Political Musings on a March

On January 21, 2017, I, as a blessed research fellow without call responsibilities, participated in a local Women’s Day march. The messages of the day, in the context of the last few months of political rancor, had led me to consider how our country’s political and social trajectory might affect a patient’s health.

Ask a nephrologist what the top causes of CKD are, and you will assuredly hear, “diabetes and hypertension,” perhaps followed by a comment about the proverbial hypertension chicken and egg. But what drives diabetes and hypertension? One might say obesity, but what about poverty and social disparities? What about the growing distance between food production and ingestion, or the discovery of “vanishing caloric density”? What about our demanding work culture and love affair with the car? Or our failing education system, which contributes to poor dietary and lifestyle choices? What about the growing connections between climate change and kidney disease (1)?

Political and societal changes are intimately linked to the diseases we see today (e.g., the rise of diabetes and obesity or the historical reduction of disease related to poor sanitation or violent and traumatic deaths). So, what is the number needed to treat or harm for these changes compared to prescribing lisinopril or paying for frequent hemodialysis? I do not know if there is an answer, but I certainly have many questions. Should politics, in its broadest sense, inform my life as a physician? Should what I support as a person, through my actions, discussions, and votes, be influenced by the experiences of my patients as well as that of myself and my family? Should medical students learn about politics and policy alongside physiology, cultural competency, and ethics? After all, our health is affected by policy and our culture, not just our blood pressures and statins.

If providers are to set examples for their patients by eating right, not smoking, and exercising, should we also advocate for sociopolitical changes? Should we be emphasizing renewable energy, implementing green nephrology principles, advocating for a living wage or universal healthcare, and addressing work-life imbalances or the failures of “renal rehabilitation” (2,3)? Many in our country value, by character and/or necessity, hard work and productivity. Should we advocate also for such quaint values as mindfulness, community service, or home-cooked meals?

I wonder, for example, if raising the minimum wage would mean more of our patients could afford healthier food, or perhaps work less and thus afford the time to prepare food at home or go for a walk. Advocating prevention, taking a holistic view of health, and effecting change through political action may improve outcomes more effectively in the long term than focusing on disease management. What if that meant prioritizing the war on poverty, overhauling our education system, or changing our capitalist culture?

In some cases, the connection between politics and our patients’ health is less opaque. To me, obstetric nephrology means preeclampsia and decisions regarding immunosuppression in pregnancy. I have never seen, and hope never to see, acute renal failure from septic or hemorrhagic illegal abortions (4). The legal right to birth control and safe abortions has made this possible in the US and many developed countries. On a different note, the experience of an undocumented immigrant in California, with access to outpatient ESRD care, is in stark contrast to one in Texas who is ineligible for outpatient treatment and therefore shows up to the emergency department routinely for emergency dialysis (5). Politics, not medicine, made that choice.

After the truly noble advocacy of patients and providers, our government made a historic decision to cover ESRD care broadly in this country. This not only allowed the extension of life-saving therapy, but also arguably created the specialty of nephrology as we now know it.

The questions and musings presented here aside, politics and advocacy are like medicine: there is something for everyone. Of note, a recent perspective in the New England Journal of Medicine outlines some issues to consider if you are interested in joining a legislative advocacy organization (6) (also see Table 1). In the end, what motivates you? Is there time in your life to reach out? I am looking for time in mine, although certainly not always finding it. However, if we as providers can’t do it, with our higher education and financial security, how can we expect our patients to?

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References

1. Tomson C, Connor A. Outlook: implications of climate change for nephrology. Nat Rev Nephrol 2015; 11:8–9.

2. Agar JWM. Green dialysis: the environmental challenges ahead. Semin Dial 2015; 28:186–92.

3. Feder J, Nadel MV, Krishnan M. A matter of choice: opportunities and obstacles facing people with ESRD. Clin J Am Soc Nephrol 2016; 11:536–538.

4. Turner N. Obstetric renal failure [Internet]. Hist Nephrol Blog 2012 Available at http://historyofnephrology.blogspot.com/2012/07/obstetric-renal-failure.html

5. Rodriguez RA. Dialysis for undocumented immigrants in the United States. Adv Chronic Kidney Dis 2015; 22:60–65.

6. Griffiths E. Effective legislative advocacy—lessons from successful medical training campaigns. New Eng J Med 2017; DOI 10.1056/NEJMp17404120