Twenty years ago, I left clinical practice for public health. I was tired of fighting against the outsized role that inadequate housing and a lack of access to healthy food, transportation, and educational opportunities had in my exam room. I wanted to make a difference upstream through policy and programs that affected whole communities so that the river of inequities could be quelled.
This journey is not unique to me and, despite the efforts of many, seemingly little has changed over the past two decades. One contributing factor is a persistent tendency to treat non-medical problems as medical issues. This so-called “medicalization” creates relatively small and temporary fixes that do not solve the larger problem and may cause long-term, negative consequences. As an example, clinicians across the country are still writing “doctor’s notes” that use their patients’ medical conditions as justification for moving them to the front of the line for adequate public housing rather than focusing on healthy housing for all.
What has changed dramatically is our current-day context. The pandemic unleashed exploding demands in health needs, especially behavioral health, that have been exacerbated by social media-driven disinformation, climate change, and whatever the other co-occurring crises of the day might be. This is putting unprecedented pressure on the “system” at the very time we are facing provider shortages and a growing trend of commercialization in medicine. Rising income inequality is further compounding these dynamics and magnifying the impact of the underlying drivers of inequities on everyday Americans, but especially those in communities of color. As a result, we are seeing poorer health outcomes and, for the first time, a drop in life expectancy not seen in generations.
The confluence of these tensions provides an urgent opportunity to push against the status quo and truly take up the task of creating a more just and equitable health ecosystem.
While New York State, like several other states, has taken a positive step in this direction by requesting a waiver from the federal government that will allow the State's Medicaid program to cover certain health-related social needs, we must continue to push for structural remedies for underlying inequities. If we allow ourselves to think that the full task is screening for social needs, such as food insecurity in children—and addressing those needs through medical referrals to food pantries—we detract from the mission of addressing inequitable systems that perpetuate food injustice. We can’t prescribe our way out of a society with misplaced priorities by treating the symptoms and not the disease.
I suspect many health care professionals have been complicit in needlessly medicalizing conditions because the “power of the white coat” was seemingly the only way to get the necessary resources to alleviate people’s suffering. Perversely, re-defining or remediating social ills through a medical lens may have the unintended consequence of laying the blame on the individual rather than on systems built to perpetuate inequities.
Through the waiver and the social care networks, we have a critical chance to learn from individual patients about social and economic barriers to optimal health. If done right, we can use this knowledge to inform and shape policies and funding priorities across multiple domains that influence health outcomes.
There are other ways to further de-medicalize parts of the health ecosystem. Increasing the use of community health and peer support workers not only incorporates their input into individual treatment plans but gives us the opportunity to aggregate information that can be shared across systems to better inform, influence, and hold government accountable in addressing underlying drivers of morbidity and mortality inequality. Medicalizing without creating feedback loops to address these drivers will not help us gain traction in getting better health outcomes faster and realizing health equity goals.
To quote author and educator bell hooks: “To be truly visionary, we have to root our imagination in our concrete reality while simultaneously imagining possibilities beyond that reality.”
We cannot allow ourselves to fall victim to pandemic fatigue and the complacency that comes with it. Rather, we should make the most of an invaluable opportunity to do away with the status quo and be intentional in aligning preventive, protective, and therapeutic services that weave a more rational system of care that supports individuals, their families, and their communities.
This commentary will soon appear in the 2023 fall issue of Blueprint.