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 seasonthen in the dry season you find you have nothing when you are pregnant.”

Women from rural communities in Kanungu District of Uganda1

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.


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.4 Hopefully, 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.


 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.

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

3 Rylander, 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.

4 Samuels, 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.

5 “Social Determinants of Health for Rural People.” Social Determinants of Health for Rural People Overview, Rural Health Information Hub, 6 June 2022,

St. Matthew, Adam Smith, and Immanuel Kant: an Unempathetic and an Empathetic Justification for Expanding Rural Healthcare Access

Michael Murakami

As an accountant and economist by trade, the theological story I am most naturally drawn to is when Jesus calls upon Matthew the tax collector (soon to be St. Matthew, Patron Saint of Accountants) to join him in ministry. Jesus’ quote in Matthew 9:12, “It is not the healthy who need a doctor, but the sick”1 was always memorable; knowing that sinners (the sick) could be drawn into and saved in the church by Jesus (the doctor) comforted me. Yet in modern society, this initially metaphorical line now applies in a very literal sense: many regions of the United States, like rural communities, are populated with “sick” people who are unable to receive treatment for a variety of reasons, such as time, cost, and access.

The Calling of St. Matthew, Caravaggio2

Background on Rural Communities

Social determinants of health (SDoH) impact rural communities by decreasing the healthcare access and utilization of residents. Some of the most common SDoH in rural areas relate to lower levels of income, education, health-related infrastructure, and health literacy as well as other determinants such as race, ethnicity, sexual orientation, and environmental impacts.3 

To exemplify the impact of a SDoH, Elisabeth Rosenthal describes in her piece, Paying till It Hurts: The $2.7 Trillion Medical Bill,4 how patients with lower incomes suffer because of rising costs and doctor-patient information asymmetry. The example she uses is colonoscopies, where it is shown that pricing is not equal nor well understood, even by doctors. However, even worse, because of the specialized knowledge of the medical field, patients typically do not understand what procedures or checkups most efficiently diagnose or aid their issues and are cornered into what doctors prescribe. The fundamental problem that results is that the motivations of doctors can be fueled by popular, but misguided medical beliefs (in this case, that colonoscopies are the best method for the early detection of GI issues) or lobbying of medical firms (more often seen in pharmaceuticals). In either case, low-income and low-access patients are most impacted by ineffective and unnecessary testing because they are least able to afford or access further care. 

Beyond lower financial access and utilization of medical care, geography plays a critical role in physically limiting the access of rural patients from doctors. According to a study comparing rural and urban specialty healthcare access by Melissa Cyr et. al., both urban and rural areas struggle with the availability and accommodation of healthcare, although rural areas are considerably worse off (a problem compounded by additional limiting factors) as seen in the infographic below.5 Here, Cyr et. al. shows the existence of a variety of significant barriers to healthcare access in rural areas.

A frequency chart of mentions of the hindrances of healthcare access from Access to specialty healthcare in urban versus rural US populations: a systematic literature review, Melissa Cyr et. al.5

This dramatic difference in access and utilization tangibly impacts the quality of life and longevity for rural and poorer communities. In his piece, Inequality and the Health-Care System in the USA, Samuel Dickman explores the lower quality of life and shorter life expectancies for low-income patients. He explains that chronic and acute conditions alike have higher prevalence with declining income (which is correlatable strongly to rural communities) as well as considerably lower life expectancy.6 These results exemplify how the negative outcomes associated with SDoH decrease the quality of an already shortened life.

The Role of Rural Communities in the United States

With an understanding of the existence of disparities and deficiencies in healthcare from the above pieces, one may ask why only a small segment of society pushes for changes to the status quo. A common response draws upon economics in a resource-constrained game; proponents believe that the tradeoff of additional healthcare being invested in densely populated areas will help more people than in rural areas. This utilitarian stance, although logical on the surface, lacks consideration for the whole picture when further analyzed. To understand an unempathetic, economic argument in support of expanding rural healthcare, one must understand the role of rural, especially farming, communities in the United States. In rural America, approximately one out of ten workers are in industries such as agriculture, fishing, and hunting which, although decreasing over time, comprises a large portion of the community and nationwide production.7 

