Should Doctors Prescribe Cleaner Air? Better Housing? A Dance Class?
Dr. Barry Zuckerman and his colleagues at Boston Medical Center were tired of fighting battles they couldn’t win. No amount of quality care could help their pediatric asthma patients over the long term if those children were being discharged to homes with mold and vermin. Zuckerman needed a new specialist on his team: a lawyer. In 1993, Zuckerman started what later became known as a medical-legal partnership. In an MLP, attorneys work alongside health care providers to address the social and legal issues that stand in the way of a patient’s well-being by, for example, writing letters to landlords to address substandard living conditions, or helping patients access assistance such as food stamps or Medicaid.The model emphasizes that health care providers need to do more than examine patients in a clinic to treat them effectively. Studies of MLPs have found they lower hospitalization rates, reduce asthma flare-ups, and generally improve well-being. Today, over 450 health organizations, across 49 states and D.C., have an MLP. Lawyers in MLPs not only tackle individual cases but often train physicians in advocacy so they can influence legislation and policy to make structural changes in their communities.Yet such practices are still relatively rare. And in the decades since Zuckerman began Boston Medical Center’s MLP, Americans’ well-being has by many metrics deteriorated. The prevalence of chronic disease is on the rise. For those without a college education, average life expectancy is falling. And more and more people are diagnosed (or self-diagnosed) with poor mental health, to the point that some experts warn of a mental illness “epidemic.”Why is our society getting sicker? In Empire of Madness: Reimagining Western Mental Health Care for Everyone, Khameer Kidia argues that an unjust world is an unhealthy world—that sickness, and in particular mental illness, can result from the gross misallocation of resources stemming from colonialism, capitalism, and the ongoing predations of rich countries and corporations. Kidia, an internist at Brigham and Women’s Hospital in Boston, reassures readers that his focus on structural and historical contributions to ill health are not intended to discredit modern medicine. “Fear not: I’m a physician, not a scientologist,” he writes in the introduction.In questioning the standard paradigm of mental illness, Kidia joins a line of physicians such as Bessel van der Kolk, Gabor Maté, and Rupa Marya, as well as social psychologist Jonathan Haidt, whose inquiries into the sources of mental distress push beyond standard biomedical approaches to emphasize how factors such as trauma, cultural environment, and social media affect well-being. But Kidia writes from a unique position: He splits his time between practicing medicine in Boston and overseeing a mental health nonprofit in Zimbabwe, where he was born and raised. As he moves between countries, both insider and outsider at any given moment, he grows more and more attuned to the culturally specific nature of healing, and critical of interventions that don’t account for the simple facts of poverty and injustice in people’s lives.Kidia calls at the outset of his book for “the end of psychiatry,” at least as a practice that limits itself to “a tiny toolbox”—a neurochemical model of mental distress overly reliant on diagnoses and drugs. Many instances of mental distress are not so much disorders as a “rational reaction to colonialism and capitalism,” he writes. “My patients are not suffering from depression; they’re suffering from oppression.” To treat such symptoms requires reckoning with the root causes: the legacies of colonialism, capitalism’s intense pressure to produce and consume, and systems that leave so many people’s basic needs unmet even as billionaires proliferate. “For the oppressed,” he adds, “psychiatry does not heal so much as mollify.”Kidia begins with his mother’s nervous breakdowns, periods of what her doctors describe as “paralytic mental distress” lasting weeks or months, which she had experienced since she was a teenager and one of just a few girls of color at an elite boarding school in what was then Rhodesia. His mother has never received an official diagnosis for these episodes, and, Kidia later discovers, “nervous breakdown” is not itself an official diagnosis, even though it is her preferred term and his—with its connotation of a break, or hiatus, from the ordinary demands of society.Kidia writes that “when she is in debt or her bank balance is low, she develops severe, often crippling anxiety.” Her mood fluctuations affected Kidia profoundly. No matter how she was feeling, he writes, “her mood would diffuse throughout our home and press up against me until I either let it in and shared it or fought against it, stirring up conflict.” He calls this early experience of intersubjectivity—“that our emotional lives don’t exist in a vacuum”—possibly the most important lesson he would ever learn about mental health.In his work, Kidia sees many cases in which personal and financial misfortune results in health problems. In his early days of clinical training as a med student, he meets Sheila, who had come to the hospital for a scheduled colonoscopy and been seized by chest pain. Asked by a colleague to interpret her electrocardiogram, or EKG, reading, the first one he’s ever read outside a classroom, he’s relieved to see that her printout doesn’t show any sign of a heart attack, although his colleague orders a second EKG to be safe. Before he can continue to treat her, however, Sheila goes missing. Later she explains why she absconded: “The last EKG I got ruined my life,” she tells them. A previous ER visit landed her with a hefty bill, and now she is $50,000 in debt.Kidia observes on her medical chart that she is on an antidepressant and a benzodiazepine. People with outstanding loans are “far more likely to suffer from depression and suicidal ideation,” he notes. One study from England