Concerns in Health and Medicine – Contemporary Concerns in Medicine

Chronic Fatigue Syndrome and Its Ever Present Issues

Introduction

Contested illnesses inflict untold burdens on their sufferers. These burdens are not simply manifested in the physiological or psychological implications that are typical of disease. These illnesses vastly impact the social and interpersonal lives of their sufferers. From six years of firsthand experiences, watching my brother battle with his own contested illness, I know how these struggles can lead to distrust, confusion, and even animosity between loved ones. Often these issues arise from misunderstandings and incomplete knowledge of the condition, a facet that is at the heart of the “contested” nature of these diseases. These personal experiences my family and I have had, have caused us to make a point of understanding and explaining the true nature of these afflictions from both objective and empathetic perspectives.

John’s Story

When my brother was going into his junior year of college, he decided to end his college baseball career and transfer back to our hometown college. Around this time he was having a series of strange symptoms come and go. Mainly, he was suffering from migraines and blurred vision. At the time he chalked this up to the stress of his new transition and a bad eyeglass prescription. Throughout the next five years, he struggled with receiving a lasting diagnosis as well as a constant increase in symptom presence and intensity. Eventually, after spending five weeks at the Mayo Clinic, John was able to finally receive the diagnosis that he was expecting, Chronic Fatigue Syndrome. As we discussed in class, this diagnosis came with mixed emotions. While being diagnosed with a contested illness may come with uncertainties and fear, this was the first time that he felt that he knew what was happening to him and he felt a sense of belonging and relief.

Having a brother experience this was hard, not just for him but for all of our family. We saw someone transition from a college athlete to being functionally disabled at times. Throughout the diagnosis process, there were times when our family and loved ones questioned his status and even his symptoms. This caused social and interpersonal strain throughout our extended family. To this day, he still faces others questioning his illness and doctors disagreeing with his diagnosis. Furthermore, this illness has burdened my mother financially as she now supports her son financially and often fills the role of unpaid caregiver.

Issues in CFS Care

Seeing this process from a closer and more personal vantage point has allowed me to see some of the issues that exist within the treatment of Chronic Fatigue Syndrome; paired with the readings from class and further outside research, I feel that I have gained a more rounded perspective on this topic. One issue that I quickly noted was the fragmentation of medical care. With specialists occupying 66% of United States doctors [1], holistic care for systemic issues becomes unattainable. In search of a diagnosis, John went to ophthalmologists, neurologists, immunologists, orthodontists, endocrinologists, and many more specialists. Each offered their own theory that fell into their category of expertise. It wasn’t until he underwent long-term testing under the supervision of multiple practitioners at the Mayo Clinic that he was officially diagnosed. According to the CDC, an estimated 836,000 to 2.5 million Americans suffer from Chronic Fatigue Syndrome [4]. With estimates this large, the current model of fragmentation of care is not sustainable. Under models of incremental care, such as that of Dr. Loder from, “The Heroism of Incremental Care” [5], patients would not need to be passed around between dozens of specialists. Rather, primary care providers could work with patients to note minute changes in their symptomology and address diagnoses and further visits from a more holistic view.

Between 836,000 and 2.5 million Americans have been estimated to have ME/CFS
CDC

A second issue that is ever present with Chronic Fatigue Syndrome is the inconsistency of therapy. Some sources, such as the CDC, focus more on short-term symptom palliation while others attempt to reduce the intensity of all symptoms on a long-term scale [8]. One example of the latter is what is known as graded exercise therapy (GET). David Scales quickly mentions this as a point of contention in Chronic Fatigue communities [6]. This program aims to slowly build up strength and condition the patients through incremental exercise regimens. However, this type of therapy can worsen the post-exertional malaise symptom of these patients and potentially be deleterious to their intended goals. Furthermore, this therapy is founded on a flawed study with improper design and poor data [7]. Even with this knowledge, GET is still widely applied. However, it seems that the tides are turning on this practice and the Mayo Clinic reversed its stance on GET, removing it from their regimen in 2021 [2].

One final issue that was at the heart of much of my brother’s pain was the disbelief tied into this condition. As a contested illness, it inherently comes with doubts and debates as to the symptomatology, etiology, prognosis, etc. but the one aspect that needs to be believed is the patient’s pain and suffering. Too often he (and many like him) was told that his symptoms were in his head, or that he needed to work harder to get through it. Just as Boodman points out with fibromyalgia patients, the disbelief from medical professionals is nothing short of “medical gaslighting” and does nothing further perpetuate their patients’ pains [3].

Conclusion

While my unique perspective has allowed me to view this condition and others like it with a particular air of empathy, I also understand that it has made me biased toward the situation. I try to view evidence from a more objective lens and view patient experiences from a more empathetic lens, though this does not breed the best level of research. However, I believe that my circumstances have given me the drive to look further into this condition and examine what areas need to be fixed. These experiences have been foundational to my desire to pursue medicine, and I hope that I carry this zeal toward all aspects of my professional career.

Sources

[1] “Active Physicians with a U.S. Doctor of Medicine (U.S. MD) Degree by Specialty, 2019.” AAMC, Dec. 2019, https://www.aamc.org/data-reports/workforce/data/active-physicians-us-doctor-medicine-us-md-degree-specialty-2019.

[2] Bateman, Lucinda, and et. al. “Myalgic Encephalomyelitis/Chronic Fatigue Syndrome: Essentials of Diagnosis and Management.” Mayo Clinic Proceedings, U.S. National Library of Medicine, 25 Aug. 2021, https://pubmed.ncbi.nlm.nih.gov/34454716/.

[3] Boodman, Eric. “In a Sea of Skeptics, This Physician Was One of Fibromyalgia Patients’ Few True Allies. or Was He?” STAT, 27 Oct. 2021, https://www.statnews.com/2021/10/20/selling-certainty-epicgenetics-physician-was-one-of-fibromyalgia-patients-few-true-allies-or-was-he/.

[4] “Epidemiology.” Centers for Disease Control and Prevention, Centers for Disease Control and Prevention, 21 Apr. 2021, https://www.cdc.gov/me-cfs/healthcare-providers/presentation-clinical-course/epidemiology.html#:~:text=Some%20important%20facts%20include%3A,diagnosis%20from%20a%20healthcare%20provider.

[5] Gawande, Atul. “The Heroism of Incremental Care.” The New Yorker, The New Yorker, 16 Jan. 2017, https://www.newyorker.com/magazine/2017/01/23/the-heroism-of-incremental-care.

[6] Scales, David. “What I’ve Learned Reporting about Lyme Disease, a Contested Illness.” Columbia Journalism Review, Columbia Journalism Review, 18 Dec. 2018, https://www.cjr.org/analysis/lyme-disease-contested-illness-empathy.php.

[7] Simon, Stephanie. “Bad Science Misled Millions with Chronic Fatigue Syndrome. Here’s How We Fought Back.” STAT, 29 Dec. 2016, https://www.statnews.com/2016/09/21/chronic-fatigue-syndrome-pace-trial/.

[8] “Treatment of ME/CFS.” Centers for Disease Control and Prevention, Centers for Disease Control and Prevention, 28 Jan. 2021, https://www.cdc.gov/me-cfs/treatment/index.html#:~:text=Some%20people%20with%20ME%2FCFS%20might%20benefit%20from%20trying%20techniques,a%20sense%20of%20well%2Dbeing.

Medicalization of Childbirth: Where We Stand and How We Can Improve

When I ask my mom about my birth story, she immediately winces and says it was the “happiest day of her life.” I always thought it was because as a young mom, birth is a foreign and frightening experience, but as I get older, the more I realize that birth should actually be one of the best days of one’s life and not frightening at all.

Childbirth is one of the most miraculous and profound moments in a woman’s life. It can be a beautiful and challenging experience for the mother and her family, especially when considering its implications for physical and psychological well-being. But, what has transformed this unique event into a terrifying experience, where doctors, hospitals, and medical intervention predominate? This question has led to the development of the medicalization of childbirth, which entails using medical interventions in a process that was initially natural.

Medicalization of childbirth refers to the medical approach to the labor process, from prenatal care to delivery. This practice focuses on the use of medical interventions and techniques aimed at reducing the time of delivery while making it more efficient and safe. While medical interventions have become useful in preventing maternal and infant mortality in the developed world, there are concerns that this approach has led to overmedicalization, where unnecessary and invasive procedures are carried out, and women become passive in the decision-making process.

How did we get here?

Medical Interventions

Medicalization of childbirth is responsible for introducing various medical interventions that aim to make the process more efficient and safer. A significant number of women receive interventions such as induction, epidurals, and c-sections, even when they didn’t want or need them. While these techniques have been helpful in reducing maternal and infant mortality rates, their overuse has led to the introduction of unnecessary procedures that can cause harm to the mother and the child. For instance, cesarean sections, which involve surgical delivery, are associated with higher risks of bleeding, infection, and other complications.

