Chapter 5 – Poverty, Class, and Privilege
Laurie Belknap DO and Camilla Curren MD
Origins of Poverty and Social Class Differences
Persons at lower income levels have consistently demonstrated less social mobility overtime than have more wealthy Americans. So generally speaking, if you started out life at the bottom of the economic ladder, you have a decreased likelihood of moving up compared with those starting at higher levels.1 What is the influence on health and well-being of starting out at a lower socioeconomic status? The role of poverty and its social impact on childhood development is well established, as is the fact that poverty has a significant role in creating lifelong limitations and in continued promotion of poverty for future generations.2 The stunting of physical growth and cognitive development can make it less likely that a child will attend school, and can cause problems with social and emotional development that contribute to poor performance in school.2 Childhood poverty and the resulting consequences cause high levels of social and emotional stress.3 Social conditions such as foster care and the involvement of child protection agencies can lead to emotional dysfunction and predispose affected children to the development of mental illness later in life.3 Children from underprivileged backgrounds or from backgrounds of social and economic deprivation are more likely to perform poorly in school, leading to a lack of education that causes profound and lifelong impact.3
Socioeconomic status has been identified as a prominent stratification factor for determinants of health
Economically advantaged people have better health outcomes than the less advantaged.4 One study demonstrated that sociodemographic factors created additional access barriers for Hispanic patients with diabetes resulting in lower utilization of healthcare and higher disease management expenditures. The same study found that Hispanic patients with diabetes were typically younger, but had higher poverty rates, less education, and lower physical activity levels when compared to non-Hispanics in the general U.S. population.5 Another study demonstrated that a person’s neighborhood of residence can predict cardiovascular mortality.6 Low socioeconomic status is known to be linked to increased cardiovascular risk factors.7 The results of another empirical analysis showed that those with higher perceived socioeconomic standing and greater resources have better health than those who have lower standing and fewer resources. In this study, self-reported health, dental health, and happiness were strongly associated with subjective assessments of social position.8
The prioritization of daily necessities for disadvantaged populations can become a way of life, which can sometimes mean that health needs are postponed or not addressed at all when resources are scarce. Healthcare and medical insurance can come long after meeting basic needs for many people who experience financial constraints or poverty.9 For example, Pamela Taylor, a resident clinic patient with several chronic medical problems, regularly uses a food pantry and must often decide between going to the grocery or to physician’s appointments as she can only afford 1/8 tank of gasoline per benefit check. Even given this frugality, she has difficulty making house payments and may soon end up homeless.
Poverty and Bias Against Patients
Dr. James Mann, an Internal Medicine Resident at The Ohio State University Wexner Medical Center, recalls several instances while he was working in the Emergency Department as an aid (before he entered medical school), where physicians or other medical staff made incorrect assumptions about patients because the patient was homeless or underprivileged.
“I don’t feel like there had been a lot of education about poverty in a medical school, or probably most medical schools, at this point, so most people wouldn’t really know how to deal with those types of people unless they had some type of experience with that.”
Dr. Mann, whose family comes from an economically disadvantaged background, noted that often providers had the perception that poverty or homelessness was a choice.
As with many biases, provider perceptions may originate from a remotely related factual cause. The role of health and perceived control at the individual level were examined in one study. The authors hypothesized that a lack of autonomy and lack of optimism combined with a perception of having little control over life would result in a low level of trust in social institutions and negatively affect the health of the population. The findings of the study were consistent with this model and showed an association between low control and self-rated poor health.10,11 Suggestions for causes of this finding included contributory health behaviors and potential neuroendocrine pathways.11
Pamela Taylor notes that patients living in poverty often are not aware of medical options that are available to more wealthy patients and that lower health literacy is a usual contributor to the problem. Lower health literacy is a pervasive problem when poverty interferes with adequate education. She feels she has been made more aware of health care options by being associated with a University residency clinic which has a team care approach including social work support but notes that advocacy for patients seeking reduced-cost or episodic care for problems vs. those with a medical home may be lacking. “There is no booklet on how to be poor and get good care,” she adds.
