Medical students need to understand poverty and its pernicious effect on health

Faiz Kidwai, as father of his family, is accessing social services for assistance with paying bills, accessing SNAP cards or applying for unemployment benefits in KCUMB’s poverty simulation. Photo courtesy of Keith King, KCU Media Relations Specialist

Poverty Simulation is a 2.5 hour event where participants experience the challenges people must manage while faced with poverty. A mock community is created, and participants are given identity cards which describe their role in the simulation. Photo courtesy of Keith King, KCU Media Relations Specialist

Participants, like med student Faiz Kidwai, go through 4 weeks (15 minutes per week) of role playing the lives of individuals in poverty. Photo courtesy of Keith King, KCU Media Relations Specialist

The simulation provides an opportunity for participants and volunteers alike to experience the immense challenges people face when trying to manage basic life skills (job, food, safety, transportation, health, accessing health services) while living in poverty.


There is little to no doubt that poverty and health are inextricably linked. If you are poor in the United States, you are more likely to die earlier,1 suffer from a mental illness2  and chronic medical conditions like obesity.3 And sadly, one could go on ad infinitum.

There are several lessons that medical students took away from the simulation, chief among them an appreciation of the daily stress that comes with being poor. How can we ever tell our patients to prepare a home-cooked meal when they could spend that time making money?

My character’s story was one that we have seen repeatedly since the economic collapse of 2008. A middle-aged college-educated father of three, who has recently been laid-off from his 20-year job as a computer programmer, with a mortgage, car payments, modest savings, and a wife (also with a college degree), who doesn’t make enough to cover the bills. My character began the simulation as a gainfully employed family man, and by the end was reduced to a man on welfare, selling drugs between jobs. Despite the incontrovertible evidence that continues to tighten the link between poor health outcomes and poverty, medical education in the United States hasn’t moved fast enough to infuse this knowledge into their curricula. This is why the Poverty Simulation conducted at Kansas City University (KCU) on April 22, 2017 came as a welcome surprise.

The simulation was put together by KCU’s Score 1 for Health program with partial funding from the Health Care Foundation of Greater Kansas City. Medical students piled in early on a Saturday morning, learning about their pre-assigned identities only a few moments earlier. Our task was simple: just get through a month.

The sharp downward spiral experienced by my character was hardly unique. In a tableau reminiscent of John Steinbeck’s magnum opus, The Grapes of Wrath, medical student Sameer Mian (MS1), who played the role of 19 year-old mother and high-school dropout living on food stamps, said that at one point, he was “willing to be arrested by the police so that my baby could be taken care of; I was about to be evicted anyway.” Andi Canhasi (MS1) played the role of a 21-year-old community college student who has recently had to assume responsibility as the head of the household following his father’s incarceration. Canhasi lamented how byzantine he found the system to be as he tried to navigate the patchwork of available resources. Another medical student, playing the role of a high-schooler, noted how he found school to be a respite from the problems at home.

There are several lessons that medical students took away from the simulation, chief among them an appreciation of the daily stress that comes with being poor. How can we ever tell our patients to prepare a home-cooked meal when they could spend that time making money? How can we expect our patients to keep appointments when they can’t get time off work, and even if they could, don’t have the means to get there? How can we blame our patients for making poor choices, when those are really the only choices they can make? Are poor choices then a consequence of moral failures, or systemic failures?

We are extolled by Atticus Finch, perhaps our greatest literary hero, to never judge a person until we’ve walked in their shoes. I don’t think that as medical students we will ever get a chance to do that. But initiatives like the poverty simulation can tell us where our patients’ shoes have been, giving context to every scuff, every tear, and every worn-down sole – pun intended on that last one.

One of the most important wisdoms that one learns in their first-year of medical school is that as a physician, one treats the cause, not the symptom. Why is it then that we don’t treat poverty when we know that it is the cause behind so many of the ills that our patients will present with? Unless medical education takes concrete steps in preparing students for tackling poverty directly, physicians will continue to go against their own learned wisdom: treating the symptom when we should really be treating the cause.

Acknowledgments: I would like to thank my fellow medical students Andi Canhasi, Sameer Mian, Jessica Ruikka, Stephan Green, and Amy Estep.

Bio:

Faiz Kidwai, MPH is a first-year medical student at Kansas City University of Medicine and Biosciences. He holds a bachelor’s degree in philosophy and chemistry from Indiana University, and a master of public health degree from the Boston University School of Public Health. His interests include the intersection of medicine and public health, health law, ethics, human rights, and racial justice. When he’s not studying for medical school, he enjoys reading philosophy, playing his acoustic guitar, and feeling guilty about not studying for medical school. You can follow him on Twitter.


About the simulation:

Poverty Simulation, hosted by Kansas City University of Medicine and Biosciences, is a 2.5 hour event where medical students experience the challenges people must manage while faced with poverty. A mock community is created, and participants are given identity cards that describe their role in the simulation.

Participants go through four weeks (15 minutes per week) of role playing the lives of individuals in poverty. It is a fairly provocative experience, and the debriefing afterward provides an opportunity for participants and volunteers alike to discuss the immense challenges people face when trying to manage basic life skills (job, food, safety, transportation, health, accessing health services) while living in poverty.

Poverty Simulation is being used in communities and at the collegiate and post-graduate level in institutions nationwide as an effective way to help students and faculty gain awareness and sensitivity to the far-reaching and devastating effects of poverty. The de-briefing was tailored to enhance learning from a medical student’s perspective.

Funds from the HCF grant and Liberty Fruit Company donation covered the cost of training and kit purchase.

 

Footnotes:

1. Committee on the Long-Run Macroeconomic Effects of the Aging et al., “The Growing Gap in Life Expectancy by Income: Implication for Federal Programs and Policy Responses” (Washington, DC: The National Academies Press, 2015), https://www.nap.edu/download/19015. 

2. Stacy Hodgkinson et al., “Improving Mental Health Access for Low-Income Children and Families in the Primary Care Setting,” Pediatrics 139, no. 1 (January 2017), doi:10.1542/peds.2015-1175. 

3. Adam M. Lippert, “Stuck in Unhealthy Places: How Entering, Exiting, and Remaining in Poor and Nonpoor Neighborhoods Is Associated with Obesity during the Transition to Adulthood,” Journal of Health and Social Behavior 57, no. 1 (March 2016): 1–21, doi:10.1177/0022146515627682. 


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HCF's Local Health Buzz Blog aims to discuss health and health policy issues that impact the uninsured and underserved in our service area. To submit a blog, please contact HCF Communications Officers, Jennifer Sykes, at jsykes@hcfgkc.org.

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