32.1% of births in the United States are vis c-sections, while the c-section rate recommended by the World Health Organization (WHO) states that “rates higher than 10% are not associated with reductions in maternal and newborn mortality rates.”

Besides, high rates of cesarean sections have been associated with reduced successful vaginal birth after cesarean (VBAC) birth, which can lead to more medical interventions during childbirth.

There is a common misconception that once a mother undergoes a c-section, their following births will also be via c-section, however, 60%- 80% of women who had a c-section have had a successful subsequent vaginal birth.

Institutionalization

When I asked my mom if there was any reason why she chose the hospital she did, she said it was because this was the “safest” option. Childbirth has become a largely institutional affair, with hospitals and other medical facilities playing a dominant role.

“The achievement of well-being was rapidly becoming a private matter, won by individual effort, professional advice, and consumer products rather than participation in social life.”
“Health as a Meaningful Practice”

Given that they provide medical equipment and expertise, these facilities are seen as safer and more efficient than home births. While hospitalization has reduced mortality rates during childbirth, it has contributed to increased use of medical interventions, leading to more perineal and episiotomy surgeries, induction of labor, and interventions such as forceps, among others. These interventions can be unnecessary, and they may reduce the natural potential of the birthing process.

“It’s an accepted way of having a baby, but it’s not the way that your body is built to have a baby. So all of a sudden there are knives and there’s pulling and you feel like this shaking and it’s sort of a weird, surreal experience.”
“I felt like I was left on my own”: A mixed-methods analysis of maternal experiences of cesarean birth and mental distress in the United States

Loss of autonomy

Medicalization of childbirth has led to the loss of autonomy for women in determining their birth plans. Owing to institutionalization, childbirth has become more medicalized, which means women have limited options and are more likely to follow the recommended medical interventions. This is particularly true for first-time mothers who might not be informed about their birthing alternatives. Mothers should have the right to choose their birth plan, including the type of medical intervention to be used, or if they undergo a Caesarean section. They also should be informed about the potential risks and benefits of each choice. Even when mothers raise concerns about their own bodies, there is still suspicion as medical training practitioners have been trained to draw suspicion of patients’ narratives .

“They said, ‘You can either leave against AMA [Against Medical Advice],’ or whatever, ‘or you can get a c-section,’ and so that was really traumatic for me.”
“I felt like I was left on my own”: A mixed-methods analysis of maternal experiences of cesarean birth and mental distress in the United States

Where do we go from here?

Medical advancements have led to the development of methods that improve the safety and efficiency of childbirth. However, it is clear that overmedicalization has led to unnecessary procedures and interventions, which can increase complications and side effects. Medicalization of childbirth has contributed to the overuse of interventions, institutionalization of childbirth, and reduced autonomy for mothers. Rights such as choice of birth plan and not losing the wisdom and traditional methods of midwifery should be respected to maintain that natural balance that birth should be. Therefore, we should consider interventions and institutionalization as an aid, not the central approach to childbirth. We must consider medicine’s relationship with social control—where medicalization is one of the key strategies employed by medical institutions to control social norms, behavior, and the functioning of society. By finding a balance between the medicalized and non-medicalized approaches, we can ensure that childbirth remains an empowering experience for women. Babies are best brought in with love and support, and a medicalized process should not compromise their natural moment.

Works Cited

Crawford, R. (2006). Health as a meaningful social practice. Health:, 10(4), 401-420.
Kleinman, A. (2020). The Meaning of Symptoms and Disorders. In The Illness Narratives: Suffering, Healing, And The Human Condition (pp. 3-30). Basic Books.
FastStats – Births – Method of Delivery. (n.d.). CDC. Retrieved March 27, 2023, from https://www.cdc.gov/nchs/fastats/delivery.htm
Infographic: The Overmedicalization of Childbirth. (2018, September 12). California Health Care Foundation. Retrieved March 27, 2023, from https://www.chcf.org/publication/infographic-overmedicalization-childbirth/#related-links-and-downloads
Maternal Mortality in the United States: A Primer. (2020, December 16). Commonwealth Fund. Retrieved March 27, 2023, from https://www.commonwealthfund.org/publications/issue-brief-report/2020/dec/maternal-mortality-united-states-primer
Scott, J. R. (n.d.). Vaginal birth after cesarean delivery: a common-sense approach. PubMed. Retrieved March 27, 2023, from https://pubmed.ncbi.nlm.nih.gov/21775851/
Sega, A., Cozart, A., Cruz, A. O., & Reyes‐Foster, B. (2021). “I felt like I was left on my own”: A mixed‐methods analysis of maternal experiences of cesarean birth and mental distress in the United States. Birth, 48(3), 319-327.
Vaginal Birth After Cesarean (VBAC): Facts, Safety & Risks. (2021, August 23). Cleveland Clinic. Retrieved March 27, 2023, from https://my.clevelandclinic.org/health/articles/21687-vaginal-birth-after-cesarean-vbac
WHO Statement on Caesarean Section Rates. (n.d.). World Health Organization (WHO). Retrieved March 27, 2023, from https://apps.who.int/iris/bitstream/handle/10665/161442/WHO_RHR_15.02_eng.pdf
Zola, I. K. (1972). Medicine as an institution of social control. The sociological review, 20(4), 487-504.

HIV/AIDS: A Highly Stigmatized Illness With the Capacity to Define a Person

In a society where being healthy is a high standard that people strive to attain, it can be very detrimental to a person when they are diagnosed with an illness that has no cure. The society we live in today has always been very individualistic in the sense that people are expected to become healthy and return to doing what they have been doing before they became sick. There is an idea that people who become sick could have avoided it by changing their lifestyle and habits. In this society, having any illness would make one feel like a burden, feel guilty, or have a sense of uselessness. Sadly, we live in a society where people with these illnesses are not treated with respect. As someone with a great family friend that was diagnosed with HIV, it can be heartbreaking to see the many ways that this diagnosis interferes with their self-image and life. As someone who also has hopes of going to medical school and becoming a doctor, the way that shame and disease can impact people is something that I want to keep in mind to provide patients with the best care. I hope to talk about the background of HIV/AIDS, the negative experience of people with illnesses and diseases, the impact of stigma and shame, and disparities in this disease that causes people with it to be an easy target for discrimination along with ways that physicians can slightly improve the experience.

HIV/AIDS Background

HIV (human immunodeficiency virus) is a virus that attacks cells that help with fighting infections in the human body (“What Are..”). HIV can be contracted by having contact with bodily fluids such as sharing injection drug equipment along with unprotected sex. Leaving HIV untreated leads to AIDS which is acquired immunodeficiency syndrome (“What Are..”). Although there is no final cure for HIV, people can take antiretroviral medications that are used to treat it, helping people live longer lives (“HIV and..”). Although there are many ways to contract HIV/AIDS, with the most common being drug equipment and unprotected sex, casually interacting with people does not put you at risk which is what makes the discrimination people with HIV/AIDS face very disconcerting

Source: HIVinfo.NIH.gov. https://hivinfo.nih.gov/understanding-hiv/fact-sheets/basics-hiv-prevention

Experience of Illness: Stigma and Shame

My family friend with HIV/AIDS has mentioned to me many times that his friends would stop reaching out to him once they found out he had it and would describe how doctors would keep their distance from him. Illness can be defined by the human experience of having to live with the symptoms of pain and suffering. The definition of illness and disease is summed up well in Illness Narratives. Since illness is an experience one has to go through, people can become demoralized, lose hope, or feel as if they are a burden to the people that are taking care of them (Kleinman, 1988, Chapter 1). Disease refers to the problem from the physician’s perspective meaning the experience of one who lives with the illness is not taken into account. There is great danger in not considering the lived experience of a person with a disease and the many obstacles they encounter. HIV/AIDS is viewed as a major threat to the major values of American society. In today’s society, people with AIDS are blamed for their “promiscuous sexual practices” (Kleinman, 1988, Chapter 1). AIDS in a way brands the person with the idea that they deserved it for the way that they were acting (Kleinman, 1988, Chapter 1).

In the case of Horacio Grippa, he not only had to deal with the symptoms that HIV/AIDS had on his body but also the way that he was treated because of it. His illness defined him in a way that got him kicked out of his apartment and made him lose his job as a teacher. He also mentioned how his nurses seemed scared to come close to him and how the doctors he would encounter would wear masks and gloves (Kleinman, 1988, Chapter 10). As a person who wants to become a doctor someday and knows someone with HIV/AIDS, reading this was emotionally taxing. For a patient, seeing a doctor should be a relief and someone that they can count on. The fact that some patients are still discriminated against because of having HIV/AIDS is truly concerning. When I become a doctor, I would hope to treat everyone with respect and make them feel safe and welcome because they already come to see you in a very vulnerable position.

