This week was my first week of residency orientation. As a part of the orientation we participated in a poverty simulation. We walked into the room we had been sitting in for the last 4 days, but it looked different. Lining the edge of the conference room were pictures of store fronts, signs saying Bank, Community Action Services, Jail, and on and on. I was given a name tag that read Eunice Ussar, Age: 85 accompanied by a picture of Eunice. I was told I was the first from my family to arrive. Find my “house”, a laminated piece of paper that said Ussar on a table. My neighbors were the Quants, a couple and two young children. I sat down, opened my packet which would give me insight into my life, who was in my family, and what my monthly expenses were. Under family members Eunice was the only listed name. Despite being a simulation, I did feel true sadness for Eunice, especially sitting across from my neighbors who were trying to figure out as a family how they were going to pay their bills and meet their other obligations. Eunice is not a unique case. According to the Institute of Aging, in 2010, of the older adults not living in an institution, nearly one-third lived alone. That is over 11 million individuals. Among women over 75 years old (like Eunice), nearly half (47%) live alone. Not only to so many older adults live alone, but many of them live in poverty as well. Over 4 million in fact. That blew my mind. So I sat there by myself trying to strategize with my limited bus passes and social security check.
The woman running the simulation started setting the parameters of the simulation. We were to simulate a full month. Each week would last 15 minutes. If you had a job, you would spend 7 minutes in the corner with the General Employer who would take punitive action if you were late, left early, etc. In order to visit any of the businesses you had to provide them with a bus pass before they would serve you. I only had 2 and I had 3 places to go. You had to use one to go to the store where you bought more so I really only had one pass I could use. I decided to use it to cash my social security check. Thankfully I had just enough money to pay my bills. Many families didn’t. In 2015, over 8.5 million families (roughly 40 million individuals under the age of 65) lived below the poverty line and likely struggled to keep afloat and probably still do. In 2015, the poverty threshold for a family of 4 was $24,257. [2,3]
I then bought more passes, paid my rent and utilities. I felt accomplished. Those at work were now off work and it became very chaotic. While trying to decide which bill to pay next I was hit with a “luck of the draw” card. There were a couple people walking around handing out these green cards. Some with good luck, some with bad luck. I pulled a bad luck card. A pipe burst in my house (which I own) and it was flooding my house. It was going to cost me $50 to fix it. I didn’t have $50….
In your packet you have a few laminated cards with household items on them along with their value. These items are “pawnable” items. So I decided to pawn my jewelry so I could pay for the plumbing. The kicker is the pawn shop only speaks Spanish. I know a little Spanish, but not enough to barter. It was rough. My jewelry was valued at $100. I needed $50. I asked for $70. They said no. We settled on $50 so I was happy with that. I ended up starving the first week because I didn’t have time to go to the grocery store. Unfortunately this is also a real struggle for many Americans. In 2014, 5.4 million people over the age of 60 were considered food insecure. The USDA defines high food security as no reported indications of food-access problems or limitations and very low food security as reports of multiple indications of disrupted eating patterns and reduced food intake.  Again, this obviously was a simulation for me and Eunice, but this is many Americans reality, many of whom will likely be my patients.
In the end, I never got my pipe fixed. I just didn’t have enough time. There was so much standing around, waiting. It was really frustrating. My utilities were shut off despite paying them. I never asked for a receipt. So it was their word against mine and I lost. I also never had the opportunity to explore the services the community had to offer. I think this was the most poignant takeaway for me in this simulation. There were services in the community that may have been able to make it possible for me to avoiding pawning my possessions in order to pay the bills or help me with my broken pipe. The fact of the matter was I had only enough resources to get to the places I HAD to go in order to keep my house, keep the lights on, and feed myself. I didn’t have time or energy to do extra.
As a provider at the end of the simulation, I felt a sense of obligation to make those connections for my patients. Being poor is hard enough. Being sick (or living with a chronic condition) and poor is even worse. Since patients have to come to the clinic to refill their medicine or follow-up on their chronic conditions why not be the point of entry for services that will improve overall health and wellbeing when possible? I went into medicine because it was very apparent to me at a young age how much social determinants effect a person’s health and wellbeing. Controlling someone’s diabetes is not accomplished through giving them more medicines. Controlling their diabetes may be the least of their concerns because they may be on the verge of eviction, have a special needs child, and don’t know how to feed them other than McDonald’s every night. Non-compliant patients often aren’t so willingly. What barriers does a patient have to living a life they would consider whole and fulfilled? How, as a provider, can we help move the needle in that direction?
Poverty as a public health issue is not a new concept unfortunately. The WHO first published the Development Assistance Committee’s Guidelines on Poverty Reduction in 2001. Since then these guidelines have been updated. The CDC has also started to look at social determinants of health, having released two reports, one in 2011 and again in 2013, looking at many variables contributing to health disparities, poverty being one.  I don’t feel the need to rehash the importance of addressing poverty as well as other sources of health inequity in the country. If you are looking for that, I would recommend exploring the National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention’s (NCHHSTP) Social Determinants of Health website. There is a lot of great stuff on their website. On a personal not though, seeing poverty firsthand in the communities where my schools have resided (as well as through this simulation), it is clear there are resources and organizations willing to help and plenty of people in need of help, but there is a disconnect. I am hoping, at least for my patients, I can bridge the gap and help bring more positive experiences into their life. I am grateful to be a part of an organization, at least for the next three years, that values these issues and believes in it enough to invest in it. I was informed of a quality improvement project in the clinic I’ll be working in that consisted of a screening tool for social and economic hardships. I am hoping this continues and helps facilitate having conversations about the gaps patients may have in their needs that are inhibiting them from having a life they feel to be content. I am really excited to start and hope to not lose the drive and energy to pursue what I feel is necessary for obtaining optimal health in each individual I interact with during residency.