Open market and even Keynesian economists may argue that we should help rural communities in order to directly strengthen our food source, therefore bettering society. This stance stems from a belief that farming communities (and other rural industries, however, farming is a clear example) will become more productive with increased average levels of health and health outcomes. Adam Smith points to this idea in The Wealth of Nations, the foundational text in support of capitalism and market economies. He describes how “no society can surely be flourishing and happy, of which the far greater part of the members are poor and miserable.”8 Even in a true capitalist market economy (which the United States is not), Smith argues that those rich in money and/or other goods will only live in a flourishing society by ensuring a respectable minimum living threshold for its members. In this case, the reward of a “flourishing” society results from the positive externalities associated with more efficient, healthier farmers who create more food for everyone. Uplifting rural farming communities’ healthcare resources and overcoming existing SDoH from this economic perspective is not an emotion-based decision but rather a net-positive sum game and an economically sensible choice. 

Yet, this economic argument does not feel satisfying, even to an economist like myself. Instead of uplifting communities for their intrinsic value, this action derives its motivation from how it benefits me and my community. Rather, it may be beneficial to consider shifting the argument away from the expected net societal value of healthcare expansion and towards viewing farmers as intrinsically valuable and deserving of better health outcomes. For this view, we turn to Immanuel Kant, who describes how we must:

“Act in such a way that you treat humanity, whether in your own person or in the person of any other, never merely as a means to an end, but always at the same time as an end.”

Immanuel Kant, The Metaphysics of Morals9

Rethinking Rural Healthcare

Therefore, more than a means to efficient food production, one ought to look at the problem of rural healthcare from the lens of helping the communities in and of themselves. This empathetic call for improved rural medical access stems from the societal obligation to help create access to foundational resources to highlight the inherent and divine dignity of every person. The conversation thus returns to the ministry that Jesus called Matthew the tax collector to join. 

Theologically, the societal obligation to assist others for their intrinsic value appears prior to the Gospel of Matthew in the Old Testament, for Proverbs 31: 8-9 declares that we must “Speak up for those who cannot speak for themselves, for the rights of all who are destitute. Speak up and judge fairly; defend the rights of the poor and needy.”10 It is not just for privileged communities to look down upon lower average health outcomes in rural communities. Much the opposite. We as members of a privileged section of society are each called upon in the fight to assist rural areas by creating new opportunities for financially and geographically feasible healthcare access. 

From all of these ideas, we find the final conclusion. It does not matter whether rural communities are viewed as a means to resources for the rest of society or end in themselves, for healthcare is not and has never been a net-zero sum game. Rather, all perspectives understand the positive-sum nature of increased healthcare and better medical outcomes for rural communities. What implementing this solution looks like in real life is not in my wheelhouse, I am just an economist after all. But in this fight, all members of society should and ought to support actions that help rural communities overcome the SDoH that plague the status quo. 

Works Cited

1)  “Bible Gateway Passage: Matthew 9 – New International Version.” Bible Gateway, 

2)  “The Calling of Saint Matthew.” Artble, Artble, 19 July 2017, 

3)  “Rural Health Information Hub.” Social Determinants of Health for Rural People Overview, 

4)  Rosenthal, Elisabeth. “The $2.7 Trillion Medical Bill.” The New York Times, The New York Times, 1 June 2013, 

5) Cyr, Melissa E., et al. “Access to Specialty Healthcare in Urban versus Rural US Populations: A Systematic Literature Review.” BMC Health Services Research, vol. 19, no. 1, 2019, doi:10.1186/s12913-019-4815-5. 

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

7)  Staff, America Counts. “More Work in Education and Health Care.”, 15 Sept. 2022, 

8)  Smith, Adam. The Wealth of Nations. Seven Treasures Publications, 2009. 

9)  Kant, Immanuel. The Metaphysics of Morals. Bobbs-Merrill Education, 1965. 

10) “Bible Gateway Passage: Proverbs 31:8-9 – New International Version.” Bible Gateway, 

Capitalism’s Overreach In Medicine

“As economic inequality in the USA has deepened, so too has inequality in health”

(Dickman 1431)

As someone who is a firm believer in capitalism, it naturally makes sense to me that the different sectors of our economy, like healthcare, should be able to function properly under a capitalistic model. However, when reflecting on our course, it is clear that our capitalist market has led to some gaps, particularly in regards to medical care. We can see these gaps in the inequalities across different races, wealth groups, and genders and while I still believe that capitalism is the best market structure, I think it struggles to work the way that it should in the case of medicine. Our society has likely overextended capitalism, and we may need to seriously reconsider if it is the best structure for medicine.