Disparities with HIV/AIDS that Lead to Easy Targets of Shame Along With Ways of Improving as a Medical Provider

In the early stages of HIV/AIDS, the predominantly affected were homosexual and bisexual men since they made up 63% of AIDS-reported cases (Bosh et. al). In 1986, the CDC began to report the disproportionate effect that HIV/AIDS was having on African Americans and Latinos (“A Timeline”). The prevalence rate of HIV for African Americans is nearly eight times greater than for white people and three times higher than for Latinos (Geary). These statistics show that HIV/AIDS is common in minority communities that are already great targets for discrimination and shame. This can also make it easier to categorize a group of people and make them feel responsible for the high prevalence rates of HIV/AIDS.

Source: CDC Fact Sheet *Today’s HIV/AIDS Epidemic,* 2016

There are many ways of improving the experience that patients encounter, especially when it relates to stigma and shame. As people that work in a clinic or are doctors, one can be understanding of the challenges that patients have such as obstacles that could cause them to need more time to make it to appointments in the example of using a wheelchair. Doctors must overcome certain biases that they are taught and always listen to their patients by not disregarding the symptoms that they are having. There must also be a reconceptualization of medical care where the physician shows empathy and takes the patient seriously. Although this will not solve all the problems and biases experienced by the patient, it would be the first major step in making them feel heard and important (Kleinman, 1988, Chapter 2).

References

“A Timeline of HIV and AIDS.” HIV.gov, www.hiv.gov/hiv-basics/overview/history/hiv-and-aids-timeline.

Bosh, KA, Hall, HI, Eastham, L, Daskalakis, D.C., Mermin, J.H. Estimated Annual Number of HIV Infections–United States, 1981-2019. MMWR Morb Wkly Rep. 2021 Jun 4;70(22):801-806. Doi 10.15585/mmwr.mm702a1. PMID: 34081686; PMCID: PMC8174674.

“CDC Fact Sheet: Today’s HIV/AIDS Epidemic.” Centers for Disease Control and Prevention, Centers for Disease Control and Prevention, Aug. 2016, https://www.cdc.gov/nchhstp/newsroom/docs/factsheets/todaysepidemic-508.pdf

Geary, Adam A. Antiblack Racism and the AIDS Epidemic State Intimacies. Palgrave Macmillan, 2014. Accessed October 8 2022.

“HIV and AIDS: The Basics.” National Institutes of Health, U.S. Department of Health and Human Services, hivinfo.nih.gov/understanding-hiv/fact-sheets/hiv-and-aids-basics.

Kleinman, Arthur. The illness narratives: Suffering, healing, and the human condition. Basic Books, 2020. https://books.google.com/books?hl=en&lr=&id=tV_ODwAAQBAJ&oi=fnd&pg=PT8&dq=illness+naratives+suffering+healing+and+the+human+condition&ots=vHKpCH05FJ&sig=bEjhFgb8K9POln0DYexQAwdBclA#v=onepage&q=illness%20naratives%20suffering%20healing%20and%20the%20human%20condition&f=false

“What Are HIV and AIDS?” HIV.gov, www.hiv.gov/hiv-basics/overview/about-hiv-and-aids/what-are-hiv-and-aids/.

Medicalization of Women’s Health

Introduction

Obstetric medicine has always been fascinating to me. However, while trends and data can be noted by anyone, the processes discussed can only truly be experienced by women. As such, it can be complicated and sometimes disingenuous to speak about, as a man. Because of this, I will largely rely on articles and experiences shared by loved ones (each of whom consented to share their story).

Medicalization of Childbirth

Reproduction and childbirth are aspects so ingrained in the human experience. Many of us have already faced questions such as; do you want children? how many children do you want? etc. For an aspect of human life that seems so joyful and exciting, it can also be one of the scariest. This is especially true when it comes to women encountering childbirth. A 2018 study, researching the prevalence of tokophobia (the fear of childbirth) among pregnant women, found that 75% of respondents were classified in the low to moderate range while up to 25% of respondents were classified in the high to very high range of tokophobia [1]. As obstetric medicine has advanced, the context and setting of childbirth have continually evolved. What was once set in homes or birthing centers has moved to hospitals and operating rooms. The rise in the medicalization of childbirth arose concurrently with this change. The California Health Care Foundation cite the following statistics; 68% of women with vaginal births were given an epidural, 31% of women had a c-section, 85% of women with previous c-sections had a repeat c-section, and 14% of women had labor induced for non-evidence based reasons [2]. These numbers show the prevalence of medical intervention in the process of childbirth.

“Fear of childbirth, also known as tokophobia or maieusiophobia, has been defined as a psychological disorder which ranges from insignificant to extreme fear of childbirth”
Demšar et al. [1]

According to a 2002 article in the British Medical Journal, the medicalization of childbirth has grown into interventions that are often unnecessary or not evidence-based [3]. This increased medicalization of childbirth paired with the predominance of hospital births likely affects the aforementioned high levels of tokophobia. While it may seem natural to fear a major event such as childbirth, it must be noted that increased fear of childbirth may correlate to increased levels of c-sections [4]. Furthermore, maternal anxiety can increase the likelihood of delivery complications (such as placental abruption) and congenital anomalies as seen with prenatal stress disorder.

While it may seem that these interventions are a negative and a medical overreach, it is necessary to understand the importance that these interventions can have. The example I often turn to when explaining my interest in obstetric care is the story of my birth. Just before my birth, my older brother found my mother (pregnant with me) semi-conscious laying on her bed, her sheets soaked in blood. She was rushed to the hospital where she underwent a premature emergency c-section. Throughout the night we were both in critical condition. Thankfully we both survived, and she was later told that she suffered from a uterine hemorrhage. Without the remarkable advancements in obstetric medical techniques and equipment, it is likely that neither of us would have survived.

In the same way that a series of statistics cannot completely explain the state of medicalized childbirth, neither can one success story. This is a complicated issue that is not black or white. It is important to recognize and utilize the tools that have allowed us to decrease infant and maternal mortality. However, it must be noted when these tools are used inappropriately. Whether it comes in the form of ignoring preconceived birthing plans or improper informed consent processes, the increased medicalization of childbirth has whittled away at women’s decision-making capacities. Medical interventions need to be balanced and contained to allow for the highest level of care and comfort in the process of childbirth.

PCOS and Simplistic Medicine

Another over medicalized area of women’s health is menstruation. One area of this that has been particularly impactful to me is polycystic ovary syndrome (PCOS). This is a hormonal disorder in which the ovary accumulates cysts and becomes enlarged. Some symptoms include; irregular periods, excess body hair, weight gain and retention, and infertility [5]. According to the CDC, up to 5 million women experience PCOS [6].

“PCOS is one of the most common causes of female infertility, affecting 6% to 12% (as many as 5 million) of US women of reproductive age.”
Centers for Disease Control and Prevention [6]

The reason PCOS is important to me is because of how it has impacted my family. My sister was recently diagnosed with PCOS. However, her path to diagnosis was anything but direct. After experiencing constant menstruation for over a month, she went to her doctor. She described the meeting as short and dismissive. She was given two options; start an oral contraceptive or lose weight. Several months and multiple doctors later, she was being given the same answers. She believed she had PCOS and feared birth control would mask the irregular menstruation symptom, impeding any further diagnosis. Furthermore, the only other option was to lose weight; misconstruing a symptom for a cause.

She eventually received the PCOS diagnosis, but this was not before several months of discomfort, embarrassment, and dismissal from her doctors. The Martin article discussed how the language around menstruation is often that of dysfunction or degradation [7]. However, in a typical menstruation cycle, those negative connotations can at least be partially ameliorated by connotations of regrowth, but not for my sister. She lived in that state, so often negatively connoted, for months without cessation. Her experience was one of lack of access, treatment, and dialogue, and of increased simplistic medicalization. Her two options were to accept blame for her state and “lose weight” or to accept the medicalized option of oral contraceptives.

Conclusion

While these are two snapshots of the medicalized state of women’s health, they are far from comprehensive. A more holistic view must examine the cause of these issues and where they overlap. Though a disorder like PCOS and medicalized childbirth may seem very different at the surface level, they share a lack of communication and a reduction in the voice of those affected. Just as pregnant mothers have fewer options so too do women suffering from disorders like PCOS have their choices minimalized; both favoring the simplest medicalized paths.

References

[1] Demšar, Karin, et al. “Tokophobia (Fear of Childbirth): Prevalence and Risk Factors.” Journal of Perinatal Medicine, vol. 46, no. 2, 2018, pp. 151–154., https://doi.org/10.1515/jpm-2016-0282.

