Doctor's stories

The Social Context and Vulnerabilities that Challenge Health Care in the San Joaquin Valley of California

by Alya Ahmad MD

Call it white privilege or health disparity, it appears to be two sides of the same coin.  We used to consider ethnic or genetic variants as risk factors and prognostic to health conditions. Yet what has become more relevant is the Social Determinants of Health (SDH) as causal to disease prevalence and complexity to health care.

This is was made more evident, in one of the many examples of care I encounter daily as a pediatric hospitalist in the San Joaquin Valley region. A 12-year-old Hispanic boy is admitted with a ruptured appendix and develops a complicated abscess with an extensive hospitalization due to his complication. Why? Did he have the genetic propensity for this adverse outcome? Was it because he was non-compliant with his antibiotic regimen?  No.

Rather it is the social construct and circumstance that hurdles his care. First, he had trouble getting to a hospital or clinic.  Both his parents are migrant workers with erratic long hours. Despite intense pain, he did not want to burden his family and further delays evaluation. In silent desperation, his mother is bounced around from clinic to emergency room and back to their rural based clinic then referred back to the same emergency room more than 20 miles from their home.  By the time he is admitted 2 days later, he is profoundly ill. The surgeon is called in the middle of night for his emergent open surgical appendectomy and drainage. Even after his post-operative care while on broad spectrum intravenous antibiotics, his conditions persists with fevers, chills, and pain. Yet, he continues to deny his symptoms to avoid worrying his mother. His Spanish speaking mother never asserts or doubts why even despite surgery and drainage he was not healing per the usual expectation. Five days post-operative he requires another procedure for complex abscess drainage.  What are the true determinants to his complicated outcome?

In a 2007 study, “We Can Do Better-Improving the Health of the American People, The New England Journal of Medicine, the proportional contributors to premature death are described, and behavioral and social patterns dominate:  

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