So what!
In the Health Gap, a book I highly recommend, Michael Marmot describes an interaction with a patient in the 1950’s that he felt absurd; instead of addressing the woman’s distress and underlying needs from domestic violence and family addictions, a red pill was prescribed, as though the patient were “deplete of red pills.” This is a situation still familiar to us all, yet few of us have gone on to conduct such extensive epidemiological research into social determinants of health as to lend our name to direct action across “Marmot regions,” of which Gwent is one.
But so what! Sure, we can identify political or societal solutions to address poverty, obesity and dental decay at scale, but how do I address this with the patient in front of me?
What’s new?
For decades clinicians from the devolved nations have led the way, including Justin Tudor Hart (Inverse Care Law 1971) and Douglas Black (Black Report 1980) while the study of fluoridation of water began in the early 1900s. I even wrote a school essay on fluoridation, which, as my kids have said, is “so last century!”
Of course there’s been progress, in the many decades since these studies, especially with communicable disease - COVID and rising cases of whooping cough aside (though be sure to see the downloadable info posters). This is why non-communicable disease - cardiovascular disorders, cancer and diabetes - have become the new epidemics with their own societal, or “communicable”, risk factors.
What’s new is that these factors are taking a greater hold, leading to reduced life spans, and the seeds of demise are now known to be set in childhood or before. We in child health, whether front line, public health, or policy wonks, have a greater responsibility.
Advocacy
There’s a need to talk about social determinants in less abstract terms and demonstrate to our community direct action is both possible and effective. Advocacy and activism is cited, see BMJ from 11 May, and at the excellent Welsh Paediatric Society meeting in Wrexham last month organisers Hamilton, Sarah and Naomi convened a breadth of impactful work, individually and collectively.
Prof Ian Sinah, Respiratory Paediatrician at Alder Hey, has taken on local and central government over individual cases and subsequently helped change policy on clean air and other environmental factors. Dr Helen Stewart has addressed social determinants through the running of her emergency care department in Sheffield and now leads change as RCPCH Officer for Health Improvement. Equally Welsh trainees demonstrated impact from taking a behavioural change model to improve vaccine uptake through to addressing variances in access to sleep support - both winning presentations.
Yet it was Kerry Evans, the lone Disability Liaison Officer at the Racecourse Ground of Wrexham AFC, who showed how individual action has a major impact on disability and neurodiversity where healthcare has failed.
Indifference or Spot the Difference
I loved comics as a kid - Beano, Whizzer and Chips, Scoop - and in idle moments I poured over Spot the Difference. Typically a large bully, leaning over a diminutive character, was about to, or not, get his or her comeuppance, and despite a missing ice-cream, a dog cocking a leg up a lamp post, a school building in the distance, a tree without a swing, the menace remained.
Outpatient consultations are no different. Do we see all of the distress and dis"ease", the complex challenges and threats, as with Marmot? Take a kid with breathlessness - a wheeze and nocturnal cough and we are happy. What if there isn't a wheeze but a tick? What if there isn't a spacer segment, or consistent school attendance, healthy diet, a home (see case study) or patient in clinic? What if there is parental fatigue or a bully?
Everyday access and action
Like Spot the Difference there is a mundanity, an everyday, to all of this. We may simply prescribe another (insert colour) inhaler or instruct on spacer use, or we may listen and observe, noting how challenges and threats intervene in even basic management. Sure it takes time, but in my experience is achievable, offset by simpler cases, and better targets intervention, facilitated, as discussed in Wrexham, by:
- Collaboration - to manage our feelings of isolation and vulnerability in uncertain and complex situations, especially if we build relationships as I wrote in my November blog. This is why we in Wales set up the Welsh Royal Colleges Child Health Collaborative and as a group of over 20 colleges and societies including therapies, radiology, nursing and pharmacy (as I shared with members in our recent eBulletin for RCPCH Wales).
- Asset based healthcare - to lean into strengths, or assets, of the individual and their family, the community and the organisation. This redirects care away from focusing on problems or weaknesses, sidesteps thorny issues and engages the patient in finding their sustainable solutions to a better quality of life. And it works (which I'll explore in a future blog!) with collaboration of community assets, whether Flying Start, charities, youth groups, or money advice services. Further:
- Use and support of schools - this community asset warrants its own blog. We have barely engaged in developing its full, life long, potential, but for now we agreed picking up the phone or organising a Team Around the Child unpicks much complexity and unhelpful assumptions to find the win-win.
- Better supported self management - this too deserves a blog because we can do so much better than our risk averse trifolds and text heavy websites. For now we should find empowering language, avoid unhelpful labels and curate recommended websites and videos to appeal to different learning styles.
- Case Study
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I was asked to review a young lad, 17y, to assess his chest shape and pain and possibility of a connective tissue disorder. He had already had multiple assessments, across different services, and in addition to mild pectus carinatum and asymmetry - a normal variant - I found poor dentition and flat affect. He was unaccompanied. It turned out he had been sofa surfing, while his mother, his only family, was in and out of hospital.
What to do? I rang his GP and combed the hospital - to meet new departments, social workers and youth workers - before I inadvertently found answers in the emergency department. A colleague there worked for St Mungo’s - bingo! And check out Byte Night, a night and a laugh under the stars in a city park to raise money for the homeless. There are 135,800 young people sleeping rough in the UK.
* this is a compiled case study indicative of challenges faced.