Swept Into the River
A medical student learns about SNAP and social medicine.
In our first year at Harvard Medical School, my classmates and I take a required course: “Introduction to Social Medicine and Global Health” (we call it “Social Med”). On the first day, our professor told us a classic story that helps illustrate an important difference between conventional medicine and social medicine. Two doctors are walking along a river when they spot a man drowning. Without hesitation they jump in and save the man’s life. Some time later they see a second man drowning. They jump in and save this man as well. Then they see a third man drowning. One doctor swims frantically to save the man, but the second doctor takes off running in the other direction. “Why are you running away?” the first yells. The second responds, “To find out why people keep falling in the river.”
I fear that America’s most vulnerable people are being pushed into the river. Recently, Congress cut $19 billion from the Supplemental Nutrition Assistance Program (SNAP), otherwise known as food stamps. As a result, one out of every seven Americans—about 50 million people—will have to make do with less food. Before taking Social Med, I would have cared that more people were going hungry, but I would not have recognized that a SNAP cut detrimentally affects the health of already marginalized people in our society.
Learning about SNAP or poverty or poor housing felt like a strange change of pace from what I expected in medical school. Instead of studying fundamental sciences like anatomy or biochemistry and learning about the physical basis of disease, in Social Med we learned to question why specific groups of people tend to get sicker than others in the first place, and then face worse health outcomes because of their illness.
I was surprised by the broad perspective required to see why, even today in the United States, the poorer someone is, the more likely he or she is to have bad health. This is no coincidence—but the causal factors shouldering the burden of disease onto the poor are complex, and thus often hidden from common sense. In class, we were taught to recognize social determinants of health—e.g. education level, housing, employment, economic status—and then we debated their impact on individual and public health and how best to respond. On the same day, my classmates and I would spend the morning in an anatomy lab learning about the human structures that sustain life, and in the afternoon we would grapple with the social structures that mitigate or exacerbate disease and death. I learned that knowledge of the pathophysiology of malnourishment by itself is not enough to prevent its effects.
Perhaps the most frustrating part of learning about the many short-sighted decisions akin to the SNAP cuts was the feeling of not being able to do anything. In other classes we could always stay up later to learn more about drugs or diagnostic tools to fight off illness. But in Social Med we vented about how disappointing it was to learn that diabetes is exacerbated in adults who lack a secure source of food, yet nothing in the physician’s conventional, well-worn toolkit would prevent SNAP funding cuts from affecting our poor diabetic patients. And nutrition is not the only social determinant of health that doctors need to be attentive to. Other examples—like jobless benefits or early childhood education—likely impact the prognoses of patients as well. Given the subtle ways these forces impact individual and public health and widen health disparities, perhaps it is not surprising that they go mostly unmentioned during political battles. Yet ignoring them does not stop the negative health consequences of marginalization from silently compounding in ways that doctors cannot combat with prescriptions and surgeries alone.
Physicians cannot train solely to jump into the river to save people; they need to try to prevent people from falling in. Public policy needs more focus on public health in order to prevent calamities like the SNAP cuts, which decreased access to food for one out of every five children. Calling and writing members of Congress is a good start. But to ensure that domestic policy is drafted such that our nation’s health trumps ideology and partisanship, it’s imperative that physicians take a more active role in state and national politics. In 1848, German physician Rudolf Virchow said, “If medicine is to fulfill her greatest task, then she must enter the political and social life. Do we not always find the diseases of the populace trace to defects in society?” Either by stepping up lobbying efforts or running for office themselves, physicians need to become more effective at keeping our most vulnerable patients from drowning.
I still want to train to become a surgeon. Yet despite the genetics, technology, and pharmaceutical advances that will become mainstream during the course of my career, it was eye-opening to learn about the broader set of challenges my colleagues and I will need to address to advance healthcare in the twenty-first century. Like many others, I am entering the field of medicine to help make the world a better place, but healing outside the confines of an office or an operating room now feels just as important a calling as conventional medicine.