[2] “Infographic: The Overmedicalization of Childbirth.” California Health Care Foundation, California Health Care Foundation, 21 Aug. 2019, https://www.chcf.org/publication/infographic-overmedicalization-childbirth/#related-links-and-downloads.

[3] Johanson, R. “Has the Medicalisation of Childbirth Gone Too Far?” BMJ, vol. 324, no. 7342, 2002, pp. 892–895., https://doi.org/10.1136/bmj.324.7342.892.

[4] Ryding, Elsa Lena, et al. “Fear of Childbirth during Pregnancy May Increase the Risk of Emergency Cesarean Section.” Acta Obstetricia Et Gynecologica Scandinavica, vol. 77, no. 5, 1998, pp. 542–547., https://doi.org/10.1034/j.1600-0412.1998.770512.x.

[5] “Polycystic Ovary Syndrome (PCOS).” Polycystic Ovary Syndrome (PCOS) | Johns Hopkins Medicine, Johns Hopkins Medicine, 28 Feb. 2022, https://www.hopkinsmedicine.org/health/conditions-and-diseases/polycystic-ovary-syndrome-pcos.

[6] “PCOS (Polycystic Ovary Syndrome) and Diabetes.” Centers for Disease Control and Prevention, Centers for Disease Control and Prevention, 30 Dec. 2022, https://www.cdc.gov/diabetes/basics/pcos.html#:~:text=What%20is%20PCOS%3F,US%20women%20of%20reproductive%20age.

[7] Martin, Emily. “Medical Metaphors of Women’s Bodies: Menstruation and Menopause.” International Journal of Health Services, vol. 18, no. 2, 1988, pp. 237–254., https://doi.org/10.2190/x1a6-jaqb-vm9n-ulcy.

Social Determinants of Health for Migrant Farm Workers

Migrant Workers picking strawberries Source: Unsplash¹

The healthcare system in the United States boasts some of the most cutting-edge technology and research, but this high quality of care is not evenly distributed. For minorities, such as Latinos living in rural areas, their health is controlled by social, economic, and political determinants. We have studied these social determinants of health in class, and learned that determinants are:

“The conditions in the environments where people are born, live, learn, work, play, worship, and age that affect a wide range of health, functioning, and quality of life outcomes and risks.”
Healthy People 2030²

While I agree that the facts and statistics about the number of people affected are important to know, I would like to share a couple of stories that show the people hidden between all those numbers. I was reminded of them after having read the Nature article by Amy Maxmen which discussed how farm worker disparities are due to their social determinants of health.³

Working at a berry farm for three years was a wonderful opportunity because I got to learn about agriculture and work alongside 200+ workers from Mexico in order to harvest over 400 acres of strawberries, blueberries, blackberries, peaches, and muscadines. The work was not for the faint of heart because it required seven days work weeks in blistering humid Arkansas heat and resulted in millions of pounds of produce each season. This became even more challenging when the company limited workers’ contact with the outside world in an attempt to reduce the chances of the Corona virus running rampant in the small rooms that housed anywhere from six to fifteen people. It was amidst all the craziness that comes with harvesting crops, that I got to know some of the workers such as Rosita and Jose and realized just how many adversities they must overcome in order to receive medical care.

Overview look of lake and blackberry field Source: Lucero Chena⁴

Rosita, The Spokeswoman

If you ever need someone to control a group of over 200 rowdy adults with one word, Rosita is the one you call. She was the unofficial spokeswoman for all the workers and was the first to voice everyone’s concerns about the COVID vaccine when it was offered at the farm. All they were told was that if any worker wished they to receive the vaccine they could do so for free. This news though exciting for some was also troublesome for others because they wanted some more information before making a decision. A week before the vaccine was to be administered, I was tasked with asking everyone whether or not they wished to receive the vaccine but was warned by my supervisor to not offer my opinion or answer questions because I was not a medical professional and could be held liable if something were to happen. Rosita was the first to bombard me with questions, but at that time, all I was able to share was that physicians are required to inform a patient of any possible side effects and must sign an informed consent form.⁵ The only problem with that is that the doctor had sent said forms, but they were in English. It took a lot of research and persuasion before the company agreed to prepare a meeting in which a doctor would address the workers’ concerns and hand out a Spanish version of the possible side effects.

Rosita’s story is just one of millions that highlight how language, education access, and socioeconomic status play a role in a person’s health. There are many Non-English speaking migrants that are not comfortable going to the doctor out of fear that the appointment or medication may be too expensive or based on previous frustrations from trying to communicate with the doctor. Many Latinos who do not speak English are less likely to receive medical care⁶ or are less informed of the medical situation due to the language barrier.⁷

Lake scene from farm where I worked Source: Lucero Chena⁸

Jose, The Veteran

By my second year, I had become the farm medic and would treat any minor injuries or acquire medication during the first year when the farm was on lockdown. I would often help the workers before or after their shift, so it wasn’t surprising that Don Jose, a man who has been working at the farm for over twenty years, was there to greet me at six thirty in the morning as I opened up the store for the day. Cuts, scrapes, and bruises are common occurrences at a farm, but when Jose began to limp into the store to ask for pain medication, I knew that the situation was more serious than he was letting on. It took a lot of convincing and promises that he would not have to miss work before he finally explained that he had hit his leg had hit a nail on the edge of a trailer when he was loading boxes of fruit, and when he finally showed me his shin, I informed my manager of the situation. During his lunch break, he was taken to a clinic an hour away where the doctor informed the other farm interpreter that the wound on his shin had become infected and would need to be cleaned daily for two weeks before asking he schedule a follow up appointment. He was told to rest his leg for three days and keep it elevated to reduce the swelling, but Jose went back to work the next day after I disinfected his wound. He continued to work with his injured leg until the end of that harvesting season where he returned to Mexico to treat his wound.

Aside from the vulnerability due to language barriers and lack of access to education, farm workers also face physical, political, and economical barriers that prevent them from seeking adequate care. Many might wonder why Jose didn’t just inform someone of his injury immediately after it occurred. The reason for that is out of fear that his injury would put him out of work and cost him a lot of money to get it looked at. In the agriculture business, migrant workers are supposed to be paid a flat hourly rate and a piece rate pay, but there are many owners who violate these wage laws or decide to return the worker to their country if they are not picking quick enough.⁹ Farm owners are also not required to provide healthcare insurance for their workers because they are seasonal employees. All of these circumstances drive many workers like Jose to work through injuries instead of seeking medical care.¹⁰

Conclusion

Although I focused on the social determinants of health of two people and how their categories affected their healthcare outcomes, these determinants apply to everyone’s life. Research continues to show us the relation between the social determinants and the disparities in healthcare for minority groups such as Latinos. These disparities were especially brought under scrutiny during the COVID pandemic, but now having acknowledged that they exist, it is time to start work to eliminate these disparities and make healthcare more accessible for everyone. I know that when those changes do come, they will be because of people like Rosita and Jose, not because of some statistics we read somewhere.

Works Cited

¹Mossholder, Tim. “Strawberry Picking.” Unsplash, 21 July 2021, https://unsplash.com/photos/Kx060cRsmt0.

²“Healthy People 2030,” U.S. Department of Health and Human Services, Office of Disease Prevention and Health Promotion, https://health.gov/healthypeople/objectives-and-data/social-determinants-health

³Maxmen, Amy. “Inequality’s Deadly Toll.” Nature News, Nature Publishing Group, 28 Apr. 2021, https://www.nature.com/immersive/d41586-021-00943-x/index.html

⁴ Chena, Lucero. “Lake and Blackberry Field View.” 6 June 2020.

⁵ Commissioner. “Pfizer-BioNTech Covid-19 Vaccines.” U.S. Food and Drug Administration, FDA, https://www.fda.gov/emergency-preparedness-and-response/coronavirus-disease-2019-covid-19/pfizer-biontech-covid-19-vaccines.

⁶Taira, D A. “Improving the Health and Health Care of Non-English-Speaking Patients.” Journal of General Internal Medicine, U.S. National Library of Medicine, May 1999, https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1496581/#:~:text=Non%2DEnglish%2Dspeaking%20patients%20receive,care%20than%20English%2Dspeaking%20patients.

⁷Al Shamsi, Hilal, et al. “Implications of Language Barriers for Healthcare: A Systematic Review.” Oman Medical Journal, U.S. National Library of Medicine, 30 Apr. 2020, https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7201401/#:~:text=Other%20studies%20found%20that%20among,a%20problem%20understanding%20their%20healthcare.

⁸ Chena, Lucero. “Gazebo Over Lake.” 6 June 2020.

