2015 Congress of Delegates

Social Determinants of Health Issues Take Center Stage

September 30, 2015 03:30 pm Chris Crawford Denver –

Delegates to the 2015 Congress of Delegates here addressed social determinants of health-related issues such as gentrification, poverty and nutrition, and discriminatory policing, among other topics, and adopted a number of resolutions during the Sept. 29 business session.

Speaking in support of a resolution on gentrification, member constituency delegate Venis Wilder, M.D., of New York, N.Y., explains that anecdotally, it's known that gentrification impacts health but there has been very little research on the topic.

Gentrification

During the Reference Committee on Health of the Public and Science hearing on Sept. 28, delegates discussed a resolution from the New York State AFP that directed the AAFP to request that the Robert Graham Center for Policy Studies in Family Medicine and Primary Care investigate how gentrification impacts health outcomes and, potentially, create policy recommendations that could improve the health of the most vulnerable populations.

Resolution co-author and member constituency delegate Venis Wilder, M.D., of New York, N.Y., said, "As a practicing physician and new homeowner in Harlem, New York City, I can tell you that gentrification is real. It's not just a concept or casual observation in our cities -- our patients are being affected by this process."

Wilder went on to explain that gentrification has resulted in people being displaced from the neighborhoods their families have been a part of for decades as rents have increased and mortgages have become unaffordable. Upscale markets such as Whole Foods and Trader Joe's have moved into gentrified neighborhoods, but their food isn't always affordable for low-income families, and consequently, food deserts persist. These new neighbors increasingly become strangers, leading to isolation that causes additional stress, she said.

Story highlights
  • Delegates to the 2015 Congress of Delegates in Denver addressed social determinants of health-related issues such as gentrification, poverty and nutrition, and discriminatory policing, among other topics.
  • Other measures adopted dealt with developing evidence-based, effective methods for discipline in schools and addressing safety and older drivers.
  • One hotly debated substitute resolution that was referred to the Board directed the Academy to oppose mandatory reporting of drug test results from pregnant women.

"Gentrification is a social determinant and we anecdotally know it impacts health, but there is little research on the topic," Wilder said. "As a result, there haven't been policies put into place to protect our most vulnerable populations in our inner cities. I am hoping the Academy will recognize that with its unique position at the intersection of primary care and public health, it could take the lead on this issue."

Ultimately, the reference committee offered a substitute resolution, which delegates adopted, that asked the AAFP to partner with public health, policy centers and/or research organizations to investigate how gentrification impacts health outcomes and use this information to possibly create recommendations to help improve the health of these vulnerable populations.

Poverty and Nutrition

A resolution submitted by the Washington AFP asked the AAFP to include in its strategic objectives the "reduction of income, education and nutrition inequality" and also to create formalized and sustainable partnerships with public health agencies to achieve this goal and to help fight overall obesity and poor health in low-income communities.

Co-author and Washington delegate Alexander Brzezny, M.D., M.P.H., of Ephrata, testified during the reference committee hearing that the measure fit into the AAFP's vision to transform health care to achieve optimal health for everyone.

"If our patients are poor, they have worse health outcomes and poor nutrition," he said.

Nutrition inequality is seen when low-income patients consume high-calorie, nutrient-deficient foods, which leads to obesity and other poor health outcomes, Brzezny explained. "We hope that putting patients first also means addressing the true reasons for their problems, which are poverty and poor nutrition," he said.

Washington delegate Alexander Brzezny, M.D., M.P.H., of Ephrata, explains that nutrition inequality is seen when low-income patients consume high-calorie, nutrient-deficient foods in their diets, which leads to obesity and other poor health outcomes.

General registrant Patricia Czapp, M.D., of Annapolis, Md., who serves on the Commission of the Health of the Public and Science and chairs its subcommittee on health equality, suggested during the hearing that more actionable language be added to the resolution and said that the AAFP already has strong relationships with public health agencies and also has a workgroup on the integration of primary care and public health.

"What we need to do is better leverage those relationships so that we can reach the goal that has been outlined," said Czapp, lead author of the Academy's recently issued Poverty and Health position paper.

General registrant and former AAFP Speaker Carolyn Lopez, M.D., of Chicago, also supported the resolution's intent, lending her perspective as the president of the Chicago Board of Health. Lopez suggested that although the spirit of this resolution was well-intentioned, she thought AAFP members might have more success in following through with this goal at the local level.

"This should be a call to action for all of us," she said. "We may not be able to write a prescription for food, but there are other things we as family physicians can do locally. Because that's where the changes will come … one ordinance at a time."

Delegates eventually adopted a substitute measure that asked for the inclusion of the "reduction of the negative effects of income, education and nutrition inequality" in the Academy's strategic goals and for collaboration with public health agencies to help achieve this objective.

Discriminatory Policing

A third resolution addressed the red-hot topic of discriminatory policing as a public health concern.

A similar resolution adopted during the 2015 National Conference of Constituency Leaders in April requested that the AAFP review the recommendations of President Obama's Task Force on 21st Century Policing and introduce a resolution on this topic in the AMA House of Delegates.

Member constituency alternate delegate Shani Muhammad, M.D., of Fresno, Calif., spoke in support of the new resolution, saying, "This resolution is asking that we as an Academy recognize excessive or unnecessary force (used by police officers) is a public health issue. Violence impacts one's health -- both mental and physical -- and it doesn't matter where that violence comes from."

Muhammad said that as of June, 490 people had been killed this year by police in the United States, and nearly 30 percent of them were African American. "This is a significantly disproportionate number considering that African Americans make up only 12 percent of the U.S. population," she said.

Multiple delegates of color took turns at the microphone telling personal stories and those relayed by their patients of discrimination, and in some cases serious abuse, at the hands of police officers.

General registrant Marie-Elizabeth Ramas, M.D., of Mount Shasta, Calif., recounted that she and her husband were stopped by police late one night and her husband was handcuffed before the police even asked them any questions. When Ramas asked why they were being detained, the officer called for backup and held them for 15 minutes before letting them go, explaining their car had been mistakenly identified as a recently stolen vehicle.

"As family physicians, it is our duty to speak up for those who are not heard," she said. "It is our mission to take care of our patients within their context. This resolution puts (the AAFP) on the map and says, 'No other medical associations are bold enough to do this, but as family physicians we will not take injustice (for our patients) any longer.'"

Ultimately, delegates adopted two of the resolution's four resolved clauses and referred the other two to the Board.

The first clause adopted asked the AAFP to create a policy statement recognizing that any use of force beyond that reasonably necessary to accomplish a lawful police purpose poses a serious ongoing public health issue that disproportionately affects minority communities.

The second clause adopted asked the Academy to support promoting communication, transparency and accountability in everyday interactions between the police and public.

Other Issues

Delegates adopted a number of substitute resolutions on various clinical and public health issues, directing the AAFP to

  • support the inclusion of quantitative risk information in published medical literature;
  • urge companies with retail clinics to cease sales of tobacco products and electronic cigarettes;
  • develop a policy regarding safety and older adult drivers;
  • develop a position paper on evidence-based, effective methods for discipline in schools; and
  • encourage more physical activity and less sedentary behavior among attendees at AAFP meetings.

Another substitute resolution that was vigorously discussed and, eventually, referred to the Board urged the Academy to oppose mandatory reporting of drug test results from pregnant women.