The San Joaquin Valley Is Suffering A Unique Healthcare Crisis
Call it what you want, white privilege and health disparity appear to be two sides of the same coin. We used to consider ethnic or genetic variants as risk factors, prognostic to health conditions. However, the social determinants of health (SDOH) have increasingly become more relevant as causes of disease prevalence and complexity in health care.
As a pediatric hospitalist in the San Joaquin Valley region, I encounter these social determinants daily. They were particularly evident as I treated a 12-year old Hispanic boy who was admitted with a ruptured appendix and developed a complicated abscess, requiring an extensive hospitalization due to his complication. Why? Did he have the genetic propensity for this adverse outcome? Was it because he was non-compliant with his antibiotic regimen? No.
Rather, circumstances due to his social context presented major hurdles to his care. He had trouble getting to a hospital or clinic. He did not want to burden his parents—migrant workers with erratic long hours—further delaying his evaluation. And his Spanish-speaking mother never wondered why, despite surgery and drainage, he was not healing per the usual expectation.
When he was first hospitalized, his mother bounced around in silent desperation from their rural clinic to the emergency room more than 20 miles from their home and back to the clinic, only to be referred again to that same emergency room. By the time he was admitted two days later, he was profoundly ill. The surgeon had to be called in the middle of the night for an emergency open surgical appendectomy and drainage. Even after post-operative care, while he was on broad-spectrum intravenous antibiotics, his fevers, chills and pain persisted. To avoid worrying his mother, he continued to deny his symptoms. Five days after his operation, he required another procedure for complex abscess drainage.
In a 2007 study published in The New England Journal of Medicine, “We Can Do Better—Improving the Health of the American People,” Steven Schroeder describes the proportional contributors to premature death. Behavioral patterns and social circumstances dominate, causing deaths more than half of the time.
More recently, there appears to be a paradigm shift in how access to care and healthcare systems are viewed. As Schroeder demonstrated, healt care delivery plays a relatively minor role in its impact on premature death. What governs the individual behavior of patients are the SDOH, which are a product of:
- Barriers to appropriate healthcare
- Economic instability
- Unsafe environment
- Poor health literacy and education
- Limited social and community support
- Food scarcity
- Social discrimination and language barriers
These are just a few of the factors that contribute to challenges in patient care and health inequities. Interestingly enough, genetics actually plays a relatively minimal risk factor for disease conditions and diagnosis. We cannot just say that black people have a greater risk of heart disease, diabetes, hypertension, etc. We need to ascertain the social context of our diverse populations in order to address the incidences of chronic disease and its effects. The issue cannot simply be blamed on the genetics of the immigrant, the refugee, the homeless, or impoverished populations that lead to greater morbidity and mortality.
In a recent 2017 report by the Center for Regional Change and Pan Valley Institute, California San Joaquin Valley, children in the area are “living under stress.” They are not only born under duress but face lifelong barriers to better physical and mental health. The occurrence of child poverty levels in counties of the San Joaquin Valley (SJV) are profound, ranging between 28% and 38% of the population by county. Furthermore, poverty rates are highest among children of color. The ethnic gap in poverty is 10-35%.
The same fertile communities of SJV, producing the food source of the nation, ironically have the largest limitations of access to food. Food scarcity, where food and especially healthy food is either limited or uncertain, remains above 26 to 29% when compared to a food shortage for the whole of California, which is at 23%.
The overall pollution burden, which represents the potential exposures to pollutants and adverse environmental conditions caused by pollutants, is greater than 8 to 10% in the Valley. Not surprisingly, asthma and lung diseases in SJV districts are highest in central California.
Health vulnerabilities in the valley are extreme and burden the limited healthcare systems servicing its communities. Support to implement and maintain medical education and training programs with retention of providers in SJV is necessary. Specific funding allotments for improving mental health, air quality, homelessness among many other SDoH’s in the region is vital.
Dr. Nadine Burke-Harris, California’s first female Surgeon General, who recently visited the Valley, announced an ACEs Aware campaign. The ACEs Aware initiative is a first-in-the-nation statewide effort to screen for childhood trauma and treats the impact of toxic stress. The bold goal of this state-wide initiative is to reduce Adverse Childhood Experiences and toxic stress by half in a single generation and to launch a national movement to ensure everyone is ACEs Aware.
Starting early, as pediatricians, we can identify kids exposed to ACEs through routine screenings and establish prevention programs in health care, schools and youth-serving organizations. In their critical and early developmental stages, resource allocation of health services can be provided. It is also imperative to know and stay engaged with our region’s leaders, telling our stories in health care, enlist our community partners, schools, regulatory agencies, and empower our patients and families to advocate for social and health equity.
Alya Ahmad, M.D. is a pediatric hospitalist who has worked in both private and academic healthcare centers. A version of this article originally appeared at The Health Care Blog