Photo taken from Unsplash

Capitalism in the Current Structure of Healthcare

Currently, the U.S. healthcare system is composed of a mixture of public and private insurers and health care providers, some of which operate for-profit and some nonprofit (Tikkanen). The U.S healthcare system also includes government sponsored programs, like Medicare and Medicaid, that help groups receive medical care. As of 2018, 92 percent of the U.S. population was estimated to have insurance coverage, which leaves “27.5 million people or 8.5 percent of the population uninsured” (Tikkanen). Part of this lack of insurance can be attributed to the rise in healthcare expenses as costs in the U.S. grow between 4.2 percent and 5.8 percent annually (Tikkanen). Because of the capitalist structure, medical care in the U.S. functions almost like a monopoly, instead of perfect competition, where costs can continually rise unopposed as medical providers and insurance companies control the market. 

Negative Effects of Capitalism

As mentioned, the evidence as to why a capitalist market does not work well in regards to medicine is seen when looking at the disparities across racial groups, wealth, and gender. Based on our current model, many people need to work to gain insurance and afford medical care. However, this pressures people to continue working even when they are sick. During the COVID-19 pandemic, certain essential workers were deemed so necessary to our economic function, that they could not stop working. In most of these instances, these essential workers were racial minorities. Our extreme focus on production and economic growth has led to “Latinx food and agriculture workers [experiencing] a nearly 60% increase in deaths compared to prior years” (Maxmen). Because we want to continuously grow, we have let the medical needs of workers shift to the background, which has disproportionately affected people of different races. Thus, the capitalist model has led to a large gap in medical care for certain groups.

Photo taken from Unsplash

The negative side effects of capitalism in healthcare can again be seen in wealth disparities. The large economic inequality in the U.S. has now bled into health disparities as wealthier Americans have a life expectancy that is now ten to fifteen years longer than poor Americans (Dickman 1431). Geography has played a large role in this as many health care providers work in cities or larger suburbs (Dickman 1434). This follows basic supply and demand functionality in capitalism. The increased demand for healthcare in more densely populated areas, coupled with the higher likelihood of patients being able to afford care or obtain their own private insurance, has led to the greater supply of doctors in these areas. Yet, there is still a large population of people who need medical care in more rural areas, which demonstrates that a capitalist market may not be the most efficient when it comes to healthcare. 

Capitalism in medicine has even extended into the creation of products and marketing campaigns to deal with natural body processes, especially for women. This is evident in the creation of hormone treatments and medications to help women during menopause. Many feminists view this as “a superfluous product designed to keep women sexually available and conventionally attractive” (Dominus). Because we have allowed a capitalist structure to take over medicine and medical treatments, large industries have developed with products claiming to solve all sorts of problems (Dominus). While some of the extension of capitalism has created medications that are truly helpful, like the F.D.A.-approved hormone therapy for women, it has also led to greater inequalities between genders. There are significantly larger pressures on women to maintain physical appearance and be healthy, and yet many female issues are still not well understood. Despite this, the market of medicine has created products and industries to “alleviate” these differences.

Concluding Thoughts

Clearly, by allowing a capitalist market structure to control the medical field, we have allowed gaps in care and inequalities to fester. When reflecting on these issues, it certainly brings a lot to mind for me. Prior to this course, I would firmly stand behind a capitalist structure as the best way for the healthcare system to function. However, now, I am not sure that is true. Nevertheless, changing the current operations of the system would likely take a major overhaul – possibly exacerbating the issues mentioned above. While it is likely best to move towards more universal medical care, it will be extremely difficult in our profit and opportunity seeking society. Even if we cannot make any direct changes to the market structure of medicine right now, at least drawing attention to the issues that the capitalist structure has created will help begin to possibly resolve them. 

Works Cited

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.

Dominus, Susan. “Women Have Been Misled about Menopause.” The New York Times, The New York Times, 1 Feb. 2023, 

Maxmen, Amy. “Inequality’s Deadly Toll.” Nature News, Nature Publishing Group, 28 Apr. 2021, 

Tikkanen, Roosa, et al. “United States.” International Health Care System Profiles: United States, The Commonwealth Fund, 5 June 2020, 

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.


