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.
“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.
Poverty can also deplete self-control. Smoking and unhealthy eating habits are more prevalent among the poor. A just-published study in the Journal of Epidemiology and Community Health found that girls who were repeatedly exposed to poverty growing up were more likely to be overweight or obese as young women.
“Habits form early,” Daphne Hernandez, the study author and health policy professor at the University of Houston, told me. “You begin to crave those [inexpensive] foods, and making the transition to healthier foods is difficult. Even when you’re not living in poverty anymore, you may still be buying the cheaper foods.”
Hernandez found that for boys, childhood poverty wasn’t linked to adult weight problems—but that isn’t necessarily anything to celebrate. Hernandez thinks it's heavy childhood manual labor that’s protecting the boys from obesity. “If you live in poverty, you’ll enter the labor market earlier,” she said. “For girls, it’s babysitting, but for boys in impoverished communities, they’ll more than likely engage in construction work.”
All of these factors combined mean that when doctors treat poor patients, they’re facing not just one ailment, but two: the illness itself, and the economic fragility that underlies it.
“Our society in general has looked at the issue of poverty in two ways: either a social problem, or a mental-health problem,” said Nadine Burke Harris, a San Francisco pediatrician. “But it's also a serious medical problem.”
A Patchwork of Programs
Some doctors are incorporating the treatment of poverty-related obstacles into their medical routines. In addition to its bicycle program, Boston Medical Center operates a food pantry for food-insecure families.
There are also groups like Health Leads, which was started by the lawyer Rebecca Onie at Boston Medical Center when she was a Harvard sophomore. Today, Health Leads allows doctors in 20 clinics across the country to “prescribe” services like healthy food or safe housing to their low-income patients. Health Leads volunteers (usually med students) set up card tables in clinic waiting areas and try to connect patients with prescribed services.
“A busy mom, a single mom who has two kids and doesn't have a car—when she walks out of the doctor’s office, she will never be more motivated than she is right there,” Health Leads’ marketing director, Connie French, told me. “If all of this can happen in one environment, it's more likely she'll have the time to do the things she needs to do to stay healthy.”
One D.C. woman, who preferred to remain anonymous, recently met with Health Leads in the lobby of the office where she takes her grandson, who lives with her, for asthma treatment. The group told her that the roaches in her mobile home might be exacerbating his asthma and taught her how to trap them with roach motels.
Roughly two-thirds of Health Leads patients secure at least one resource—receiving food, getting their heat turned back on, or finding a job—within 90 days of speaking to a volunteer, Onie told The Atlantic in 2011.
In San Francisco, Burke Harris launched the Center for Youth Wellness, where each child gets a universal screening for adverse childhood experiences as part of his or her first doctor's visit. Depending on the roots of the patient’s stress, the Center may provide counseling for both mother and child. Or it might refer them to a practitioner trained in biofeedback—a type of meditative training that aims to bring relaxation through greater awareness.
“[The biofeedback specialist] hooks the kid up to a bunch of electrodes that measure things like heart rate and breathing,” Burke Harris said. “It helps them to bring a cognitive awareness to kids of their internal states. One thing we know that happens is that kids with toxic stress have decreased engagement of prefrontal cortex. When you have strengthening of the prefrontal cortex circuit, it helps to physiologically and neurologically balance effects of chronic stress.”
Payment and Culture Obstacles
The rub is that Medicaid and other insurance don’t cover many of these services, so the groups are often left scrambling for funds. As Perrin puts it, the programs are “being paid for with a combination of bubble gum and rubber bands.”
French told me that Health Leads also saw that, in addition to the roaches, the D.C. woman’s mobile home had very old carpet that needed to be replaced—but the organization can't afford to buy her new carpet right now.
Meyers said that Boston’s city government, which picks up the tab for the discount bike program, would probably tolerate “two or three” bikes being stolen before they pulled out, but “there are many ways that this could cause a problem. The thing might just end.”
Another challenge is getting primary care physicians to screen for toxic stress and other poverty indicators in the first place.
“That's something the medical community has not responded to at all,” Burke Harris said. “Physicians say, ‘What do you want me to do? I have a 15-minute patient visit.’”
Perrin said the connections between destitution and illness have grown so strong that he’s been moved to push for poverty-combating legislation from a medical point of view.
“We have a role to argue that we need to do things better for America’s families, like the minimum wage, and the Earned Income Tax Credit,” he said. “Those aren’t things doctors have traditionally talked about, but we’re starting to. If patients get the resources they need, we’ll have healthier people.”