of more than 7,000 people found that those with debts were three times more likely to have a common mental disorder and an American study of more than 27,000 people found those with depression and anxiety were two to three times more likely to have medical debt. This debt, in turn, decreased the likelihood that they would pursue mental health treatment. (As he is treating Sheila, Kidia is himself desperately and unsuccessfully trying to secure $100,000 in student loans to continue his medical education. “Sheila was suffering because she had too much debt, and I was suffering because I couldn’t access debt,” he writes.)As Kidia shifts his attention and his work between countries, he registers how cultural context shapes ideas of what is healthy and normal. When he was 18, he moved from Harare to Princeton, New Jersey, where the median household income is $192,079. He finds himself absorbing the status hierarchies around him—clocking the wealthy kids, and then the truly wealthy kids, princesses and heirs and children of Fortune 500 CEOs. Such status hierarchies, he notes, are themselves bad for one’s health, which is one reason highly and visibly unequal societies like America’s tend to have higher rates of mental illness than do social democratic countries such as Germany.On arrival in the United States, Kidia also finds himself falling behind academically. In Zimbabwe, he was “considered one of the best high school seniors in the country,” yet at Princeton University, he is judged “ineffective and underproductive.” He develops canker sores, acne, and muscle spasms. Then, a friend advises him to try to get diagnosed with ADHD so that he can access productivity-boosting drugs. He grows addicted to Adderall and other stimulants—or, perhaps more precisely, he is addicted to the exhilarating feeling of productivity, which comes to a grinding halt when he crashes during a chemistry exam, taking a few pills before gently laying his head down on his exam booklet and sleeping through the test.Recounting his experience, Kidia probes the distinctions between drug tolerance (needing more drugs to get the same effect), dependence (needing them to function), and addiction (dependence, but without the functioning). He was addicted to his little blue pills; he had lost control over his life because of a drug he felt compelled to take. But the common metaphor of addiction as a brain disease, he writes, doesn’t map onto its complexity, which goes well beyond the limited neuroimaging research on what is popularly understood (and oversimplified) as the brain’s “circuitry.” He cites the neuroscientist Carl Hart, the former chair of psychology at Columbia University, who argues that it is inaccurate to call addiction a brain disease. “There is no brain scan or blood test doctors can do that lights up and allows us to say, ‘Aha, you’re an addict,’” he writes.He locates the source of his own addiction in the mismatch between what was expected of him, and what he felt capable of; it sprang from his desperate attempt “to fit into a mold that made me take those stimulants in the first place.” Addiction is “a phenomenon that society causes, not a ‘brain disease’ that people have.” This view means less judgment of those who take drugs—including some of his patients, “who are dependent on and take astronomical doses of stimulants and opioid painkillers multiple times a day,” all while caring for their children, working, and paying taxes. It would mean more scrutiny of companies like Purdue Pharma and the doctors who too readily would “discharge patients with monthlong prescriptions for Percocet or Vicodin or oxycodone after simple procedures that heal after a couple of days.”Kidia also questions who qualifies as afflicted. As he carefully edges into the apartment of Daniel, a homebound patient with low blood pressure and what, since 2013, the Diagnostic and Statistical Manual of Mental Disorders has classified as “hoarding disorder,” Kidia inhales the smell of boiled cabbage and cat urine, before tripping over a milk carton and scattering a pile of papers onto the floor. Daniel’s behavior is a problem: Among the many things he hoards are medications that have expired or that he is no longer supposed to be taking, all of which he sheepishly presents to Kidia in “a plastic bag bulging with pill bottles.”But Kidia wants to know why hoarding, which his medical textbooks define as pathological “when it is harmful to either the patient or others,” is only problematic when observed in patients like Daniel. What about, say, Jeff Bezos, “who hoards more than $200 billion made on the backs of underpaid, contingent warehouse workers who are twice as likely to be injured as other warehouse workers”? Daniel, “with his harmless piles of People magazines,” has been labeled diseased, yet Bezos and the other nine men at the top of Forbes rich list, whose collective $1.5 trillion in assets could end world hunger many times over, are the ones harming countless others with their hoarding. Rich countries hoarded the Covid vaccine, he points out, while his mother “and other Zimbabweans waited, uncertain if vaccines would ever come their way at all.”The home visit also helps Kidia understand Daniel’s hoarding. Kidia writes that as he watched the sun pour in through the window of the apartment, “I could feel Daniel’s nest, constructed scrap by scrap, giving me a hug.” Now that Kidia has for several years seen up close America’s privations and excess, he can grasp how such a deluge of belongings might serve as a balm of sorts, “how the safety of all this stuff could comfort someone who feels insecure.”The Mount Sinai Visiting Doctors program that took Kidia into Daniel’s home is unusual. Most medical care today is delivered in hospitals or clinics, where doctors can see more patients, more quickly. He describes in painful detail a system that limits physicians to 10- or 15-minute visits, incentivizes them to order costly tests and scans, and relies on drugs and devices to tranquilize and restrain