Knight of the Round Wing

I kneel before you
Gowned and gloved,

Yet you bless me still

With a gallant kiss

To the hand you hold

With more gentle care

Than it has to give.

Barrier precautions

Preclude contact,

Yet you touch me still,

Lips through latex,

Warmth into skin and veins

Flowing upwards to

Somber, smiling cheeks.

I knelt before you,

Humble and distraught,

No more cures to offer,

No way to raise the sun

On your tomorrow,

Yet you blessed me still,

And still you remain.

Health is not about Medicine

"Water-borne diseases are not caused by lack of antibiotics but by dirty water, 
and by the political, social, and economic forces that fail to make clean 
water available to all; heart disease is caused not by a lack of coronary care 
units but by the lives people lead, which are shaped by the environments 
in which they live; obesity is not caused by moral failure on the part of 
individuals but by the excess availability of high-fat and high-sugar foods."

- WHO’s Commission on Social Determinants of Health, 2008

Medicine may be about health and illness, but health is not about medicine. It is about the lives people lead, and the world in which that happens. Medicine can save lives, sometimes miraculously. It can improve quality of life, sometimes significantly. But we know now, or perhaps have re-learned, that health is determined by all sorts of factors far more than medicine or health care. (Not to mention how all those factors affect access to care.)

This 2012 infographic from the Bipartisan Policy Center's Lots to Lose illustrates the gap between what matters and what we spend on. What it does not show is the extent to which healthy behaviors and environment are themselves dependent on social, economic, and political factors. 

 It is hard to eat healthily when the closest supermarket is over a mile away and you have no car. It is hard to get an education when your family needs you at home to work or take care of younger children. It is hard to enjoy activity and sleep when you might be arrested for loitering and being homeless. It is hard to find a home when your prior incarceration prevents you from finding a job.

Is it any surprise, then, that the United States performs so poorly compared to other high-income countries? We are among the most unequal nations in the world, and our social institutions (including health care systems) are far from equitable. Our best hospitals can work magic to save patients from heart attacks and strokes, but our impact on chronic disease is tepid at best. Our impact on what causes chronic disease is not tepid, but instead profoundly detrimental. Public health matters, so public policy matters. As is often said in the quality improvement world, "every system is perfectly designed to get the results it gets."

Further reading:

1. "Tools for Putting Social Determinants of Health into Action." CDC, 2018.
2. "It's an Unequal World. It Doesn't Have to Be." New York Times, 2017.
3. "Poor Health: When Poverty Becomes Disease." UCSF News Center, 2016.
4. "Criminal Justice, Homelessness, and Health." NHCHC, 2012.