I. The chronic and the acute
Today’s American healthcare system is built to address the acute. Healthcare professionals medically lower blood pressures and blood sugars, crack open sterna, excise, break and reattach, detain, cut, laparoscopically solder and burn and fuse. Expensive machines, well-compensated workers. As a community, we respond to the explosive. Our system is attuned to this urgency and we spend trillions of dollars every year to make it better.
Where our system thinks about prevention, it only goes so far as secondary and tertiary preventions, ignoring the possibility of primary prevention. That is, we are willing to try to detect disease early, and to reduce future complications of disease, but we are not willing to provide communities with the resources necessary to address much of American health burden before it starts. We will mete out to diabetics hordes of subspecialists–a podiatrist for neuropathic complications, an opthalmologist for visual complications, a nephrologist for renal complications, an infectious disease doctor for infectious causes—but we will not ensure safe housing, we will not ensure access to healthy foods early in life, we will not ensure healthy eating in homes that people can afford, we will not advocate for better pay for our teachers, we will not build parks, gyms, and outdoor spaces to assure that communities have the tools necessary to remain healthy.
As a third-year medical student, I am frustrated by all the things that seem to fall outside the scope of our healthcare practice. I am frustrated that we know that diet and exercise can radically alter health outcomes in the diseases that constitute most of our healthcare spending (Hawkes 2015, NEJM 2000, Pan et. Al 1997). I am frustrated that we know that health outcomes change based on race and on income. I am frustrated that we know that certain children in this country are more likely to be poisoned by their environment than others (Hatisha 2016, Ram 2016). I am frustrated that we know that health is about so much more than medication and surgery, but that we are unwilling to redefine what it means to be a doctor or a healthcare worker and instead to use our healthcare dollars to move into communities to prevent illness and health disparities before we see them in the hospital.
I call this frustration “the chronic.” It’s the landscape of preventable states of ill health that are distributed based on differential access to the social determinants of health: food, water, shelter, education, opportunity, and safety. The chronic manifests in first world countries (and particularly in the United States) as the health burden of conditions such as coronary artery disease, hypertension, tobacco addiction, opiate use, diabetes, end-stage renal disease, obesity, and stroke amongst others. In the global south, the chronic manifests as preventable mortality related to two major killers: infection and malnutrition.
The chronic is the slow, everyday illness. It unfolds over generations. It is differentially distributed based on income, zip code, and identity. Our healthcare environment leaves it unmanaged until it decompensates into the acute, when our system raises its scalpels and sets to work. I believe that understanding this tendency to build hospitals that address the downstream effects of the chronic instead of entering into communities and stopping disease before it occurs is essential for all healthcare professionals. Why are we doing what we are doing?
There are two primary reasons that we wait for the chronic to manifest as the acute, instead of entering into communities and addressing the chronic directly. The first is profit generation. Although it would cost our healthcare system less money to serve healthy lunches and breakfast at school, to pay public teachers more, to get parents out of jail, to build more parks, our system as it stands has a lot of bills to pay. Our healthcare system, with its employees, machines, and capital investments, accounts for 18% of our GDP and employs over 16 million people. Every day, we are training new professionals with the specific skillset to function in this system; there appears to be simply no economic incentive for the system to stop people from getting sick in the first place. We spend over 3.5 trillion dollars a year on healthcare, but our reluctance to address the chronic is the reason we only spend 2.5% of that sum on Public Health (National Health Expenditure Accounts, 2018).
The second reason for this reluctance is the one I hope to unpack here. That reason is invisibility and scale. The chronic is massive. It is slow. It is psychologically and cognitively difficult to conceptualize. It crosses disciplines and evades responsibility. It is omnipresent, and it masquerades as inevitable. This second reason hamstrings activists’ attempts to advocate for systemic change. It robs healthcare employees of the critical tools to self-reflect on the system and to work as advocates for something different. To better understand the challenge of invisibility and scale, I would like to borrow a term coined by Rob Nixon in his attempt to outline the challenges faced in addressing climate change: slow violence. I believe the parallels between climate change and the chronic can help to demonstrate how we have built a healthcare environment that erroneously defines progress based on solutions to acute manifestations of the underlying chronic, while making the chronic itself increasingly invisible and unmanageable.
