What would you think if your doctor handed you a prescription that recommended filing your tax returns or applying for food stamps instead of the usual medicines for high blood pressure or diabetes? You'd probably say the physician was nuts. Tax refunds? Food? What do they have to do with making you healthier?
I just returned from a month long Fulbright fellowship in Canada and met such a physician, Dr. Gary Bloch, who practices family medicine at St. Michael's Hospital in Toronto. We had a long conversation about what makes people healthy. He wasn't interested in talking about new drugs to lower cholesterol hyped by the latest drug salesperson to walk through his door.
"We've created an advocacy or interventional initiative aimed at changing the conversation about poverty and how doctors think about poverty as a health issue," Bloch told me. "It's one of those cultural shift things. My job is to push ideas for physician interventions around poverty." Bloch showed me a clinical tool used by primary care practices in Ontario that is based on strong evidence linking poverty to bad health outcomes.
The tool, a four-page brochure, is simple in design but powerful in concept. "You come at poverty from every possible angle," Bloch said. "You start from the evidence and frame the issue in language doctors can understand."
The evidence: Page one of the tool points out that "poverty accounts for 24percent of person years of life lost in Canada (second only to 30 percent for neoplasms)," and notes that "higher social and economic status seem to be the most important determinants of health."
The tool: Three steps to address poverty in primary care practices.
Step 1: Screen everyone by asking, "Do you ever have difficulty making ends meet at the end of the month?" Using the language of clinical tests, the tool says that this question yields a sensitivity of 98 percent (the ability to predict the number of people with the disease) and a specificity of 64 percent (the ability to predict those without the disease).
Step 2: Factor poverty into clinical decisions like other patient risk factors. The tool provides examples, such as noting that a man living in the lowest quartile of poverty has twice the risk of diabetes as a high income man. Therefore, when a 35-year-old man comes to the office without risk factors for diabetes but has a very low or no income, doctors should consider ordering a screening test for the disease.
Step 3: Intervene by asking questions. Here's where that prescription to file your tax returns comes in. Bloch suggests asking if older patients have applied for all the supplemental income benefits they're entitled to or whether all patients have applied for drug benefits they may be eligible for.
While these seem pretty straightforward and useful, I wondered how many primary care docs in the U.S. have thought about asking similar questions. I don't know how many times I've heard physicians say they order prescriptions for expensive meds knowing that even cheap, basic antibiotics are out of reach for their patients. That's where the conversation ends, and so does care for those who need treatment.
I asked Bloch about the impact of his poverty tool, a simple paper brochure, in an age when the press, the public and the medical profession are focused more on shiny, new technology and drugs than the basics of life. He said this approach is "one of those snowball things that keeps rolling."
The Ontario Medical Association will soon publish a poverty intervention tool, and the Canadian Medical Association held town hall meetings earlier this year in several Canadian cities. Participants identified four main social determinants of health: income, housing, nutrition and food security, and early childhood development.
Put all this in the current American political context, which calls for cutting food stamps, making seniors pay more for their Medicare benefits, changing the calculation of the Social Security cost-of-living formula, and the lack of focus on early education and affordable housing. Contrast the latter with all the media hype about affordable health care. In the end, affordable housing may trump affordable health care if the objective is really better health.