⁹ Robinson, Erin, et al. “Wages, Wage Violations, and Pesticide Safety Experienced by Migrant Farmworkers in North Carolina.” New Solutions: a Journal of Environmental and Occupational Health Policy : NS, U.S. National Library of Medicine, 2011, https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3291018/.

¹⁰Bail, Kari M., et al. “The Impact of Invisibility on the Health of Migrant Farmworkers in the Southeastern United States: A Case Study from Georgia.” Nursing Research and Practice, Hindawi, 1 July 2012, https://www.hindawi.com/journals/nrp/2012/760418/.

Limits to Motherhood: Overmedicalization within Pregnancy and Childbirth

The term medicalization is not shy in the healthcare field, as its overuse has come to dominate aspects of women’s daily lives, such as pregnancy and childbirth. Overmedicalization, or excessive medical treatment during pregnancy and childbirth continues to be used as a tool to make women lose control over their bodies. Examining the medical model of motherhood, many argue that women have the right to make informed medical decisions when considering their bodies. However, the idea that women possess the capacity to have a choice in their own medical decisions is a false reality as we disregard them as these passive recipients in healthcare. This form of neglect toward the identity and anatomy of women’s bodies not only alters and interferes with the previously considered natural experience of pregnancy and childbirth, but also implicates women’s view of their own bodies, and their roles as mothers^[3].

Women: The Passive Recipients of Healthcare

While medicalization has transformed the once natural process of childbirth and pregnancy into a medical event, this has led to the loss of control and agency for women. Overmedicalization can also reinforce traditional gender roles by positioning women as passive recipients of medical care rather than active participants in their own health and well-being. It can lead to a lack of trust between the patient and their healthcare provider, as the provider may be seen as the expert, and the patient may feel powerless to make decisions for themselves. This issue can result in a lack of informed consent and autonomy in decision-making as we brush aside women’s feelings and have others decide for them^[1].

The medicalization of pregnancy and childbirth can also lead to a decreased sense of control and autonomy for women during their pregnancy and childbirth. Women may feel pressured to comply with medical recommendations rather than make their own informed decisions^[2]. For instance, a woman may be told by her doctor that she needs to have a cesarean section for reasons she does not fully understand and may feel like she has no other option but to comply with the recommendation^[1]. This may lead to feelings of anxiety, trauma, helplessness, and a sense of disconnection from the process before and after giving birth.

Reproduction as a Social Control

Has the overmedicalization of pregnancy and childbirth become a social control?

“The most powerful emperical stimulus for this realization of how much everyone has or believes he has something organically wrong with him, or more positively put, how much can be done to make one feel, look, or function better^[4].”
Irving Kenneth Zola in Medicine as an Institution of Social Control

Overmedicalizing pregnancy and childbirth has become a social control as there is an expectation that women are to conform to medical norms and standards. Rather than being allowed to make their own choices about bodies, the reliance on medical professionals to make decisions about their bodies continues to perpetuate a form social control over women^[3].

In general, medicalization has become a tool used to exert social control over women’s bodies during both pregnancy and childbirth as it goes way beyond what is necessary to treat or prevent illness. Pregnancy for example has been medicalized to an unnecessary degree, with routine procedures and interventions that may not be necessary for all women. Prenatal care has become increasingly routine, with frequent ultrasounds, blood tests, and other procedures that can be expensive and time-consuming^[4]. More specifically, the routine use of fetal monitors during labor. Fetal monitors were introduced in the 1970s to detect and prevent fetal distress, but they have become a routine part of the labor process, even for women who are not at high risk^[4]. Moreover, fetal monitors have not been shown to improve the outcomes for low-risk pregnancies. Alongside many others, fetal monitors fall under the category of unnecessary procedures performed that may potentially lead to risks and complications for both mother and baby^[3].

Increase in Medical Interventions

“According to the Listening to Mothers in California survey, 74% of California mothers agreed that childbirth should not be interfered with unless medically necessary, but only 5% gave birth with no major medical intervention.^[1]“
Listening to Mothers in California, “Infographic: The Overmedicalization of Childbirth.”

While statistically speaking, according to Listening to Mothers in California, 74%, or rather the majority of expecting mothers preferred to have an absence of any interference during childbirth^[1]. Yet, only 5% gave birth without any medical interferences – what are possible factors that contribute to these drastic statistics, and what are the alternatives^[1]?

Pregnancy and childbirth are natural experiences, but overmedicalization can make them seem like medical conditions that require constant monitoring and intervention^[2]. Medical interventions during pregnancy and childbirth are often driven by the desire for control and profit rather than medical necessity. These interventions can increase the risk of complications and interfere with the natural birthing process, which can be traumatizing for the mother and the baby. Induction is perhaps considered an intervention, often used to prevent complications. Epidurals and cesarean sections are other procedures increasingly used that are not always necessary^[2]. Using an episiotomy, a surgical incision made in the perineum during childbirth to widen the vaginal opening is another medical procedure that isn’t always necessary. The routine use of episiotomies has been debunked as unnecessary by research, yet the procedure is still performed routinely in many hospitals^[2].

While medical interventions are necessary in some cases, there are alternatives to the overuse of medical technologies for pregnancy and childbirth. One alternative is the use of midwifery care, which emphasizes a holistic, patient-centered approach to pregnancy and childbirth. Midwifery care has been shown to be associated with improved maternal and infant health outcomes, as well as higher rates of patient satisfaction^[5]. Education is also an important alternative to medicalization. Women who are well-informed about the risks and benefits of medical interventions are more likely to make informed decisions about their healthcare. Education can also help to reduce fear and anxiety about pregnancy and childbirth, which can lead to a more positive experience overall.

Looking at the Bigger Picture

Like many young women, I have grown up watching movies, reading stories, seeing social media posts and television ads that feature the joys and beautiful moments of pregnancy and childbirth. The messages are usually very uplifting and focuses on the emotional part of reproduction. However, there is another side of pregnancy and childbirth that is rarely discussed or featured in news articles on overmedicalization, and other limitations within the health system for women during childbirth. While I have not experienced childbirth, and hope to have a family in the future, I am much more aware of potential limitations and challenges that I may face when I navigate my own pregnancy or childbirth. Growing up, I was taught to fight for personal choices and value my ability to make my own health care decisions. It is imperative that all women choosing to bear children and enter motherhood have the ability to navigate their own health care options. While society tends to highlight the joys of pregnancy, there needs to be more open discussions on the limitations, potential interventions and overmedicalization of childbirth so women can make informed decisions about their own health care.

It is important to recognize that the phenomenon of overmedicalization is not limited to pregnancy and childbirth. Overmedicalization can also occur in other areas of healthcare, such as the management of menopause or the treatment of mental health disorders^[5]. Overmedicalization of women’s pregnancy and childbirth can have significant consequences for both the mother and the child. It is essential to balance medical interventions with respect for women’s autonomy and agency in making informed decisions about their bodies and health. On the one hand, medicalization can lead to an increased understanding of the medical aspects of pregnancy and childbirth, as well as increased safety and access to care. On the other hand, it can lead to a lack of autonomy and respect for traditional birthing practices, as well as increased risks and complications^[2]. It is essential for healthcare providers to be aware of these impacts and to ensure that women are informed and empowered throughout the birthing process.

References

^[1]“Infographic: The Overmedicalization of Childbirth.” California Health Care Foundation, August 21, 2019. https://www.chcf.org/publication/infographic-overmedicalization-childbirth/#related-links-and-downloads.

^[2]Martin, Emily. “Medical Metaphors of Women’s Bodies: Menstruation and Menopause – JSTOR.” Accessed February 20, 2023. https://www.jstor.org/stable/45130557.

^[3]“Medicalization, Social Control, and the Relief of Suffering.” Accessed February 20, 2023. https://onlinelibrary.wiley.com/doi/10.1002/9781444314786.ch10.

^[4]“Medicine as an Institution of Social Control – Irving Kenneth Zola, 1972.” Accessed February 20, 2023. https://journals.sagepub.com/doi/abs/10.1111/j.1467-954X.1972.tb00220.x.

^[5]“Women Have Been Misled about Menopause.” NYT inEducation. Accessed February 20, 2023. https://nytimesineducation.com/women-have-been-misled-about-menopause/.

Climate Change’s Amplified Impact on the Health of Rural Pregnant Women

Pregnancy is viewed as a normal process of life, a cycle that is repeated so frequently that the risks are often forgotten. However, millions of pregnant women die before, during, or after birth each year, largely due to preventable causes. Lack of access to health care (an obstacle faced by many women living in rural areas) is a huge risk factor for maternal and infant mortality/poor birth outcomes. Furthermore, the intersection of little to no health care and impacts of climate change poses an even greater risk for rural women. Surmounting evidence shows that the negative effects of climate change compound on pregnant women in rural areas to a higher degree than women in nonrural areas. As the earth continues to warm, healthcare initiatives must be put in place to protect rural pregnant women and prevent poor birth outcomes.