II. Slow Violence
Translating the concept of slow violence from environmental to medical contexts has the potential to equip healthcare professionals with a new framework for thinking about health burden in the United States, and to mobilize writers and activists in making the chronic feel urgent and immediate.
What is slow violence? In contrast to customarily conceived violence—which Nixon describes as “an event or action that is immediate in time, explosive and spectacular in space, and [erupting] into instant sensational visibility”—slow violence is “a violence that occurs gradually and out of sight, a violence of delayed destruction that is dispersed across time and space, an attritional violence that is typically not viewed as violence at all” (1). It transpires over generations, delaying environmental action by always being perpetually “critical, yet not urgent” (9). Resistance to the slow violence of climate change is perpetually delayed by its pace, with the needle only being pushed during sensational disasters that would seem to demand instant action.
Like climate change, the chronic is slow. The damage of climate change unfolds over generations in dying species, rising water levels, atrophying ecological diversity; the chronic is also a drama that unfolds slowly in neighborhoods that have no access to fresh produce or public outdoor spaces. The chronic begins in childhood and flourishes over the course of a lifetime.
But just as society responds to climate change only during quickly unfolding moments of crisis, explosion, and spilling, the chronic also only has meaning within our modern healthcare system at moments of rapid profit generation: prescription medications, invasive medical procedures, hyper-specific diagnostics, tools and skills that are perfectly honed to bringing someone back from the brink of death, or stopping further damage. But the idea of stopping individuals from getting so sick in the first place is anathema to our workflow as healthcare professionals.
This temporal breadth of slow violence is further complicated by its geographic breadth and its immense interconnectedness. In the case of climate change, slow violence is, by its very nature, planetary. Its violence is made manifest in international, intranational, and regional relationships that are interconnected ecologically and humanologically, from migrating birds, spawning cycles, and flows of fluids, seeds, loam, and wind, to immigrating refugees, toxic fallout from war, trade policy, resource management, and steel containers.
As with climate change, the slow violence of the chronic is also massive and interconnected. It is the fire that first incinerates neighborhoods—taking with it fathers, homes, teachers, markets, parks, sidewalks, streetlights, and community centers—and then rebuilds them with fast food chains, Dollar Generals, and militarized police officers. The chronic sits in the intersection of gutted public education, glutted prisons, and hastened all-cause mortality.
III. Representation and Accountability
This geographic scale, this interconnectedness, is overwhelmingly challenging to understand. Meanwhile, the people most likely to be impacted by slow violence are those affected by what Judith Butler would call precarity, “that politically induced condition in which certain populations suffer from failing social and economic networks of support more than others, and become differentially exposed to injury, violence, and death” (33). The precarious are the first to have their lands stolen, the first to be poisoned by leaking pipes, the first to be resource cursed, the first to go hungry, the first to go shelterless, the first to be forced to labor, and the last to be heard.
The chronic shares slow violence’s hunger for the precarious. This hunger is manifest in African American and Native American mothers three times more likely to die from pregnancy-related causes than white mothers, in life expectancy that increases continuously with income, in the poisoned waters of Flint, Michigan, in the homeless mentally ill more likely to see prison than shelter, in undocumented immigrants trapped between deportation and unlivable wages. This destruction is wrought precisely on those individuals least compatible with media’s logic of who does and does not deserve attention, and the result is a violence that is imaginatively resistant to the norms of storytelling.