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, 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, Accessed 19 Feb. 2023.

“What Is Breast Cancer Screening?” Centers for Disease Control and Prevention, Centers for Disease Control and Prevention, 26 Sept. 2022, 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.  


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. Accessed 20 February 23.

“Health Coverage and Care of Immigrants.” KFF, 20 December 2022, Accessed 18 February 23. 

Maxmen, Amy. “Inequality’s deadly toll.” Nature (2021). Accessed 18 February 23. 

“Social Determinants of Health.” Social Determinants of Health – Healthy People 2030 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. 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.


1 Robert H. Shmerling, MD. “Is Our Healthcare System Broken?” Harvard Health, 13 July 2021, 

 2 Zola, Irving Kenneth. “Medicine as an Institution of Social Control.” The Sociological Review, vol. 20, no. 4, 1972, pp. 487–504.,

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.,

5 Gawande, Atul. “The Heroism of Incremental Care.” The New Yorker, 16 Jan. 2017,

Lack of Language

Communication Challenges to Health in Rural America

My hometown of Harrisonburg, Virginia is a hub for the world’s nationalities and ethnicities in the heart of the rural Shenandoah Valley. In our public school system, 53 birth countries and 57 foreign languages are represented (Harrisonburg City Public Schools, 2017). From my experiences with first- and second-generation immigrants, I’ve learned how vital language is in everyday life. Fundamental activities like running errands and ordering at restaurants require communication that I would not give a second thought. However, for those that lack English fluency, these can create difficult and anxiety-provoking situations. Furthermore, when the non-native English speaker becomes a patient, these language barriers become especially challenging.

Keezletown Road runs just behind my neighborhood, connecting hundreds of acres of farmland in Harrisonburg and its surrounding area. (Photo by Holly Bill)

There are a multitude of factors that impede effective communication regarding healthcare. Individuals that are not fluent in English may have difficulty grasping the complicated syntax used to convey serious medical information, even if they are knowledgeable about health-related concepts. These subsequent language barriers are heightened in rural areas, causing their extension into spheres outside of direct physician-patient interactions. 

Language in the Rural

According to the U.S. Department of Health, limited English proficiency can prevent access to health care services, clearly indicating language as a social determinant of health (Healthy People 2030, n.d.). This is generally tied to health literacy, defined as “the degree to which patients understand basic health information,” which has lower rates in rural areas (Rural Health Information Hub, 2022). However, after reflecting upon this definition and its use of the word “understand,” I feel as though there is a distinction between language and health literacy as social determinants of health. An immigrant patient may have a strong perception of their health based on information they received in their first language. However, the patient may struggle with language barriers if they reside in an area that lacks access to interpreters, like in rural communities (Rural Health Information Hub, 2022). This can result in poor health outcomes, such as improper medication use or health screening misunderstandings. While closely related to health literacy, language differences result in more of a fundamental miscommunication barrier, especially in rural areas where there are limited resources to overcome the challenges they create. 

Silver Lake Mill, a farm located just west of Harrisonburg in the rural town of Dayton, VA. (Photo by Holly Bill)

Taking the case of Harrisonburg in particular, those in my town fall victim to the underlying language divide, despite the area’s diversity. There is a shortage of interpreters and multilingual physicians, and offering translated medical documents is not common practice (Kraska, 2016, 18). This reminded me of the Nature article’s meat-packing vignette in the rural San Joaquin Valley. Despite the poultry plant’s employees speaking strictly Spanish, Hmong, and Punjabi, all of the signs in the building about coronavirus safety and statistics were in English (Maxmen, 2021, 680). The lack of accessible COVID-19 information for the workers posed a serious health hazard. Even in rural communities where those fluent in English are the minority, language barriers to health persist. 

“Hard copies of consent forms, aftercare instructions, any of those
things, all of the brochures…I just don’t think they’re out there in all the possible languages that they can just pick up.”

Danielle, a Harrisonburg-based Spanish interpreter in reference to the lack of written medical information in more than one language (Kraska, 2016, 19-20).

