The United States has one of the most villainized healthcare systems among developed nations. Insurance costs are out of control, with unmanageable premiums, limited coverage, and high deductibles. A medical emergency at the wrong time can bankrupt even the fiscally responsible.
Rural populations and the elderly, ethnic minorities, and the impoverished have an even tougher uphill climb. Duquesne University cites “the high cost of medical services and medical insurance” as the leading barrier to vulnerable populations accessing care. The financial strain is compounded by lower health literacy and potentially discriminatory practitioners. With the healthcare industry facing a shortage of practitioners in upcoming years, the outlook is bleak for underserved communities and populations.
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The nation’s communities are getting sicker as the wage gap continues to grow. Rates of obesity, heart disease, and STDs are on the rise due to socioeconomic factors limiting appropriate care. When care is received, it can do more harm than good or create more problems for the patient, as evidenced by the raging opioid epidemic in the United States.
Public policy is attempting to address health concerns. The insurance market is undergoing radical changes amid a flurry of opinions. Health officials weigh in on the state of nutrition in our country, and opioids have been declared a public health emergency. However, all the good intent in the world won’t balance out poorly executed policies. It’s impossible to discuss solving public health problems without considering vulnerable and at-risk populations.
The nuances of day-to-day care aren’t apparent to those in a position to design policy or implement sweeping solutions. Practitioners on the front lines of medical care will be responsible for implementing solutions, policy or otherwise, in a way that benefits their communities as much as possible.
Consider the intricacies of three of the biggest public health challenges — opioids, STDs, and obesity. Each has a different cause, affects various demographics, and requires unique solutions that won’t work across the board.
Photo by Pexelson
The Opioid Epidemic
Pain is a difficult beast to manage, and under the scrutiny of pain being undertreated and not taken seriously by medical professionals, the prescription of opioid painkillers began to rise. Throughout the 1990s and 2000s, pain pills were prescribed at an unprecedented rate and promoted as a non-addictive, long-term solution to pain. Physicians used opioids as a treatment for mysterious pain — the source may not be known, but at least they were doing something to help their patients and alleviate the pain.
Throughout the years, the truly addictive nature of opioids came to light as more and more patients struggled with dependence on the drugs. Pharmacy companies were legally challenged for their role in creating misleading advertising and painting the drugs as a no-harm solution to chronic pain.
It’s not enough to stop prescribing opioids — and even that is a flawed solution. While other treatment options are available, opioids still have their place, albeit under strictly monitored circumstances. However, in combating the epidemic as a whole, doctors need to reevaluate how they look at pain. How can preventative care be leveraged to create healthier patients with lower pain levels?
Doctors do not bear the burden alone, though. Insurers need to expand their coverage of alternative treatment options or access drugs with a lower likelihood of addiction. In populations that rely on government-sponsored health plans, preventative care needs to emphasize and options for addiction or substance abuse treatment.
The medical overhaul will help with access to opioids, but there are economic factors at play. Unemployment and lack of insurance are associated with increased levels of addiction, and those who live in rural areas with little access to consistent healthcare also see a spike in addiction levels. Addiction may be responsible for some level of poverty — it becomes difficult to maintain employment or lead a functional life while under the thumb of opioid addiction. Still, access to treatment is curtailed as well.
Eventually, opioid addiction may lead to dependence on heroin — it’s cheaper and easier to get than prescription pills, and it placates the drive for opiates. Graduation to heroin increases an individual’s risk of overdose, though it’s certainly still a problem for those who only take pills.
To combat the death toll from opiates, naloxone is being used as a medical intervention. Pharmaceuticals can help individuals reduce their dependence on opiates, and in dire cases, it can reverse the effects of an overdose. Clinics and treatment centers can help those suffering from addiction by providing a medical intervention using naloxone to manage withdrawal in a controlled environment.
With health insurance less likely to cover addiction services as government-sponsored health plans are reimagined, the light at the end of the tunnel is starting to fade. Treatment needs to be prioritized and funded, prevention of the next generation of addicts needs to be paramount, and the country must re-evaluate prescription monitoring programs. The United States has prescribed itself into a deadly epidemic, and radical change regarding economic policies and medical treatment mindsets seem to be the only way out.
STDs and HIV/AIDs Transmission
Any conversation about sex comes with a little bit of stigma, though it can increase for certain groups. It’s expected that young, college-aged singles will be at the center of any conversation about sexually transmitted diseases, but what often comes as a surprise is the necessary inclusion of the elderly and rural populations, as well as those in impoverished urban areas.
College students and other young adults find themselves at risk for STD contraction due to a high rate of unprotected sex. It is estimated youth under the age of 25 are responsible for nearly half of all new STD diagnoses. Increased use of technology to connect individuals who don’t know each other’s sexual history may account for part of the upward trend in transmission, exacerbated by a lack of knowledge about safe sex practices.
Elderly populations find themselves in a similar situation; in 2015, seniors accounted for 17 percent of the HIV diagnoses in the United States. Other STDs are on the rise among the population, as well. Seniors who are single or widowed, especially those in retirement communities or nursing facilities, find themselves in a unique situation. Without the threat of pregnancy, there is little incentive to practice safe sexual behavior, putting elderly populations at high risk for transmission. Couple that with aging immune systems, and it’s much easier for the elderly to catch an STD than most might think.
