We conclude our week-long feature on Vital Conversations: Improving Communication Between Doctors and Patients, with an excerpt from the book in which Dennis Rosen explores how socioeconomic disparities affect communication between doctor and patient:
Even when socioeconomic disparities between physician and patient are not glaringly obvious, they can and often do heavily influence the quality of physician-patient communication during the visit as well as its outcomes. Researchers have found that patients from lower socioeconomic backgrounds tend to participate less in medical decision making, which … results in lower adherence and higher overall health-care costs. These patients are also generally provided with less information and socioemotional support by their physicians. In contrast, patients from higher socioeconomic backgrounds tend to be much more involved in the management of their own care. There are many possible explanations for this, including societal boundaries that limit the scope of communication between people of different social stations and differences in education levels that can impede the ability of physician and patient to find a common language. Whatever the reasons, however, the fact remains that some patients are consistently less engaged by physicians than others, with consequent effects upon their participation in defining the parameters of their care and, ultimately, their adherence with the treatment.
Disparities in socioeconomic status can also have profound effects on how disease is contextualized and understood. In some cases, these can lead to active resistance on the part of patients to public-health disease prevention and treatment efforts. Marilyn Nations of Harvard and Cristina Monte of the Federal University of Ceara Medical School, Brazil, interviewed the indigent residents of two favelas (shantytowns) that were hit hard by the 1993 cholera epidemic. Their aim was to understand more fully why there had been such a high degree of resistance by the favelados to governmental efforts to control the outbreak, such as water purification and the use of prophylactic antibiotics. Nations and Monte confirmed that in many instances the favelados’ refusal to cooperate with the campaign was a response to a longstanding sense of marginalization and stigmatization, which was potentiated by the use of certain metaphors in the prevention campaign that seemed to blame them for becoming sick in the first place. By rejecting the government-sponsored prevention efforts, the favelados were also rejecting the stigma of being made responsible for the epidemic.
Nations and Monte also discovered a heavy reliance by many of the favelados upon supernatural protection.This may have been the consequence of their dismissal of the government-led biomedical disease-prevention campaign, fulfilling their need for some form of protection against the cholera. Conversely, it may have been what empowered and emboldened the favelados to reject the government’s efforts in the first place, making them secure to do so knowing that they could turn elsewhere for salvation. Nations and Monte recommended that traditional healers and laypeople be involved early on in the prevention and treatment of future epidemics and that the use of fear-driven messaging and stigmatizing metaphor be consciously avoided so as not to alienate the intended beneficiaries. Charles Briggs of the University of California, Berkeley, also described similar experiences to those of the favelados in Brazil among the indigenous Warao people of Venezuela during an outbreak of cholera in that country at around the same time. This speaks to the connection between how people contextualize conditions of disease within their socioeconomic status and situation, cultural surroundings, and personal experiences. By seeking out the presence of alternative belief systems in parallel to the biomedical among their patients, and by addressing or even embracing them as appropriate, better physician-patient collaboration can be achieved,resulting in better health outcomes.
Paul Farmer, the physician and anthropologist who is also a cofounder of the humanitarian organization Partners in Health,wrote in his book Partner to the Poor that “the failure to contemplate social and economic aspects of epidemics stunts our understanding of them.” This is especially true with campaigns to prevent the spread of infectious disease, in which success is predicated upon patients having access to a basic degree of resources that, although taken for granted by either physician or the larger biomedical establishment, might remain beyond the reach of the specific patient. Because differences in socioeconomic status play an important role in the communication between physician and patient, a patient who lacks the necessary resources to participate in a public-health disease-prevention campaign may be too embarrassed to speak up and bring this to the physician’s attention precisely because of the socioeconomic disparities between them. This in turn can result in the failure of those efforts, leaving the physician and larger medical establishment wondering what went wrong. It is not dissimilar to the shame that prevents patients who have difficulty paying for their medications from discussing this with their physicians.
Robert Gilman, of the Johns Hopkins School of Hygiene, and colleagues did a study in the shantytowns of Peru, in which hand-washing practices were observed and knowledge of hygiene tested, in order to determine whether lapses in the former might be explained by deficiencies in the latter and thereby be a contributing factor to the frequent occurrence of diarrheal disease. Gilman found no connection between observed rates of hand washing and whether or not people understood how to maintain good hand hygiene, and he observed a high number of fecal contamination events in the Peruvian shantytowns despite the fact that those involved knew exactly what it was that they were supposed to be doing.These findings contrasted with studies from Bangladesh that had found hygiene-education campaigns to be highly effective in improving hand washing.The difference in behavior between the two populations was explained by the much higher cost of water for washing in Peru, where it was simply too expensive for people to wash their hands even though they knew they should. Lack of knowledge, it turned out, was not the barrier to good health practices.Instead, it was the high cost of adherence. The same failure has been found to occur when people are instructed to boil drinking water with fuel they cannot afford or when the cost of pots and storage containers necessary to treat and store water is beyond their means.