A Barrier Beyond Healthcare

Communication differences can also play a role in scenarios tangentially related to healthcare access, such as those within the legal system. Rural areas have been hit particularly hard by the drug epidemic and have high rates of substance use disorders (Dickman et al., 2017, 1434). My mother is a psychiatrist at a state hospital, and she deals with the repercussions of  these crises not only on her ward but also in court. She speaks about the hardships faced by non-native English speakers because they have difficulty understanding the jargon of judicial proceedings. Without confidence in their English proficiency, these individuals are often frightened to stand trial. 

Medical-legal partnerships are valuable for residents of rural communities concerning issues like family law and insurance benefits, and these improve health outcomes (Rural Health Information Hub, 2022). However, if a patient doesn’t speak fluent English and lacks an interpreter, they cannot advocate for themselves in the midst of legal scenarios. 

We discussed the importance of addressing the underlying social determinants of health in confronting rural healthcare inequalities, and legal assistance is an example that does so beneficially. Yet, my mother’s experiences with many immigrants show that the efficacy of these solutions is limited. Individuals that do not speak the same language as the professionals offering assistance cannot reap the full benefits of these interventions. 

Modes of Action

After relating what we’ve learned in class regarding social determinants of health to the experiences of immigrants in my hometown, I have found that language significantly influences health outcomes. The barriers that arise from language differences are especially prevalent in rural areas and are so foundational to everyday life that they expand into realms outside of health. Thus, efforts to address these barriers are essential for tackling health disparities. These could include increased educational initiatives for both English learners (to increase their understanding of medical language) and providers (to train them to work with patients that are not fluent English speakers). Additionally, perhaps investing in translation technology and hiring more multilingual medical staff and interpreters would prove beneficial. 

“You shall love every foreigner as yourself.”

A Bible verse displayed outside of a refugee church in San Joaquin Valley, CA (Maxmen, 2021, 677).

Harrisonburg calls itself “the Friendly City” because of our supportive, welcoming nature to people from across the world. I am proud to be from such a diverse town, but I know work is necessary to ensure that every resident, especially those suffering from language barriers, can live a healthy life.  


Dickman, S. L., Himmelstein, D. U., & Woolhandler, S. (2017, April 8). Inequality and the health-care system in the USA. Lancet, 389(10077), 1431-1441.

Harrisonburg City Public Schools. (2017, September 10). Enrollment of English Learners – September 29, 2017. Harrisonburg City Public Schools Enrollment Statistics. Retrieved February 30, 2023, from

Healthy People 2030. (n.d.). Social Determinants of Health. Office of Disease Prevention and Health Promotion. Retrieved February 15, 2023, from

Kraska, S. J. (2016, May). Examination of the effects of language and cultural barriers on Spanish-speaking patients in health settings as observed by medical Spanish interpreters. Senior Honors Projects, 185, 1-44.

Maxmen, A. (2021, April 29). Inequality’s Deadly Toll. Nature, 592, 674-680.

Public School Review. (2023). Harrisonburg High School (2023 Ranking) – Harrisonburg, VA. Public School Review. Retrieved February 15, 2023, from

Rural Health Information Hub. (2022, June 6). Social Determinants of Health for Rural People Overview. Rural Health Information Hub. Retrieved February 16, 2023, from

Brick by Brick

America is the land of the free and home of the brave. It is the land of opportunity where so many have come to try to live their own American dream and make it big. However, this country is in no way perfect and has a handful of glaring flaws, one of the biggest and most significant being the healthcare system. Still, throughout the nation’s history, we have shown the ability to recognize our flaws, address them, and turn out better in the end. The healthcare system is broken, but not beyond repair. The key is finding exactly where and why it is broken and then repairing it piece by piece, brick by brick.

Trials and Failures

America is the world’s largest economy by nominal GDP and spends more on health care than any other country. Despite this fact, the US scores surprisingly poorly on a variety of key health measures, such as life expectancy, preventable hospitable admissions, suicide, maternal mortality, and obesity rate4. In this country, it is mostly pay to win, but many are still paying a lot just to continue to get the short end of the stick. 

