'Dramatic Societal Events' Tied to Patients' Health

Clinicians should keep in mind the serious physiological and psychological effects on patients from a dramatic public event such as a divisive presidential election, researchers said.

"Campaigns that give voice to the disenfranchised have been shown to have positive but short-term effects on health," David Williams, PhD, MPH, of Harvard University, and Morgan Medlock, MD, MDiv, of Massachusetts General Hospital, both in Boston, wrote in a "Medicine and Society" review for the New England Journal of Medicine.

"Thus, increases in psychological well-being, pride, and hope for the future are likely to be evident among Donald Trump supporters. At the same time, events linked to the recent presidential campaign and election have given rise to fear and anxiety in many Americans," they noted.

Recent years have brought an increase in racial resentment, animosity, and political polarization in the U.S., the authors noted.

"The election of President Obama played a key role: research indicates that Obama's election led to increases in the rate of belief among white Americans, especially conservatives, that racism no longer exists," they wrote.

"At the same time, in the wake of his election, one third of white Americans indicated that they were 'troubled' that a black man was President," the authors continued. "The Tea Party movement emerged with anti-minority rhetoric ... and white support for addressing racial inequities decreased."

And although it can't be causally linked, recent studies have found that living in areas with high levels of prejudice "is associated with an elevated risk of disease and death," they wrote.

Other health effects may also ensue, Williams and Medlock added. "Other research using relatively small, non-representative samples has documented that incidents of racial discrimination experienced by teenagers predicted flatter diurnal cortisol slopes and lower cortisol awakening response in young adulthood, elevated levels of endocrine, cardiovascular, and metabolic parameters at age 20, as well as epigenetic patterns of aging at age 22."

Clinicians can help by giving patients an outlet for their anxieties, according to the authors. "At a minimum, it's important that healthcare providers actively work to create safe spaces, where patients' fears and concerns are listened to and met with compassion and support ... Clinicians can actively and sensitively inquire about patients' experiences, worries, and fears, and the effects that they may be having on the patient's health and symptoms."

They suggested other steps healthcare providers could take:

• Stand up against hate crimes, discriminatory political rhetoric, and incivility. "It is also important to make clear that their services are provided to all, regardless of race, ethnicity, nationality, socioeconomic status, religion, or citizenship status."
• Educate yourself about local and federal policies and their effects on vulnerable people; make sure patients know where they can seek help.
• Consider becoming an advocate or getting involved in policy-making. "They can begin within their own institutions to generate greater awareness of the challenges faced by stigmatized populations and to foster a culture of inclusion with a greater emphasis on promoting health equity," the authors said.
• Advocate for research and perform studies "that systematically assess the health effects of the societal climate and policies. Future research could delineate the psychosocial and biologic pathways by which these effects occur and identify the factors that facilitate effective coping and resilience."

The article "is very important as far as helping to explain the disparities issue," said Thomas LaVeist, PhD, chairman of the Department of Health Policy and Management at George Washington University in Washington, in a phone interview. "When we look at differences in health outcomes across race or socioeconomic groups, and immigrant populations, we often make assumptions that there are biological differences between groups ... But we're not accounting for people having different experiences in the broader society, and for people responding differently to the same social experiences."

LaVeist expressed some skepticism, however, at the idea of clinicians trying to address these problems. "I wonder to what extent clinicians are trained or equipped to take that on, and whether that is appropriate," he said. "Most clinicians don't have the training to deal with these social factors."

Also a practical matter, the way primary care is practiced in this country, clinicians have very little time, and if they're in a small practice with a lot of patients from economically disadvantaged backgrounds, "you're going to see more patients with these types of problems" -- but the practice's economic survival is tied to seeing as many patients in as short amount of time as possible.

Shervin Assari, MD, MPH, a research investigator in psychiatry at the University of Michigan in Ann Arbor, agreed that the article was important and useful but said that -- contrary to what some might expect -- in terms of the effect on certain minority groups, blacks might actually fare better than their white counterparts in times of heightened racism and economic uncertainty.

"The history of racism and prejudice and discrimination is nothing new," he said in a phone interview. "Over the past several decades, the group who has shown increases in its mortality rate, suicide, and alcoholism -- it's white males who have low education levels."

"Hostility and anger kills people through heart attacks -- but it kills more whites than blacks," as does depression, Assari continued. "My argument [for why blacks fare better] is that they are used to it." So while a divisive election or other dramatic societal events do have an effect on the population, "I don't agree the effect would be that big."

Assari also had another take on the suggestions the authors made for healthcare providers. "It's very difficult to undo a structural change through small behavioral changes among some of the doctors," he said. "A better solution would be a policy solution, to undo some of the new administration policies ... It's not [going to be solved by] a change in the behavior of physicians who provide care one by one for patients; it's fighting back against some policies that would damage the minority population on a larger scale."

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