Living on the Moon

The shocking distance from health providers experienced by some communities can be perfectly encapsulated by Stan Brock, the creator of Remote Area Medical (a program that provides free pop-up clinics to rural communities). When describing a trip to a rural area of the Amazon, locals told him that the nearest doctor was 26 days away by foot. After relaying the story to astronaut Ed Mitchell, Brock was told that astronauts on the moon were a mere 3 days away from the nearest doctor.² Brock’s grave revelation that people living in remote areas of the world are basically living on the moon has stark implications for pregnant women.

“People in the rural Amazon and rural America basically live on the moon.”
Stan Brock from Remote Area Medical²

Pregnant women living in rural areas with little to no access to healthcare have heightened vulnerability to several factors that climate change also influences, such as environmental health and housing/food security. The limited access to health providers increases risk of poor birth outcomes when complications from these factors occur; in fact, over half of rural American women live at least 30 minutes away from a hospital with a labor and delivery unit.⁵ It is also common for rural women to attend prenatal appointments much later in their pregnancies than nonrural women.⁵ Furthermore, environmental hazards from industries commonly found in rural areas (such as agriculture, logging, and mining), unsafe housing that lacks temperature control and other necessities, and limited access to fresh and affordable food pose existing threats to the health of pregnant rural women.⁵ These social determinants of rural health compound the effects of climate change, creating a dangerous environment for rural women to go through their pregnancies.

Climate Change and Pregnancy Outcomes

As the effects of climate change become increasingly drastic, it is important that healthcare workers are prepared to combat the negative consequences on pregnant women’s health. As global temperature hikes increase the frequency and intensity of extreme weather events such as droughts, food insecurity subsequently increases. Such weather conditions also make homes without temperature control unsafe to live in, which can lead to negative birth outcomes, increased morbidity, and forced migration. Tropical developing countries, along with any areas with high poverty rates, poor healthcare systems, or little to no healthcare access will be hit the hardest by these effects.³ Many rural communities fall into all of these high risk areas, meaning increased prenatal care to rural women is integral.

As the most vulnerable members of society, pregnant women, fetuses, and newborns are prone to suffering from the effects of food/housing insecurity and high ambient temperatures. During pregnancy, energy demand increases by 20%.³ This means that more food is required for all of a pregnant woman’s bodily functions to operate at full capacity, but food insecurity means that food is not a reliable source in equal quantities throughout the pregnancy. Underweight women are more likely to give birth to underweight or intrauterine growth restricted babies, which inherently places newborns in a vulnerable position.³ Additionally, food and water insecurity leads to mass migration. With an estimated several hundred million climate refugees by 2050, prenatal care will be virtually impossible for displaced women.³ Throughout the upcoming decades, the lives and health of pregnant women and newborns are in imminent danger.

Ugandan Case Study

“During the dry season, it’s suffering. If you don’t save what [food] you had during the rainy season, then in the dry season you find you have nothing when you are pregnant.”
Women from rural communities in Kanungu District of Uganda_¹

The damage to the health of pregnant women living in tropical, rural areas is exemplified by a case study conducted in the rural Kanungu District in Uganda. This area is already threatened by food insecurity due to droughts and other weather that harm the region’s agriculture, particularly in the dry season. In a series of interviews conducted with adult women of all ages, it was noted that the rainy season is the best because “every crop grows” and that the insecurity has reached a point where food grown in the rainy season must be saved for the dry season to avoid starvation.¹ The women reported many negative symptoms during pregnancy, including “nausea”, “general malaise”, “dizziness”, “shivering”, and “weakness”, in addition to a recent increase in babies that are “weak”, “small”, and “having more sickness”.¹ They noted that this was due to mothers not having enough to eat anymore due to droughts. Another observation indicated that babies born in the rainy season are typically stronger due to an increase in food availability towards the end of pregnancy. Since food variability late in pregnancy becomes increasingly detrimental to the health of the baby, some mothers expressed interest in trying to plan pregnancies around rainy and dry seasons, although this often isn’t possible due to family planning challenges.¹ The health observations by these mothers make it evident that climate change is already affecting rural regions negatively and that it will only continue to do so as global temperatures increase.

Source: *Seasonality, climate change, and food security during pregnancy among indigenous and non-indigenous women in rural Uganda: Implications for maternal-infant health.*

Implications

Although millions of rural women are at risk of increasingly dangerous pregnancies in the upcoming decades, there isn’t a lot of research documenting the physiological reasons negative birth outcomes due to various climate change effects occur.⁴ How can public health officials be prepared to face a crisis that they aren’t armed to fight? Until research investigating the physiological effects of factors such as heat exposure at different gestational periods, chronic heat exposure, and heat acting in tandem with environmental pollutants becomes available, increasing the amount of prenatal care to rural women is the best solution.⁴Hopefully, awareness of the risks that rural pregnant women face in the upcoming decades will become more widespread before a major public health crisis occurs. In our ever changing world, we cannot let rural women and their babies fall through the cracks.

References

¹Bryson, J., Patterson, K., Berrang-Ford, L., Lwasa, S., Namanya, D. B., Twesigomwe, S., Kesande, C., Ford, J. D., & Harper, S. L. (2021). Seasonality, climate change, and food security during pregnancy among indigenous and non-indigenous women in rural Uganda: Implications for maternal-infant health. PloS One, 16(3), e0247198. https://doi.org/10.1371/journal.pone.0247198

²Remote Area Medical. Directed by Farihah Zaman and Jeff Reichert, Candescent Films, 2013.

³Rylander, C., Øyvind Odland, J., & Manning Sandanger, T. (2013). Climate change and the potential effects on maternal and pregnancy outcomes: an assessment of the most vulnerable – the mother, fetus, and newborn child. Global Health Action, 6(1), 19538–19539. https://doi.org/10.3402/gha.v6i0.19538

⁴Samuels, L., Nakstad, B., Roos, N., Bonell, A., Chersich, M., Havenith, G., Luchters, S., Day, L.-T., Hirst, J. E., Singh, T., Elliott-Sale, K., Hetem, R., Part, C., Sawry, S., Le Roux, J., & Kovats, S. (2022). Physiological mechanisms of the impact of heat during pregnancy and the clinical implications: review of the evidence from an expert group meeting. International Journal of Biometeorology, 66(8), 1505–1513. https://doi.org/10.1007/s00484-022-02301-6

⁵ “Social Determinants of Health for Rural People.” Social Determinants of Health for Rural People Overview, Rural Health Information Hub, 6 June 2022, https://www.ruralhealthinfo.org/topics/social-determinants-of-health.

The Importance of Primary Care Physicians and the Negative Health Effects from a Lack of Access to Primary Care

*A primary care physician providing care*.

Importance of Primary Care

Primary care physicians play a vital role in the healthcare system. Examples of their work include preventing diseases by identifying risk factors and managing chronic disease care for longevity and better quality of life. Despite the important work that primary care physicians do, primary care physicians do not always get the credit they deserve, even from other physicians who work in different specialties. Atul Gawande is a well-renowned surgeon who writes about his evolved thinking and understanding of primary care physicians and the strong impact that they have on their patients in his article “The Heroism of Incremental Care” published in The New Yorker in 2017. Atul Gawande used to believe that surgeons have more opportunities to make direct impacts on their patients’ lives because surgery is a clear-cut intervention at a critical moment in a person’s life. He also used to believe that primary care physicians could not make this same impact because primary care medicine is often uncertain.

However, Gawande’s mindset regarding primary care medicine started to change when he spoke with Asaf Bitton, an internist. Bitton argued that primary care physicians have the greatest overall impact by lowering mortality rates and bettering health, and primary care medicine has lower medical costs. Bitton also provided Gawande with studies that showed that “states with higher ratios of primary-care physicians have lower rates of general mortality, infant mortality, and mortality from specific conditions such as heart disease and stroke” (Gawande). After Bitton’s explanation and taking a deeper look into primary care, Gawande changed his mind and agreed that primary care is extremely important and may even do more good for people in the long run than his work as a surgeon.

“States with higher ratios of primary-care physicians have lower rates of general mortality, infant mortality, and mortality from specific conditions such as heart disease and stroke.”
Atul Gawande, “The Heroism of Incremental Care.”

Suffering from the Lack of Access to Primary Care

Despite the fact that primary care medicine reduces risks and greatly improves the overall health of an individual, many people in the U.S. do not have access to primary care due to reasons such as a lack of health insurance and living in a rural area. The film Remote Area Medical highlights the effects of a lack of access to primary care physicians. The film documents the annual three day pop-up medical clinic organized by the non-profit Remote Area Medical in Bristol, Tennessee. Many people who live in rural Bristol do not regularly see a primary care physician because they do not have health insurance and cannot afford the costs.