The systems that perpetuate these health disparities are cross-disciplinary and sustained by massive networks of ownerships, policies, sciences, psychologies, histories, tendencies. To begin to untangle these relationships, and to build healing systems that address the underlying causes of disease, healthcare professionals must be willing to step out of their traditional training and engage in new types of knowledge. Atul Gawande is one physician who has begun to ask big, interconnected questions about the chronic. In his 2009 piece, “The Cost Conundrum,” Gawande reflects on opposing tendencies in hospitalist medicine: one to produce a “fragmented, quantity-driven system” and the other to form “accountable-care organizations, in which doctors collaborate to increase prevention and quality of care, while discouraging overtreatment, undertreatment, and sheer profiteering.” Gawande arrives at this reflection through a narrative of visiting rival neighboring hospitals—McAllen and Grand Junction—where a threefold cost of care does not guarantee a better health outcome.
Like Gawande, medical writers can use narrative to interrogate and illuminate health disparities. Indeed, Nixon argues, writing is the only way that “imaginative focus” can be brought to bear on problems of slow violence. Without translation into narrative, how can we understand what is incomprehensible or invisible—“How, indeed, are we to act ethically toward human and biotic communities that lie beyond our sensory ken?” (15). I would extend this challenge not only to the writers whose job it is to translate American medicine’s slow violence into material that can be understood both semantically and psychologically—but also to those in positions of power to make a change. Understanding the tendency of slow violence to elude comprehension and to sidestep urgency in favor of acute solutions is essential if we are to expect progress in addressing slow violence—whether in climate change or in the health burden of the chronic.
Slow violence resists how humans tell stories; it’s not on a scale of person, place, or action that we are evolutionarily equipped to understand and appreciate. Its danger is heightened by the difficulty in assigning blame. Nixon highlights this feature of slow violence through Indra Sinha’s novel Animal’s People, a fictional work about the damage wrought after Bhopal gas explosion in 1984. In the aftermath of the explosion, which exposed hundreds of thousands of people to poisonous methyl isocyanate gas, the American company that owned the plant in India, Union Carbide, was bought out by Dow Chemical, “and so the name indelibly associated with disaster evaporated, further confounding the quest in Bhopal for environmental justice, compensation, remediation, and redress” (Nixon 63).
Climate change is planetary, interconnected, super-human, temporally and geographically inconceivable, but there are nonetheless perpetrators like Union Carbide. Dysregulated global neoliberal capitalism gives corporations the right to spill, explode, emit, poison, and slaughter, and it simultaneously equips them with the necromantic toolset necessary to escape culpability at all times. If we cannot even hold companies accountable for the disasters that they cause, how can we ever expect to establish culpability for slow, extractive, generational damage?
By taking the framework of slow violence from climate change and applying it to the chronic, we can develop a new capacity to expose its dangerous logic. We need to give “imaginative focus” to the interconnected and generational damage that chronic damage wreaks, and be critical of the optimistic narratives of the life-saving hospital and the superhuman healthcare team. We need to question the mantle of “science” that our healthcare system uses, and to ask why certain brands of solutions–pharmaceuticals and surgeries–are so abundant in the literature, and why other brands—public health initiatives—are relatively absent. We need to be sensitive to whose voice is not in the room when we are talking about our solutions, and recognize that the burden of the chronic falls disproportionately on those who are, from a young age, entrapped by poor eating habits, lack of access to outdoor spaces, and lack of tools to succeed academically. We need to recognize how difficult it is to point at an aggressor, and above all, we need to be willing to acknowledge our own complicity in health burden in America, and stop shrugging our shoulders and saying, “well, what can we do about it?
IV. Envoi
One word of addendum: I hope that, in translating the paradigm of slow violence from climate change to healthcare in America, I have not inadvertently undermined the concept by applying it in an overly specific way. This is especially a concern of mine in light of the climate-destroying waste that our medical system produces. Moreover, I hope that I have not fallen prey to a logic of prevention that is used internationally to justify denying acute lifesaving care from the globally precarious. Dr. Paul Farmer highlights this tension well:
In discussing settings with ‘limited resources’ – usually code for people living in poverty and without medical insurance – it was widely argued (in discussions about poor people rather than with them) that medical care was a luxury compared to efforts further ‘upstream’ to promote economic development and basic sanitation… In the face of rapid medical advances, and dizzying fluctuations in both the cost (to say nothing of price) and effectiveness of these advances, it was increasingly the global poor who were asked to make do with the ‘basic minimum package.’ (Who Lives and Who Dies, 2015).
