare for the Homeless Houston and through HOMES clinic truly opened my eyes to this – because these patients lack so many basic needs, they experience horrific trauma and shortened life spans. Another example of an issue molded by social determinants of health, which is particularly salient to the state of Texas, is maternal mortality. Texan women are dying from childbirth. Our neighbors are dying. Many of us have heard the statistics: here in Texas there are 34.2 deaths per 100,000 live births, a rate that’s double the national average, worse than several developing nations, and that appears to be increasing. It’s deplorable and shameful. We should all be ashamed of any maternal death that could be prevented - yet what can we do? Here’s my attempt to put the puzzle pieces together to try and figure that out.
For me, it starts at Angela House, a transitional facility for women leaving the criminal justice system, located in Southeast Houston. These women have been through unimaginable trauma – childhood sex abuse, alienation from their families, homelessness, human trafficking, and prostitution - and live with mental health issues as a consequence. Being at Angela House is the first, very important step for them to start to take control of their lives and head down a brighter, less perilous path. I got to know these women while implementing a wellness curriculum I’d designed for them. Over the course of more than a hundred hours with them, one thing became clear to me:
These women have perpetually fallen through the cracks of society and, as a result, their health is suffering. Substance addiction could be from attempting to escape the pain of early childhood trauma and/or sex abuse. Anxiety and depression could be a consequence of living with an abusive partner. Obesity, hypertension and diabetes could be a secondary effect of living in constant, toxic stress on the streets… or from living from paycheck to paycheck supporting a family… or from dealing with constant discrimination as a Black woman… or even from the fear of being arbitrarily punished by a pimp. Viral hepatitis, HIV and HPV infections could be due to unsafe drug and sex practices from being trafficked and prostituted, or from sleeping with others out of necessity to fund a drug habit. Which was instigated by early childhood trauma. And the cycle goes around and around. To me, it became clear that social determinants of health were influencing these women’s health to a greater degree than biological and medical determinants.
Those women at Angela House are not the ones in our maternity wards now, who are suffering while or after giving birth. But they are going through the same issues that the sickest moms are dealing with – obesity, drug use, poverty, STDs, hypertension, diabetes, and mental health issues. I could easily imagine one of these women a decade or two ago, fighting to make it out of the Labor and Delivery unit alive.
So, what can we do?
For the last month of my clinical training, I helped to care for homeless patients at Healthcare for the Homeless – Houston. There, doctors work hand-in-hand with social workers, psychologists, and housing providers, and next door to legal aid. This team of experts, all in one spot, confidently and compassionately address these patients’ complicated medical histories and tough social backgrounds from all angles and offer them concrete steps to change their situation, if they choose to do so. Observing these direct and effective partnerships gives me hope that, with this model, we can help many more patients reshape their current circumstances to become more healthy and beneficial for their future goals.
These issues are daunting, and wide-ranging – after all, they shape our society. Sometimes just thinking about how deeply engrained, prevalent and messy these problems are makes me want to crawl into bed and never come out. But there are people, organizations, ideas, and organizations like Healthcare for the Homeless Houston that are actively combating social determinants of health that give me hope and make me get up, face the world, and fight again. There is a way forward to chip away at these injustices, and as a Texan physician-in-training, I accept the challenge.