Anxieties about being able to access care in the US is an experience that none of our patients should face, yet so many do, writes Gaurab Basu
I opened the door to exam room 2 in the middle of another busy day in primary care to begin an establish care visit. Immediately, I could see the worry and fear in my new patient’s eyes. His shoulders were tense. He sat next to his wife who gazed solemnly at the ground as she rocked their young child. From chart review, I knew the past two weeks had upended their lives.
My patient was an otherwise healthy young man, who had come to the emergency room due to persistent viral symptoms, which evolved into shortness of breath. Basic labs were taken and revealed a creatinine over 10. His kidneys were in failure, and he needed urgent dialysis. His life was forever changed.
In my primary care clinic, I tried to get a sense of how he was doing in processing his new diagnosis. And then we began coordinating the important follow-up—medication reconciliation, continued dialysis, fistula placement, and evaluation for transplant. He was ready to do everything needed to deal with this disease. But he had just one question for me: “Will I be able to get this medical care here?”
Further discussion made clear to me that as an immigrant he had faced repeated acts of xenophobia, and engaging in the US healthcare system felt like hostile territory. “You are going to get all the care you need and deserve,” I said. His shoulders relaxed. His wife exhaled softly.
As I collected his social history, I learnt that he was an outdoor laborer and his previous work had exposed him to chronic severe heat. He had worked as an essential worker so that his community could benefit. After an extensive evaluation, he was diagnosed with chronic kidney disease of unknown origin (CKDu). While much about CKDu is not well understood and under researched, chronic exposure to severe heat is an understood mechanism of disease progression. It seems likely to me that working in the heat day in and day out could have caused his kidneys to slowly lose their critical function.
My patient was telling me important stories. But I needed to listen carefully to fully hear them. His chief concern was not about having to figure out how to manage dialysis and keep a job, or taking all the new medications he needed to take, or even worrying about how long he would live. It was simply whether we would welcome him into our healthcare system and provide him with care. His fears were rooted in experiences of structural racism and xenophobia that made him worry he would be left to die. It is an experience that none of our patients should face, yet so many do.
Caring for my patient was an important part of my awakening to the threat of climate change to human health. I realized that as the planet continued to warm, my patients would increasingly be at risk. Exposure to severe heat increases the risks of heart attacks, respiratory disease, strokes, mood disorder, and even adverse pregnancy outcomes like premature labor and low birth weight. I learnt that climate change also threatens to inflict greater food insecurity and water scarcity. And if people cannot grow food in their communities, it will worsen the chances of forced migration and even political conflict. I reflected on the deep connections between structural racism and the disproportionate harm that people of color will continue to bear in a dangerously warming planet.
The United States is in the midst of ending a most painful era. The past few years have been defined by a denial of science, harm to our earth, bigotry towards immigrants who have given so much to our country, and unimaginable suffering caused by a global pandemic—along with our failed response to it.
Vaccines and new presidential leadership offer hope as we begin a new year. And as we enter a new era, healthcare professionals can play a critical part in creating a more decent, compassionate, and just society. But we have to speak up for change to happen. Instead of locking up children at the border and separating them from their parents, we must demand that we see their intrinsic value, dignity, and humanity. Instead of exploiting nature, depriving our children of a safe, sustainable, and healthy future, we must lead the work to repair our planet. Instead of simply watching as white supremacy threatens our democracy, we must call it out and root it out. We can be ambassadors of a world in which we better care for our earth and one another. A world in which we heal.
And we will come to know what needs healing from the important stories our patients are telling us, if we listen carefully.
Patient consent obtained.
Gaurab Basu is a physician, instructor at Harvard Medical School, co-director of the Cambridge Health Alliance Center for Health Equity Education and Advocacy, and a health equity fellow at the Center for Climate, Health and the Global Environment at the Harvard TH Chan School of Public Health. He has a background in human rights, health equity medication education, and climate change. Twitter @GaurabBasuMDMPH
Competing interests: None declared.