First, Seek To Understand: Doctors, HIV, and Poverty

Every year, for the past 15 years, a group of first-year medical students in St. Louis, Missouri have climbed on board three yellow school buses and headed north. The students, from Washington University’s School of Medicine, take a route that passes through the city’s poorest neighborhoods in an exercise designed to teach them about the lives of their future patients. It’s a trip the school hopes will make them better doctors. Lessons on housing and structural racism may seem out of place in a medical school curriculum, but a growing body of research establishes a connection that cannot be ignored. A patient’s environment may increase their risk of cancer, chronic illness and premature death. A doctor who doesn’t realize this may make things worse.

Researchers recently reported the gap between the lowest and highest life expectancies can be as much as 20 years — and it appears to be widening. The counties with the highest life expectancies are among the country’s most affluent. The places with the lowest life expectancies are also some of the poorest. Here, in St Louis, the life expectancy gap between the poorest and richest parts of the city is 15 years or more. “To be frank, a lot of students in medical schools are coming from affluent backgrounds,” said Dr. Will Ross, a kidney specialist and associate dean of diversity at Washington University’s School of Medicine. “I think a lot of us need to — literally and figuratively — get on the bus. ”This year, the first stop was Ivory Perry Park on the city's north side. The streets nearby are a mix of stately, turn-of-the-century homes — some of them empty or falling into disrepair — and modest, newly-constructed units. The buildings are punctuated by grassy, vacant lots. The neighborhood is just two miles from the glossy academic medical center where the students will learn how to be doctors. They sat cross-legged on the blacktop of a playground to listen to a short lecture by local activist and architecture professor, Bob Hansman.“One of the things that make a place safe is people,” Hansman explained. “People make it safe for other people. People can see what’s happening.”

About 315,000 people live in the city of St. Louis today; that's a little more than one-third of its peak population in 1950. This massive exodus left several city neighborhoods underpopulated, abandoned and plagued by crime — further intensifying parts of the city's downward spiral as people continue to move away. “There are places in this city now that have been so depleted of resources of people that packs of feral wild dogs can run through the neighborhoods looking for something to eat,” Hansman said. “And this is where it happened.” He told the story of 10-year-old Rodney McAllister. One night in 2001, the boy was playing alone in this park next to his home, when he was attacked by a pack of wild dogs. His body was found, mutilated, the next morning. “People in the city spent a lot of time pointing fingers at each other. Nobody wanted to see themselves as part of this larger pattern that could create a situation where a 10-year-old child in 2001 could be eaten alive by wild dogs,” Hansman said. To Hansman, this is an example of neighborhood disinvestment gone deadly. It’s something less likely to happen in the wealthier parts of St. Louis that have street lighting and foot traffic — places where someone would hear a child scream and be able to help. After more than a decade of incorporating the tour into medical school orientation, Ross has seen the potential to start shaping his students’ perspectives early.  He’s presented the idea to other medical schools and knows of a few that have adopted the practice. For some of his first-year students, this bus tour was their first time in a neighborhood with a high poverty rate or HIV rates. They may not see the connection between depopulation, stress and health outcomes immediately, but when the lessons kick into place, Ross sees a difference in the way students write their patient’s social histories. “When we were students, we would ask, 'Do you smoke? Do you drink alcohol?'... The social history was like a line and a half. Now I look, and they’re like a paragraph,” he said. “They truly know how to ask the right questions: ‘What’s happening in your life?’” On a national level, there is a growing realization among medical colleges that doctors need to consider the health effects of poverty, and students have to be exposed to it to really understand. “All of our medical schools in some way instruct students on the upstream factors that impact downstream health. The range of activities is really quite broad,” said Philip Alberti, director of health equity research and policy for the Association of American Medical Colleges.Alberti points to schools that have incorporated community service requirements into curriculums, as well as working directly with patients who live in poverty. In 2015, the MCAT, a standardized entry test for medical schools, introduced questions on how behavior, psychology and social inequalities can affect the health of a patient. On the bus tour, students went from Hansman’s lecture at Ivory Perry Park to a highway overpass. The area used to be the Mill Creek Valley neighborhood; a predominantly African American community that was bulldozed to make way for the interstate in 1959.At another stop, students walked up to the vacant facade of People’s Hospital on Locust Street, a facility that served African Americans when even hospitals segregated their patients. In the early half of the 20th century, the facility was crowded; retired doctors remembered tying two beds together to accommodate three patients. It was nicknamed “the firetrap. ”Later, the bus stopped at a small forest that has grown over the site of Pruitt Igoe, a massive public housing complex built in the 1950’s and razed twenty years later. An area nearby will soon be replaced by the new campus of the National Geospatial-Intelligence Agency. As the students hiked through the forest, student Amir Kucharski said that even though he has studied health disparity issues before, this experience has made him think.“It’s not so much someone’s cancer necessarily, that they can’t pay for their prescription. But … you’ve got to think about the way people are being segregated, and how that influences their health outcomes,” Kucharski said.Sometimes the connection is deeply personal, added first-year student Kamaria Lee, from Michigan.“For example, a patient comes in and they have cirrhosis, which is a hard liver. If you’re just seeing them as a liver and try to treat it as such, you’re going to miss things,” Lee said. “That person might be drinking a lot and that can be the cause. If you ask why are they drinking, they could be depressed. ”In that case, treating the depression might be more effective than just treating the liver.The students still have four years of study before they’re practicing M.D.’s, but they said they’ll take the perspectives they’ve learned from this tour with them. This trip is just the beginning.

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This story was produced by a partnership between St. Louis Public Radio and Side Effects Public Media, a reporting collaborative focused on public health.