instead of investing in the human personnel that can provide genuine care.In one especially heartrending passage, he’s asked to prescribe the powerful antipsychotic Haldol to an elderly woman, Geraldine, who keeps getting out of her hospital bed, which sets off the bed alarm and wakes up her roommate. Anti-psychotics can increase the risk of death in the elderly population, but Geraldine’s nurse is worried about her taking a fall, which can be harmful to a frail patient and costly for the hospital. He asks for a sitter, someone “whose sole job is to sit and watch a patient.” They are used when someone is on suicide watch, or to keep patients like Geraldine from falling out of their beds. But the hospital is out of sitters, and the nurse must attend to other patients. Kidia, too, is paged to attend to a lifesaving intervention for a patient with a dangerously elevated heart rate. Eventually, against his better judgment, he is compelled to prescribe the medicine for Geraldine, because “it is cheaper for hospital corporations to make us quiet patients with antipsychotics, or even to physically restrain them, than it is to hire more doctors, nurses, and sitters.” Small wonder, then, that doctors and nurses have been leaving their profession in droves, pushed out not merely by Covid-related burnout but by the moral injury of being unable to practice medicine humanely when corporate managers or private-equity owners are breathing down their necks.What do patients actually need from medicine? And what is the doctor’s role in delivering it to them? Kidia insists on the hybrid role of physician-advocate, duty bound to use their institutional authority to push for structural change in the wider world. He criticizes the gatekeeping function of diagnosis, the need for a label to unlock access to care. And while he is careful to note that emotions are simultaneously biological and psychological, a purely medical model is often not the right tool for addressing the source of distress.Kidia makes an eloquent case for the practice of “social prescribing,” in which health care workers “prescribe (sometimes via literal written prescriptions) social and structural resources—from food to housing to social events to exercise—that patients need to live healthier lives.” Of course, gaining insight into what might spark genuine healing—would this patient benefit more from a Zumba class or a walk in the forest?—would require more knowledge of a person’s life than a 15-minute doctor’s visit will typically yield. Young people, who report over and over they feel detrimental impacts from social media yet feel compelled to participate, may warrant a prescription for more in-person connection.Health care providers, he concludes, should first and foremost offer their patients humanity: presence, attention, nonjudgmental listening. Mental health care can also be provided by, simply, people who care. The Friendship Bench is an innovative Zimbabwean mental health intervention in which local grandmothers are given basic training to counsel people in their community. Grandmother and patient meet weekly on a designated bench in urban Harare, the capital, an outdoor setting that also serves to destigmatize therapy. The program, developed by Dixon Chibanda, one of the country’s 12 psychiatrists, was shown to improve patients’ mental illness symptoms more effectively than typical medical care, and has been fêted in venues from Davos to the World Bank.The Friendship Bench is not a panacea. When Kidia studied it in a rural setting, he found that few people were able to prioritize traveling from their villages to visit the bench. An exception was the small subset of study participants who received a $5 travel stipend. He suspects that the weekly $5 disbursement may have been more responsible for the participants’ improved mental health, rather than the bench. When poverty is causing depression, he concludes, the most effective prescription is money.Mental well-being requires not just care and social connection, but some measure of redistribution. This insight implies that mental well-being requires not just care and social connection, but some measure of redistribution. In the United States, at least, both financial resources and human relationships are distributed unequally. College-educated Americans are more likely to marry and have far more close friendships than their peers without higher education, and economic inequality has grown to almost farcical levels. On an international scale, colonialism enriched some countries while impoverishing others, a historical injustice with far-reaching effects.Scribbling on his prescription pad, Kidia comes up with a remedy that is, at its heart, a shift in thinking. The Bantu concept of ubuntu, meaning “the force that inextricably ties our mental states with those around us,” is a way of acknowledging that our own well-being depends on that of others, that we will never be healthy and well if others, near and far, are sick and deprived. The healing he envisions takes the form of a global redistribution of wealth through taxes on millionaires, reparations on a worldwide scale, and multilateral debt forgiveness through institutions like the International Monetary Fund and the World Bank. Healing also looks like Friendship Benches, or policies that allow people to work less and care more, or a blessing from his mother, in the depths of a depressive spell, to leave Harare and go finish his book.In essence, Kidia has written us a prescription for more humanity, both at the structural and interpersonal levels. In an era of tax cuts for the rich, the slashing of foreign aid, and supercharged xenophobia, this call for a deeper and more encompassing humanity can feel as distant a possibility as a global wealth tax. But as he shows over and over, there is no shortage of evidence that more humanity—whether in the form of time with friends and family, a connection to our community, or a welfare state that underpins a dignified life—is the cure for what ails us.