Baltimore is the epicenter of trauma in the U.S. — gun violence, mass incarceration, poverty, heroin. I care for some of the most marginalized people in the nation, whom we refer to as “high-needs, high-cost” — the latest in a series of labels for a population that is facing multiple medical and behavioral health comorbidities, in addition to extreme poverty and social dysfunction. More often than not, my patients come to me with physical complaints that stem from an underlying psychological maladaptation to stress.
I was awestruck when I encountered a similar situation when I visited a small hospital in rural India. My preconceived notion of medicine in an impoverished developing country was an amalgam of National Geographic images and CDC outbreak maps. I pictured emaciated families struck down with infectious diseases like malaria, dysentery and tuberculosis. While mortality from infectious disease is certainly still higher in India than in the U.S., this was not the most urgent issue facing the Indian hospital. Instead, a tidal wave of social and mental health issues is bearing down on the Indian health system just like in the U.S., with no high ground in sight.
I saw numerous parallels between the rural farmers in India and the urban poor in Baltimore: Both populations are plagued by trauma, poverty and discrimination. A woman in her 30s was admitted to the Indian hospital for a vague constellation of complaints including dizziness and upper respiratory symptoms. Her initial workup was negative, with no abnormal findings on exam or labs. She was treated with IV fluids and a chest x-ray was ordered. During morning rounds, she was identified as likely having a “conversion disorder” which is a psychiatric diagnosis that encompasses varying neurologic symptoms with no underlying medical disease. Conversion disorders, or functional neurologic disorders, are thought to be triggered by stressful life events, and are much more common in women than men. I was told by the Indian doctor that, in India, diagnoses such as this often equate to “problems with the in-laws,” implying that stressful family relationships are the root cause of the dysfunction.
Bam. Mind blown. Could this young woman be experiencing the exact dysfunction I see in so many of the young women I care for in Baltimore City? Her case brought to mind several of my current patients, including one woman who has shaking spells, often in response to conflict within her family. She lost her mother to breast cancer at a young age, was raised by a grandmother with addiction who lords over the chaotic household through manipulation and secrecy. She has been hospitalized numerous times for her shaking spells and treated with antiepileptic drugs. Through mental health therapy and health education, she has gained some insight into the cause of her symptoms. But the origin of her disorder has not been alleviated — this would require a multifaceted social and behavioral family intervention.
The young Indian wife later refused the chest x-ray, indicated she wanted to go home and was discharged AMA (against medical advice). Perhaps she realized the hospital had limited resources to assist her. Or maybe her family pressured her to come home and resume her responsibilities. Whatever the case, this young woman did not get any lasting intervention for her stressors.
In two totally disparate countries with radically different cultures, the same societal problem exists — little to no access to mental health care and social services within the health care system.
The health care system in India as well as the U.S. is just not set up to help people with the fundamental stresses of life — having enough food, secure housing and safe relationships — even though these stresses often manifest as “medical” complaints. Surely, there must be a better way.
We are on the cusp of a global shift in the way physical health is understood. The progress of medicine is undeniable as people are living longer lives and have access to technology to sustain life. But medicine alone cannot continue to forge improvements in wellness. Much of the physical dysfunction we see lies on a complex foundation of stress of all shapes and sizes.
The tragic separation of children from their immigrant families is one of many examples of adverse childhood experiences that predisposes to poor health. Children with these traumatic experiences will grow up to be more sick, more disabled and have problems with reasoning and relationships. They will die earlier than they otherwise would.
The separation of body and mind that humanity has created is artificial. We as a society should not continue to tolerate a medical system that treats the body but fails to acknowledge and prevent the negative health effects of social injustice, poverty and trauma.
Katherine Rediger is a nurse practitioner; her email is firstname.lastname@example.org.