How Being Poor Makes You Sick

Some patients are being "prescribed" bicycles and groceries as doctors attempt to treat the lifestyle consequences of poverty, in addition to its medical symptoms. Can it work?
Lucy Nicholson/Reuters

When poor teenagers arrive at their appointments with Alan Meyers, a pediatrician at Boston Medical Center, he performs a standard examination and prescribes whatever medication they need. But if the patient is struggling with transportation or weight issues, he asks an unorthodox question:

“Do you have a bicycle?”

Often, the answer is “no” or “it’s broken” or “it got stolen.”

In those cases, Meyers does something even more unusual: He prescribes them year-long memberships to Hubway, Boston’s bike sharing program, for just $5 per year—a steep discount from the regular $85 price.

“What we know is that if we are trying to get some sort of exercise incorporated into their daily routine, [the bike] works better than saying, ‘Take x time every day and go do this,’” Meyers told me.

The bike-prescribing program is paid for by the city. For patients without bank accounts, Boston even puts up its own city credit card. Meyers thinks the two-wheeled solution tackles several problems at once.

A Hubway bike in Boston (Louis Oliveira/Flickr)

“Boston is pretty compact, parking is always a problem, and getting around on a bicycle makes all the sense in the world,” he said. Plus, doctors at Boston Medical Center use their electronic medical records to prescribe the bikes, and they plan to measure how patients’ use of the bikes tracks with their weight and health over time.

Meyers realizes that sedentariness is one of the many ills that afflict the poor to a greater degree than the rich. People earning less than $36,000 are far less likely to exercise than those earning $80,000 or more. Low-income people may live in dangerous areas, have little free time, lack access to parks, or some combination.

The bike program is one example of the various ways physicians are attacking a vexing problem that’s not in any medical handbook: Poor patients are sicker, and their poverty actually makes them sick.

How ‘Toxic Stress’ Damages the Brain

One in every six Americans lives in poverty–for an individual, that means earning less than $11,670 per year. The immediate lifestyle implications of such an income are clear: It’s not enough to buy a decent one-bedroom apartment in most cities, let alone a gym membership, fresh produce, or access to high-end medical care. A healthy diet, as one study determined last year, costs $1.50 more per day than an unhealthy one.

And it’s well known that low-income people aren’t as healthy. People of a lower socioeconomic status have a 50 percent higher risk of developing heart disease, for example. Writing in the New York Times, Annie Lowrey found that though Virginia’s Fairfax County and West Virginia’s McDowell County are separated by just 350 miles, men in the richer Fairfax County have “a life expectancy of 82 years and women, 85, about the same as in Sweden. In McDowell, the averages are 64 and 73, about the same as in Iraq.”

But a growing body of evidence suggests that the very condition of living with no money, in a tumultuous environment, and amid stark inequality can alter individuals’ gene expression. What’s more, the pressure of being poor sometimes weighs so heavily that the body pumps out more stress hormones, which ravage the immune system over time.

Poor nutrition, trying times, and environmental toxins in childhood can turn certain genes “on” or “off.” Even poor children who seemingly overcome the hardships of poverty—by making good grades and adapting socially—tend to have higher levels of stress hormones, blood pressure, and body mass index than their wealthier peers.

"Exposure to stress over time gets under the skin of children and adolescents, which makes them more vulnerable to disease later in life," says Gene Brody, founder and director of the University of Georgia Center for Family Research.

Child-rearing problems that are more prevalent among poor households, such as chronic neglect or a parent's incarceration, compound on money woes and congeal into something known as “toxic stress.” These “adverse childhood experiences” jab at the brain at critical moments in its development, changing the architecture of key brain structures and setting the stage for long-term anxiety and mood-control issues.

“If you have a whole bunch of bad experiences growing up, you set up your brain in such a way that it’s your expectation that that’s what life is about,” James Perrin, president of the American Academy of Pediatrics, told me.

In a groundbreaking study in Science last year, people who were primed to think about financial problems did worse on a series of tests that involved decision-making—a sign that physical scarcity can make it difficult for our brains to free up enough space for long-term planning.

One study found that the anxiety of living in poverty is a stronger predictor of mental health problems than going to war. Food-stamp recipients cannot use their benefits to buy diapers, and last year, a team of researchers at Yale University’s School of Medicine found that mothers who couldn’t afford diapers for their babies were more likely to feel depressed and anxious.

These worries can leave their mark on children, both in the form of a more volatile childhood environment and, potentially, through the mother’s own genetic makeup: Animal studies have shown that anxieties about certain stimuli can be hereditary.

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Olga Khazan is a staff writer at The Atlantic, where she covers health.

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