One 44-year-old woman who attended the clinic wanted to get a mammogram because she had never gotten one before. Mammograms are used for early detection of breast cancer, which is extremely important because the earlier breast cancer is detected, the more likely that person will survive. The CDC recommends that women get a mammogram every two years. All women should be able to get mammograms to reduce the risk of developing severe breast cancer. However, since this woman lives in a rural area in the U.S. and does not have access to primary care medicine, she does not have the ability to get a mammogram and is consequently at a higher risk for developing breast cancer without detection that can advance to the point where her chances for survival are very low.

*Patients receiving care from the annual three day Remote Area Medical pop-up clinic in Bristol, Tennessee.*

Another woman shown in the film is one who wanted to get a chest x-ray. She had never had an x-ray before, and the physician who went over the results of the x-ray with her explained to the woman that she had spots on her x-ray that could potentially be cancer. Although this woman was informed that she had spots in her lungs at the pop-up clinic, she most likely does not have the ability to get follow-up care after the clinic closes at the end of the weekend because she does not have access to a primary care physician and cannot afford the high costs of going to the doctor. If this woman had a primary care physician, she would be able to get continued care and treatment for the spots shown on her chest x-ray. However, since she does not have access to a primary care physician, she is left with a probable cancer diagnosis and the inability to get the continued care that she needs.

Reflecting

Similar to Gawande, I did not realize how important primary care is prior to this course. Additionally, I did not realize how lucky I am to have a primary care physician who I have a developed relationship with and am comfortable going to with medical problems or routine check-ups. Exposure to material such as the film Remote Area Medical has opened up eyes to seeing how critical primary care is for preventing diseases and providing important medical treatment that I had previously taken for granted. Although it is easy to look at a medical intervention such as surgery and see the immediate results of that intervention, it is vital to understand the importance of primary care because primary care prevents diseases, allows people to develop a strong relationship with their healthcare provider, and improves overall health.

The examples of the women from the Remote Area Medical film calls attention to the negative effects of not having access to a regular primary care physician and how this is detrimental to health. We need to figure out how to get more people access to a regular primary care physician so they do not need to wait for a pop-up clinic that comes around once a year to get care that they desperately need all the time.

Works Cited

Gawande, Atul. “The Heroism of Incremental Care.” The New Yorker, 15 Jan. 2017,
https://www.newyorker.com/magazine/2017/01/23/the-heroism-of-incremental-care. Accessed 19 Feb. 2023.

Remote Area Medical. Directed by Jeff Reichert and Farihah Zaman, 2013.

“The Importance of Having a Primary Care Doctor.” Cleveland Clinic, 5 Oct. 2020, https://my.clevelandclinic.org/health/articles/16507-the-importance-of-having-a-primary-care-doctor. Accessed 19 Feb. 2023.

“What Is Breast Cancer Screening?” Centers for Disease Control and Prevention, Centers for Disease Control and Prevention, 26 Sept. 2022, https://www.cdc.gov/cancer/breast/basic_info/screening.htm. Accessed 19 Feb. 2023.

Race and Poverty: Non-biological and Non-medical Factors that Greatly Influence Health Outcomes

Race is a social construct that was created to categorize people and justify the atrocious acts of slavery and oppression. In reality, there is more genetic variation found within a racial group than between racial groups (Wu et al., 2005). Although race is not biological, the lack of healthcare access and significantly worse healthcare outcomes present in communities that suffer from poverty, oppression, and racism are staggering when compared to the outcomes found for the wealthiest Americans. Social determinants of health, racial domination, and racism in medicine are the root causes of this disparity found in the United States today. As someone who has parents that were born and raised in Mexico, I have seen firsthand the impact that poverty and lack of healthcare can have on racial minorities, especially with the recent COVID-19 pandemic.

Defining Social Determinants of Health

I grew up in a very small town in west Omaha, Nebraska, which is a predominantly white community. I was the only person of color in my elementary school and middle school. I would notice that the houses were nice and my education system was great. Since we had many family members and friends who lived in south Omaha, where there is a predominant Latino presence, I would notice the instant differences between these two parts of the city. There is an abundance of fast food chains in south Omaha along with beaten down buildings, cramped housing, and trash accumulating on the streets. At this young age, I did not know that these differences in living conditions would cause staggering differences in health outcomes.

Social determinants of health are defined as where people live, work, play, and age that affect a wide range of health functioning along with the quality of life outcomes and risks (“Social Determinants..”). They can be divided into domains which include economic stability, education access and quality, health care access and quality, neighborhood and built environment, and social community context. Some examples of how these domains can affect health outcomes include being exposed to polluted air and water along with having access to safe housing and transportation (“Social Determinants..”).

Photo retrieved from Healthy People 2030, U.S. Department of Health and Human Services, Office of Disease Prevention and Health Promotion

Income Inequality Across Different Races

Social determinants of health are the primary contributors to health disparities and inequalities since they can lower life expectancies and raise the risks of health conditions like heart disease and obesity. Since social determinants of health include where people live and the education people receive, it is no surprise that income plays an important role. Almost every chronic condition follows a pattern of rising prevalence with declining income. It is no surprise that racial minorities, such as Hispanics and African-Americans are the ones that face the lower end of income inequality, and therefore experience the worst health outcomes. In 2013, the median family wealth for the white population was more than 10 times that for Hispanics and 12 times that for African-Americans (Dickman et al., 2017). It does not help that the U.S. healthcare system contributes to this inequality because many people are not able to afford expensive medical care and high cost-sharing since the U.S. is by far the world’s most expensive medical care. Since the most burden is placed on the uninsured, they delay seeking medical care which causes a rise in their preventable deaths (Dickman et al., 2017). Likewise, there is strong evidence that the quality of care is worse for racial and ethnic minorities. For example, African-Americans are more likely to live closer to high-quality hospitals, but they are less likely to receive care there (Dickman et al., 2017).

It is evident now that social determinants of health, such as income and where someone lives, have a greater effect on the health outcomes of certain people. This can explain why the Hispanic and African-American population is more likely to have certain diseases, especially in light of the recent COVID-19 pandemic. Black and Latinx people are twice as likely to die from COVID-19 than white people in the United States (Maxmen, 2021). Even from a young age, the differences I would experience in a predominantly white population compared to a Hispanic population are proof of the drastic difference that income can have on one’s living conditions.

Recent COVID-19 Pandemic on Racial Minorities

The racial disparities found in the U.S. healthcare system are most noticed in the recent COVID-19 pandemic. I vividly remember how the pandemic affected everything around me. I was worried for my dad who still had to go to work because his job could not be remote. It upset me how there was no intervention or virtual option available for people like my dad. Most of the jobs that could go remote were the ones of office jobs or middle-class jobs that most racial minorities do not have. Many immigrants or minorities were not able to be cautious because they needed to work to maintain their families. It is upsetting to know that poverty and discrimination drive disease but so little is done to help with these disparities.

“Farmworkers don’t stop for a pandemic,” he says. “We keep working.”
“Inequalities Deadly Toll” (Maxmen, 2021)

As someone who grew up as part of the Latino community, I have heard quotes very similar to the one above. Almost everyone I knew continued working despite all the CDC recommendations because they would have no other ways to pay for bills and food. Black, Latinx, and Indigenous people have been affected by COVID-19 more than white people in the United States. Latinx food and agriculture workers experienced a nearly 60% increase in COVID-19-related deaths compared with the previous years when the increase for white workers was only 16% (Maxmen, 2021). It is upsetting that the U.S. relies on immigrant labor yet they are not provided with a living wage or affordable health care, although they are paying taxes.

Lack of Healthcare For Immigrants

The uninsured face the greatest barriers to care, and among the non-elderly population, one in four lawfully present immigrants, and almost half of the undocumented immigrants were uninsured (“Health Coverage..”). Because many of these people do not have insurance, they are less likely to access healthcare even when they need it. The high cost of healthcare in the U.S. does not help as 33% of non citizens have reported not having a usual source of care and 10% not going with medical care due to its high cost which is shown in the figure below (“Health Coverage..”).

Source: KFF analysis of 2021 National Health Survey (NHIS) sample adult interview

Immigrants are not the only population that suffers from lack of health care, but also many citizens in the United States. Action must be taken to reduce these racial disparities that stem from differences in social determinants of health. It has been known for decades that poverty and discrimination drive diseases, and, unfortunately, COVID-19-related deaths is just another demonstration of racial inequality.

References

Dickman, Samuel L., David U. Himmelstein, and Steffie Woolhandler. “Inequality and the health-care system in the USA.” The Lancet 389.10077 (2017): 1431-1441. https://www.sciencedirect.com/science/article/pii/S0140673617303987. Accessed 20 February 23.

