Richard* comes into my office with low back pain.
He was 27 when he first tweaked his back while loading some tools into his work truck. It had been sore for a week, but nothing a little ibuprofen couldn’t help. Certainly he was glad that he didn’t have to take time off of work. A couple years later, he slipped on some spilled lubricant. Fortunately, he didn’t crack his head, but this time his back hurt so bad that it was three days before he could get out of bed and get back to work.
Even when he was able to pick up a shift again, there was a dull, throbbing pain that stayed with him for weeks. He thought he had healed, but then a couple months later the pain came back after driving four hours out to a work site. He could hardly get out of the truck because of the pain, but he took a couple more ibuprofen and pushed through. At first it flared once a month, then once a week. He started moving slower, avoiding work that would requiring lifting because that would make the pain worse.
Soon enough he was taking ibuprofen every day just to get by. Then, one morning he noticed his urine was bloody. He went to the emergency room and found out that the ibuprofen had been damaging his kidneys. “Acute interstitial nephritis” is what they wrote on the paperwork, though he had no idea what that meant. All he knew was that he couldn’t take the ibuprofen anymore without risking kidney failure.
Without these medications, he couldn’t get through a day of work. He applied for disability, but the application was denied. The letter explaining the denial was incomprehensible to him, but he was sufficiently demoralized to not apply again. His wife had a job as a teacher, so his unemployment wasn’t an immediate disaster, but he felt worthless sending his kids to school and his wife to work while he sat around the house all day in pain.
And so he comes into my office and says, “Doc, I’m in pain.”
This scenario, all too common in my medical practice, is the focus of “Work, worklessness and the political economy of health inequalities” by Clare Bambra. People of low socioeconomic status have fewer job opportunities available to them, and the jobs that they can get have a higher risk of causing workplace injury. To add insult to injury, because these jobs generally require more physical labor, workplace injury is much more likely to disable these workers and expel them from the labor force. Unemployment and underemployment themselves have severe psychosocial and financial consequences and without strong social safety nets, the bottom quickly falls out.
Medical professionals are increasingly coming to grips with the fact that healthcare-based interventions have at best a marginal impact on our communities’ health and quality of life. In the case of Richard, by the time he arrives to my office, pain relievers and physical therapy have very little power to restore his quality of life.
This is the tortured position of the modern physician. Every day we face the consequences of socioeconomic deprivation as borne by the bodies of our patients, and yet the pharmacological and surgical therapies we have at our disposal offer meager relief.
However, this does not mean we are powerless in the face of suffering, because we have two compelling tools at our disposal. The first is social status in a society obsessed with respectability politics. The second is our witness to the true ugliness of socioeconomic inequality.
To proclaim this witness is a political act, one that many physicians are deeply uncomfortable with. However, to deny the witness and stay silent is also a political act. In truth, as soon as we are witnesses to injustice, we lose the option of true neutrality.
It is for this reason that I believe that for every physician-scientist we need a physician-witness. We need a workforce of doctors who can correctly diagnose both the pathophysiology and pathosociology (just making words up now) of a patient’s ill health and intervene on both.
As Bambra’s work argues, we need to target our socioeconomic interventions not just on individuals but on the socioeconomic systems in which those individuals operate. For Richard, this means not only referring him to a medical-legal partner so that he can get access to the disability payments that he’s entitled to (individual intervention), but also political action for safer working environments and more equitable economic opportunity (systems intervention).
This is not a trivial task, which is why I believe that we need training in the correct diagnosis of pathosociology as part of our medical training. We need to create training opportunities for physician-witnesses that begin during pre-medical education. We need to recruit students with a talent for witness into medicine, recognizing that these talents are more often found in students who themselves were raised in the midst of social and economic inequality. We need to ally ourselves with non-medical folk with talent for witness and use our voices to amplify theirs. We need to use our social privilege as doctors to speak truth to those in power who are slaves to respectability politics and would not get the message otherwise.
There is work here for all of us, and its a labor that is necessary if we are to truly work for the health and well-being of our patients.
*To protect patient privacy, this narrative is an amalgamation of several different patients’ stories.
Toward Health 