While in residency, I took care of a toddler who was hospitalized following an anaphylactic reaction. During a diaper change at home the child suddenly developed lip swelling and severe difficulty breathing for no apparent reason. The child was urgently brought to the hospital by ambulance and initially treated in the emergency room. By the time I met her on the inpatient floor her breathing and swelling had significantly improved. The first thing I noticed, however, was the child’s bumpy and irritated red skin which was covered with a thick layer of ointment. While I examined her she would claw and scratch at her skin with little relief. She looked miserable. Her mother had been suspecting food allergies and described a frustrating process of selective food avoidance and various skin treatments with little to no improvement.
Keeping in mind that eczema and allergic reactions are in the same family of disease, it was not surprising that this child was more prone to anaphylaxis. While her symptoms improved and she was sent home, the trigger for the severe reaction remained a mystery.
About 6 months later I ran into the child’s mother in clinic. The mystery behind the life threatening illness made this child memorable so I asked how her daughter was doing. Mom was happy to share that her daughter had not had any further allergic reactions and that the skin problems had nearly resolved.
So how did they cure her disease?
They moved.
After countless visits to specialists and various drugs that were not addressing the primary cause of her problems, one day the parents opened an infrequently used closet in their home. Inside they found the closet saturated with mold. Shortly after moving to a new mold-free home the child’s eczema immediately began to improve.
Its estimated that 70% of the factors that influence health are environmental and behavioral. It seems fairly obvious that food, access to transportation, and housing can affect health. But the health care system, and physicians specifically, are ill-prepared to address these social determinants of disease.
A survey of 1000 American physicians conducted for the Robert Wood Johnson Foundation released recently showed that doctors know how important social factors are to health but feel unprepared to address them. 85% of surveyed physicians said that unmet social needs directly led to worse health. The same percentage of physicians said that a patient’s social needs are “as important to address” as medical problems. Of concern, 80% were not confident in their capacity to address their patients’ social needs even though it would improve the patient’s health.
Interestingly, if prescriptions could be written to treat social needs the way they could be used to treat illnesses, social prescriptions would represent one of every seven prescriptions the surveyed physicians would write. The top social needs physicians said they would write prescriptions for included:
Fitness programs
Nutritional food
Transportation Assistance
Housing Assistance
Employment Assistance
So what is to be done?
Are health care providers really addressing the root causes of health problems? How much incorrect treatment or unnecessary diagnostic testing occurs because these factors are not considered? Perhaps my patient could have been spared the the anaphylactic reaction had mold been investigated as a possible cause of her eczema.
How can health care professionals better address the circumstances in which we live, work, and play?
How can we structure the health care system to reimburse health care providers for addressing the behavioral and social factors that cause 80% of disease?
Stay tuned.
Ricky Y. Choi, MD, MPH 