“Health Coverage and Care of Immigrants.” KFF, 20 December 2022, https://www.kff.org/racial-equity-and-health-policy/fact-sheet/health-coverage-and-care-of-immigrants/. Accessed 18 February 23.

Maxmen, Amy. “Inequality’s deadly toll.” Nature (2021). https://www.nature.com/immersive/d41586-021-00943-x/index.html. Accessed 18 February 23.

“Social Determinants of Health.” Social Determinants of Health – Healthy People 2030, https://health.gov/healthypeople/priority-areas/social-determinants-health. Accessed 18 February 23.

Wu, Zheng, and Christoph M. Schimmele. “Racial/ethnic variation in functional and self-reported health.” American Journal of Public Health 95.4 (2005): 710-716. https://ajph.aphapublications.org/doi/abs/10.2105/AJPH.2003.027110. Accessed 19 February 23.

The Stealing of Our Humanity: A Loss of Dignity

With its overwhelming resources, technological advancements, and so called exceptional medical training, the United States is expected to have the ability and intention to provide quality and fair treatment for all. However, we are failing to do just that. Despite the talk of the American Dream, all of America’s riches, and the idea of equality for all, numerous flaws are intertwined into the foundation of America, primarily seen in the quality of care for Americans. Not only are individuals, primarily those who identify as lower class or people of color, struggling to find proper access and affordability to care but humans are simply viewed as machines and statistics by the healthcare system. They are not seen for their individuality as a human and their dignity has failed to be recognized and acted upon. Therefore, they are not at all treated equally, respectfully, empathetically, or fairly. This is an issue that must be acted on with urgency so that the very system that is meant to protect and care for us most can do just that.

A Humanitarian Crisis

Once a person is not seen for their innate dignity, any treatment becomes acceptable. It is easy to mistreat someone when they are not seen for the person they are and the individuality that makes them who they are. This is what allows for the many issues in the U.S. healthcare system such as the financial burden on the poor, access problems for those in rural areas, over medicalization of female bodies, and racism against people of color.

A primary example to note is the emphasis on symptoms rather than holistic care of patients through factors such as a heavy reliance on electronic healthcare records. There is a greater focus on fragmented care than on holistic and integrated care, leading to handoff of patients between different providers in the system increasing the likelihood of error. There is a tendency for individuals to get tossed around to different settings that may not even have a connection to one another leading to duplicated care, uncoordinated services and increased expenses.¹ There is also often danger in prescribing medications that interact poorly with others or a repetition of tests already performed. Physicians and the health care system are also more focused on profits rather than the health outcomes of patients. Although the U.S. spends more on healthcare than any other nation in the world, there are poorer outcomes for many significant health measures such as “life expectancy, preventable hospital admissions, suicide, and maternal mortality.”¹ This type of treatment should not be considered proper or quality care for individual humans who experience pain, have unique health conditions specific to them, face their own surrounding circumstances and are overall not simply numbers or objects.

“The most powerful empirical stimulus for this is the realization of how much everyone has or believes he has something organically wrong with him, or more positively put, how much can be done to make one feel, look or function better.”
Irving Kenneth Zola in Medicine as an Institution of Social Control²

This is similar to how people are seen only for their sickness rather than who they are. Although a person is not condemned for having a disease, they are still seen as flawed if they don’t deal with the disease the “right way” by breaking appointments, not following treatment regimens, and delaying their seek of medical care.² This sick role imagines sickness through a lens of deviance and social obligation. Judgment and use of labels puts an additional burden on those that are sick when they are already feeling shameful, overwhelmed, and mistrusting due to their illness. Not only is this extremely problematic but medicine has become a force of authority and social control that remains unquestioned so this is a continuous pattern. It has been used as a way to secularize moral authority just as religion and law were once used to dictate what was wrong with a person and define them with their illness.² Due to their diseases, individuals become forbidden from certain activities, confined until cured, and subject to assumption and discrimination, leaving them with no choice but to feel defined by their sickness and punished for their illness.² We are simply looked at for our sickness and begin to be solely defined by being labeled as dysfunctional and in need of medical intervention rather than our identities. This interferes with every individual’s own human experience, giving medical professionals and institutions sole access into the area of people’s human existences and the unique circumstances that come with it.

Slipping away

There is very often an immediate instinct and reliance on determining a medical reason for issues and medicating resulting in unnecessary diagnoses, prescribing of drugs, and performances of tests due to the over medicalization out of fear of getting sued.¹ This is seen through medical care often being immediately offered to pinpoint a specific issue and prevent the risk of blame. It is almost as if patients are seen as guinea pigs that are experimented on and medicated rather than humans with dignity and individuality who deserve to be talked to, treated fairly, and most importantly respected and understood.

This theme is shown in the Remote Area Medical (RAM) film surrounding a nonprofit that helped to alleviate and serve a community with a pop up clinic providing free medical services.³ Although the organization has been successful at stepping up for a group that struggled receiving access and opportunity to just and quality healthcare due to the area they resided in, there was still an issue in the way they provided care. I felt as though the people receiving RAM’s help were dehumanized in a way. They were seen as numbers rather than individual persons. Although it was a very hectic situation where everyone attempted to keep everything in order and keep the lines moving, the workers and volunteers shouted out numbers hastily. It was clear that the people attending were anxious to get in and get help but rather than the workers empathizing with their extenuating situations and circumstances, they shouted at them and were not understanding. This is a prime example of the issue of assembly line care where significant issues and hardships are overlooked, patient stories are not heard, trust and personal relationships are not able to be developed, and patients feel the need to give up and avoid the care they need.¹

As a young black woman from a single parent household, my family and I faced a lack of access to proper healthcare continuously–care that was affordable and given without judgment or assumptions. We were looked at as statistics that they rushed caring for just to carry on and get to the next person. It was often that physicians and other medical authorities urged that they always knew what was best and because of our physical appearance or financial status, we were seen as not educated enough to make informed decisions for ourselves. My mom constantly had to stand up for herself and for us whenever she had any questions or needed clarification about certain vaccines, procedures, or tests she was uncertain about. Overall, our dignity as human beings was overlooked.

Reclaiming our Individuality

So how do we reclaim our human individuality in the intense world of healthcare and medicine?

“The question going forward is whether there will be trust, will, and vision necessary to build something better.”
Rob H. Shmerling from Harvard Health¹

America’s healthcare system has the ability to soften effects of hardships such as economic inequality through delivery of high quality care to everyone but the institutions as well as the expensive financing patterns of the system are built against achieving this.⁴ Access to medical services is unequal in this nation, lower income families experience the most financial burdens, and disparities flood the system. Individuals struggle to gain a grasp on quality care and a quality of life as they are labeled as less than and are seen as a number when they are uninsured, uneducated, rural residents, female, or a person of color.

Despite this country’s healthcare system and its countless issues, there is hope. There is no simple solution but I believe the greatest change will come through 1% solutions, which are tiny tweaks done to the healthcare system until there is a significant difference in patient outcomes.⁵ Although we can’t fully anticipate or shape the future by preventing all problems, as patterns in healthcare outcomes become more susceptible to empiricism, this ambition is what will allow for incrementalist solutions promising benefits down the road, which is something that we will have to be patient about and trust in as we “recognize problems before they happen” and use “steady, iterative effort [to] reduce, delay, or eliminate them.”⁵

Doctor holding hand of patient to give comfort, express health care sympathy, and build medical trust and support, encouraging and reassuring the patient.

All in all, we need advocates, people who care and have the power to stick up for us with the utilization of their voices and platforms. These are the people that can make the most change and the greatest difference in our lives. They are the people that see us for who we are. Step by step and day by day we can truly become what America is known for, a nation that cares about the health of all of its people, one that strives towards equal access and opportunity for all.

References

¹ Robert H. Shmerling, MD. “Is Our Healthcare System Broken?” Harvard Health, 13 July 2021, https://www.health.harvard.edu/blog/is-our-healthcare-system-broken-202107132542.

² Zola, Irving Kenneth. “Medicine as an Institution of Social Control.” The Sociological Review, vol. 20, no. 4, 1972, pp. 487–504., https://doi.org/10.1111/j.1467-954x.1972.tb00220.x.

³ Reichart, Jeff and Farihah Zaman, directors. Remote Area Medical. Candescent Films, 2013.

⁴ Dickman, Samuel L, et al. “Inequality and the Health-Care System in the USA.” The Lancet, vol. 389, no. 10077, 2017, pp. 1431–1441., https://doi.org/10.1016/s0140-6736(17)30398-7.

⁵ Gawande, Atul. “The Heroism of Incremental Care.” The New Yorker, 16 Jan. 2017, https://www.newyorker.com/magazine/2017/01/23/the-heroism-of-incremental-care.