Those who are afflicted with an STD face significant stigma when seeking treatment. Commonly, STDs are seen as dirty and get lumped in with “slutty” or undesirable sexual behavior. Historically, and still in some places today, contracting HIV is associated with homosexuality, which may be looked down upon in the culture or community. Sexual deviance and promiscuity are powerful motivators for privacy, and though doctor-patient confidentiality exists to protect people, it’s not always possible to treat the conditions in a vacuum.
Rural communities struggle uniquely with STDs and HIV transmissions. Populations are so small and often tight-knit that even doctor-patient confidentiality can’t protect all patients seeking treatment. Confidentiality is a concern in areas where one practitioner serves multiple regions, and there may only be one or two pharmacy options. In the same vein, when there’s a high ratio of patients to practitioners, finding the time to travel to the clinic or getting an appointment when practitioners are in high demand is incredibly difficult.
For those living in poverty, taking time off of work or swinging the extra money for copays or coinsurance isn’t feasible despite other bills and obligations. And ultimately, for those who are diagnosed with an STD, the costs don’t stop with the testing fee. Many STDs are treated with antibiotics or other medication designed to control symptoms, even if it’s not curable. An HIV/AIDs diagnosis comes with the perpetual burden of antiretroviral drugs that stress budgets, especially for uninsured patients.
STD transmission is often combated with education. However, before education can be fully effective, the stigma around treatment and conversation needs to be removed. A practitioner can’t diagnose and treat an STD for a patient who denies being sexually active or refuses the conversation and testing. Schools are often the last opportunity for education and conversation about safe sex practices. Still, those who drop out of school, don’t continue to college, or live in an area that promotes abstinence-only sex ed, even school health classes, are failures.
Obesity and Nutritional Deficiencies
It’s no secret that the United States has an obesity problem; political cartoons and international humor from around the globe poke fun at portly Americans. It’s no laughing matter, though. Obesity, especially through childhood and adolescence, can contribute to lifelong medical conditions like type II diabetes or heart disease development.
For years, the debate has raged about the true cause of America’s propensity for carrying extra weight. There are many factors, including sedentary lifestyles and genetic predisposition, but one piece of the puzzle can’t be ignored: food. It is cheaper and more convenient to eat processed, prepackaged meal options than opt for nutritious items requiring time and energy to prepare.
In the rat race, an everybody-for-themselves culture built by the American dream, stress and business is widespread. Beyond the effect of stress on metabolism and weight gain, the constant need to work to get ahead leaves little time to prepare food or maintain healthy habits. When people spend more time working — getting up earlier to get ahead or burning the midnight oil to snag a promotion — sleep often suffers, which further complicates dietary insufficiencies and reduces performance and irritability.
For individuals who have to work multiple jobs to make ends meet, the process is exacerbated. Those who live below the poverty line and rely on SNAP or other supplemental programs have limited choices regarding food options, and getting the most caloric bang for your buck means sacrificing nutritional quality in many cases.
Others never learned to cook or never developed a taste for fruit and vegetables; it’s easy to prefer sugary, salty, or fatty snacks that stimulate the brain’s reward centers over fruits and grains that require a more savory palate. The United States’ food is designed to be marketable and rewarding rather than setting up the population for nutritional success and a healthy lifestyle.
Some urban areas have begun to introduce methods to increase accessibility to healthy food choices. In Seattle, the Fresh Bucks Rx program offers low-income patients “prescriptions” for healthy food that they can redeem at local grocery stores. The food does not add to the family’s grocery bill and allows the children to make positive choices, fostering a sense of agency and personal responsibility.
Unfortunately, the same can’t be said for rural areas that already have a limited food supply. Impoverished families often have to purchase shelf-stable ingredients, which means passing up on fresh produce favoring canned or frozen fruits and vegetables. From a provider’s perspective, telling these patients to make healthier meal choices doesn’t do any good if the food isn’t an economically feasible choice.
Preventing Future Crises
There will, unfortunately, never be a perfect world where public health is a static, successful industry. As the world changes and society evolves, epidemics will come and go. Each one will create a new set of problems to answer, and the solutions to the country’s current issues may beget even more problems than they solve.
As opioids, STDs, and obesity are evaluated, there are two inescapable contributing factors: access and stigma. Individuals without reasonable access to education, medical care, and other tools for a healthy life are more likely to suffer from one or more diseases. Quality of life decreases, and economic or regional stresses prevent effective treatment solutions. For those who seek treatment or who find themselves suffering from a traditionally shamed affliction, asking for help can be as big a hurdle as completing treatment. Health must become an open conversation with fewer points of stigma and less unmerited blame.
In addressing both access and stigma, the policy will be required. Public officials will need to contribute funding and aid programs and open the conversation to help shift the national climate. However, patients cannot be treated by the House and the Senate alone, and medical practitioners offer a unique, hands-on perspective on the effectiveness of care. Listening to our doctors and nurses and partnering with medical professionals will be paramount in overcoming current epidemics and avoiding those yet to come.
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