Structural and Attitudinal Barriers to Health Care for Patients in Poverty
The structural organization of healthcare systems contributes to adverse patient outcomes when the result is a lack of access to resources. One study found that health outcomes were worse for patients who lived in an area with fewer resources when concentrations of deprivation and privilege were used to compare health outcomes. In this study, a numeric assessment called the Index of Concentration at the Extremes was used as an indicator of health equity and found to be more indicative of population health status than measuring poverty levels.12
Dana Vallangeon, M.D., is a family medicine physician and a graduate of the Ohio State University College of Medicine. She is the is founder and C.E.O. of the Lower Lights Christian Medical Center which provides health care to approximately 14,000 underserved patients in the Franklinton neighborhood of Columbus.
“In the last 15 years there has been more diversity in the neighborhood, but still with a lot of underserved. Only 48% of the children in Franklinton complete high school,” says Vallangeon. She notes, “Franklinton has many strengths and assets, but some of the areas it has struggled with over the years has been healthcare and food because it is a food desert and we have a lack of food opportunities for individuals.”
Dr. Vallangeon notes that, in addition to a lack of physical health care resources, physician behaviors that may arise from bias can form barriers to healthcare for patients with limited resources.
Dr. Mann agrees. “It is our job as physicians and healthcare providers to make judgments in general, and that is a good thing in many cases in order to treat patients. However, making judgments based on your perceptions of what’s normal for you and what’s different with the patient, or if you make judgments because you don’t really understand the culture, then you aren’t really treating the patient effectively.”
The physician-patient relationship can become challenged by the lack of understanding of the patient circumstances, or by challenges with the patient’s compliance with treatment. Noncompliance can result from a multitude of problems, including inadequate resources, or a lack of education to enable understanding, says Dr. Mann. Provider assumptions can also contribute to a patient’s lack of compliance with care. “Sometimes after discharge from the hospital or clinic, you are making assumptions that the patient has money to pay for prescriptions, or has a car,” says Dr. Mann. “Anytime you are making assumptions it can be bad for healthcare.”
Challenges with patient compliance can also stem from misperceptions about privilege and discrimination, as suggested by a recent study that found that patient-perceived discrimination in health care tends to promote the underutilization of health services, including preventive screenings, medical testing, and acute treatment. This study suggested that patients who perceive socioeconomic status discrimination by providers in the health care system may have lower levels of compliance, and report lower satisfaction with care or with patient-physician communication.4 Patient perspectives of the physician/patient relationship were also thought to contribute to problems with compliance or treatment adherence.4
Bias in Healthcare Provider Relationships
Dr. Mann, who describes himself as coming from a background of poverty, notes that he has never met with overt discrimination from other healthcare providers during his training. However, he believes that poverty restricts many potential physicians’ horizons. People living in poverty may not know physicians or of how to become a physician, and may not even consider this as a career option due to a lack of mentoring. Lack of promotion of medicine as a career option to a diverse population, in fact, has been linked to the fact that under 2% of medical students in the UK are from poorer backgrounds.13 Furthermore, costs of medical school and inability to get student loans with poor credit, as well as difficulty navigating the maze of financial hurdles entailed in completing an MD or DO degree, prove barriers to some less wealthy applicants, according to Mann. And, once the student has been accepted to medical school, he adds, career choices and money management prove problematic to many whose families are not able to provide guidance in these areas.
Strategies to Reduce Bias in the Setting of Poverty
The need for training and education of health care providers to recognize and reduce attitudinal bias is clear. The linkage between cultural competency and reducing health care disparities has been demonstrated by multiple sources, including the Institute of Medicine Report of Unequal Treatment from 2002.14
Several methods of reducing attitudinal bias and improving both communication and relational skills in medical care providers are suggested. One study explored the use of simulation and role-playing in poverty based scenarios for new medical interns interacting with community volunteers posing as family members. Post experience debriefing and discussion were used to solidify learning.15 The post experience debriefing promoted the use of reflection and dialogue about the challenges faced by low-income families. Another article outlined an interactive educational module for medical students and residents to enhance communication skills, self-awareness and reflection. This served to further understanding and knowledge of poverty and the importance of responsiveness to people living in poverty.18 The module also promoted self-reflection and recognition of personal biases and limitations.16 Another study evaluated the unconscious biases of health care providers in a large metropolitan health system by providing training to further understanding of privilege and to promote cultural competency. The study suggested that cultural humility may be useful in reducing health care inequities as providers integrate new skills into their daily work.17
And, finally, according to both Taylor and Mann, diversification of the physician and medical provider applicant pools to ensure providers from a range of economic and social backgrounds seems a logical step toward resolving the problem of bias in medicine.