by Brian C. Castrucci
We are fortunate to live in a nation where our healthcare system is filled with dedicated providers offering cutting-edge, innovative clinical care to prevent and control diseases. However, despite all the money we spend on health, the United States still lags behind other countries in terms of health outcomes such as life expectancy.
The reason this paradox exists may be found, in part, in an article summarizing a discussion recently held by the American Medical Association, “2 Ways to Spark Change in Minority Patients and Prevent Diabetes,” AMA Wire, June 18). The discussion focused on ways providers can encourage patients to take the steps needed to control their diabetes, but much of the advice is not practical for people who live in communications without access to conveniences that many of us take for granted.
As the head of the de Beaumont Foundation, which focuses on public health, and as a type 2 diabetic myself, I found the advice valuable but incomplete. In pursuit of the dream of “no new cases of preventable type 2 diabetes,” Dr. Niva Lubin-Johnson recommends that providers should “stress things the patient can control” like “diet, exercise, and getting enough rest.” She advises physicians to talk to patients about what they are willing to do, and she notes possible barriers to behavior change like time management. Because “it’s not easy for a single mother with school-aged children to go grocery shopping or find time to exercise,” she encourages providers to “spend the time to talk with them about how it can be done.”
While this advice is reasonable from a medical perspective, health professionals can’t ignore the indelible link between individual and community health. If we stop at simply identifying what the barriers are, and don’t intentionally look at why they are there, we miss a critical opportunity to address the root causes of chronic diseases like diabetes. A clinical approach alone to preventing diabetes — or any chronic disease — places the burden on the patient and his or her willingness to make necessary behavioral changes.
Yes, that single mother may have challenges finding time to exercise or go grocery shopping, but challenges with time management aren’t unique to any person or group in our culture. But maybe she doesn’t have access to places that offer affordable exercise options, or safe places to walk, bike, or run after dark, or grocery stores where she can buy fresh fruits and vegetables. Maybe her employer doesn’t have policies that allow her to take time during her workday to exercise, even though it might be in its best interest. (Each year, $90 million is lost in reduced productivity due to diabetes.) These community factors shape our individual choices, and no amount of talking can change them.
The truth is, health starts — and is sustained — in the community. If the places where you live, work, and play don’t allow you to achieve optimal health, there is very little that can be done in a doctor’s office that can change that. And that’s not a criticism of healthcare. It’s just a reality. A large percentage of Americans get a 30-minute wellness visit once a year, but what about the other 525,530 minutes?
To be honest, I am the type of person who would have benefited from the interventions Dr. Lubin-Johnson described. My community fully supported any choice that I wanted to make to improve my health. I have access to at least four large grocery chains that sell every fruit and vegetable there is. I can afford a gym membership and extended day care for my children. There’s a safe and well-lit park in my neighborhood with outdoor exercise equipment. In my case, it was my health choices — a poor diet and a general disregard for exercise — that led to my disease, but my behavior also led to control of my diabetes when I made better choices.
For people who have chronic conditions but don’t share my privilege, no amount of clinical intervention will make them healthy. Achieving and maintaining health requires the efforts of not only physicians, but also urban planners, housing experts, political leaders, educators, and many others. Only when we pair clinical intervention with smart policy and intentional planning will be able to envision a world free of preventable disease.