With Dr. Farmer’s caveat about the trap of selectively foregrounding preventative medicine in “resource limited” settings, I believe the chronic requires the attention of all of us working in healthcare. It is my hope that the paradigm of slow violence might highlight some of the reasons our healthcare community is structurally and psychologically disincentivized from preventing the chronic — and in so doing, that it might equip professionals and activists alike with tools to help locate themselves in this dialogue.
Raghav K. Goyal is currently a third year medical student at the Larner College of Medicine in Vermont. He is interested in bikes, books, and knowing others.
References
Berger, John. “Fellow Prisoners.” Guernica, 15 Jan, 2011, www.guernicamag.com/john_berger_7_15_11/.
Butler, Judith. Notes toward a Performative Theory of Assembly. Harvard University Press, 2018.
Chetty, Raj et al. “The Association Between Income and Life Expectancy in the United States, 2001-2014.” JAMA vol. 315,16 (2016): 1750-66. doi:10.1001/jama.2016.4226
DeLauro, Rosa L. “H.R.2426 – 111th Congress (2009-2010): MEAL Act.” Congress.gov, 15 May 2009, http://www.congress.gov/bill/111th-congress/house-bill/2426.
Farmer, Paul. “Who Lives and Who Dies.” London Review of Books, 5 Feb. 2015, www.lrb.co.uk/v37/n03/paul-farmer/who-lives-and-who-dies.
Gawande, Atul. “The Cost Conundrum.” The New Yorker, accessed 19 June 2017, www.newyorker.com/magazine/2009/06/01/the-cost-conundrum.
Hawkes, C., Smith, T. G., Jewell, J., Wardle, J., Hammond, R. A., Friel, S., . . . Kain, J. (2015). Smart food policies for obesity prevention. The Lancet, 385(9985), 2410-2421. doi:http://dx.doi.org.ezproxy.uvm.edu/10.1016/S0140-6736(14)61745-1
Hanna-Attisha, M., Lachance, J., Sadler, R. C., & Schnepp, A. C. (2016). Elevated Blood Lead Levels in Children Associated With the Flint Drinking Water Crisis: A Spatial Analysis of Risk and Public Health Response. American Journal of Public Health,106(2), 283-290. doi:10.2105/ajph.2015.303003
“National Health Expenditure Accounts.” Centers for Medicare & Medicaid Services, 11 Dec. 2018, www.cms.gov/Research-Statistics-Data-and-Systems/Statistics-Trends-and-Reports/NationalHealthExpendData/NationalHealthAccountsHistorical.html.
National Center for Health Statistics (US). Health, United States, 2015: With Special Feature on Racial and Ethnic Health Disparities. Hyattsville (MD): National Center for Health Statistics (US); 2016 May. At a Glance Table. Available from: https://www.ncbi.nlm.nih.gov/books/NBK367644/
Nixon, Rob. Slow Violence and the Environmentalism of the Poor. Harvard University Press, 2013.
Pan, X., Li, G., Hu, Y., & Wang, J. (1997). Effects of Diet and Exercise in Preventing NIDDM in People With Impaired Glucose Tolerance: The Da Qing IGT and Diabetes Study. Diabetes Care,20(4), 537-544. doi:10.2337/diacare.20.4.537
Primary Prevention of Coronary Heart Disease in Women through Diet and Lifestyle. (2000). New England Journal of Medicine,343(24), 1814-1815. doi:10.1056/nejm200012143432415
Ram, N. M., Moore, C., & Mctiernan, L. (2016). Cleanup Options for Navajo Abandoned Uranium Mines. Remediation Journal,26(3), 131-148. doi:10.1002/rem.21473