Certain efforts are geared towards improving the current system, but many of them do not address any of the root causes of these current issues. In fact, the majority of the investments in the healthcare system simply perpetuate and intensify the system’s flaws. For one, there is an extreme overemphasis on procedures and drugs4. While these options should generally be seen as secondary, tertiary, or last resort alternatives, they make up a sizable chunk of primary treatment decisions. These options can be helpful and beneficial, but they are often burdensome on the body and usually come with a collection of side effects making them less than ideal.  Focusing on drugs and procedures has also led to a high emphasis on technology and specialty care4. Innovation in these fields can be very exciting and life changing for many people, but it also diminishes the attention towards promoting basic health practices such as nutrition, exercise, mental health, and primary care in general. This is extremely problematic as ignoring these components of people’s lives is often what leads to the more serious health issues. 

Building From the Ground Up

Since there are so many problems that can be prevented, addressed, and treated on the primary care level, there needs to be more emphasis on its importance. Due to social media and pop culture, people often get lost in the alure and flare of the operating room, dramatic technological innovation, and breakthroughs in medical research. Shows like Grey’s Anatomy or ER demonstrate the adrenaline, excitement, and miraculous effects of surgery and medical innovation, and these values and perspectives seep into the viewers mind, distorting the image of the real healthcare system in its entirety. Each of these components holds intrinsic value but can overshadow the power and impact of incremental primary care2

“Governments everywhere tend to drastically undervalue incrementalism and overvalue heroism.”

Atul Gawande from the New Yorker2

I have seen this firsthand when my own little sister’s life was saved because of the attention, care, and intuition of her primary care physician, Dr. Nicholas Kyriazi. My older sister, myself, and my younger brother all had the same doctor, so our family had a good, long-standing relationship with him. One day, during a routine check-up, he was listening to my little sister’s heart and noticed the rhythm was slightly off. He notified my mom that he had identified a heart arrythmia and advised that she follow up with a cardiologist to confirm and seek proper treatment. Through a variety of tests and scans, the cardiologist confirmed what Dr. Kyriazi had detected with his stethoscope. The cardiologist found a small hole in my sister’s heart which was the source of the arrythmia. However, since it had been caught so early on, there was plenty of time to address the issue and ensure the best treatment be put in place. At 5 years old, my little sister had successful open-heart surgery to repair the hole in her heart, and she is now a fully healthy and happy 15-year-old having no issues since. The surgeon directly resolved the issue in the end, but Dr. Kyriazi identified the problem and gave our family plenty of time to find the best solution. He is a hero.

Giving Care to Those Who Need It Most

“Until today, I didn’t know what a leaf looked like.”

4 year old child after receiving glasses for the first time at RAM3

My sister needed a hero, and there are plenty more out there who need a hero just as much if not more than she did. A multitude of those in need are suffering from more than just medical issues. One of these groups includes middle-aged, non-Hispanic white people, especially those without a college degree. Throughout the past few decades, this group in particular has experienced a spike in mortality, identified by a Princeton University study1. These so-called “deaths of despair” include “white, working-class people ages 45 to 54 were drinking themselves to death with alcohol, accidentally overdosing on opioids and other drugs, and killing themselves, often by shooting or hanging1.” These source from four main indicators which include feelings of hopelessness, having low self-esteem, feeling unloved, and worrying frequently. Both the deaths and the associated indicators are evidence of the social determinants of health. 

Source: Science News

There have been efforts to address these issues and kickstart some reparations to this broken system. Organizations such as Remote Area Medical have made an incredible impact in these rural communities of Appalachia. They travel and set up large medical clinics in rural areas where they provide free medical, vision, and dental treatment to people who generally do not have financial or geographical access to healthcare3. They provide relatively simple care, but the effects of what they do change the lives of so many underserved individuals. Organizations like RAM and individuals like Dr. Kyriazi represent the small yet powerful solutions to our broken system. Recognize them, celebrate them, and emphasize their power and importance. 


1Bower, Bruce. “’Deaths of Despair’ Are Rising. It’s Time to Define Despair.” Science News, 2 Nov. 2020, 

2Gawande, Atul. “The Heroism of Incremental Care.” The New Yorker, 16 Jan. 2017, 

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

4Robert H. Shmerling, MD. “Is Our Healthcare System Broken?” Harvard Health, 13 July 2021, 

5Tikkanen, Roosa, and Melinda K Abrams. “U.S. Health Care from a Global Perspective, 2019: Higher Spending, Worse Outcomes?” U.S. Health Care from a Global Perspective, 2019 | Commonwealth Fund, 30 Jan. 2020,