Psychiatrist Leslie Bronner, MD, DrPH, cares for patients hospitalized with serious mental illness, discharging them once their health stabilizes. But too many of her patients end up back in the emergency department or inpatient unit with the same illnesses.
Thinking about this persistent challenge inspired Bronner, an assistant professor of psychiatry and behavioral sciences, to examine the community factors that can derail a patient’s recovery—and what can be done to improve them. That deep dive eventually led to the publication of her new book, America’s Health: The Community Is Now the Patient.
In America’s Health, Bronner calls attention to the outsize impact of community conditions on our health and the need for policies and systems that better support our wellbeing. Aimed at health professionals, policy makers, and lay people, the book weaves together research, fresh ideas, and engaging vignettes drawn from Bronner’s clinical experiences.
We recently talked with Bronner about the book and her vision for a healthier community. Our conversation has been lightly edited and condensed for length and clarity.
Duke Psychiatry: What does the phrase “the community is now the patient” mean to you, and why did you choose that subtitle for your book?
Bronner: In my mind, if we’re serious about improving people’s health, we have to diagnose patients and develop treatment plans with a better understanding of community resources and the needs of the community.
We’re spending trillions of dollars treating people, and we’re not getting a great return on our investment. We’re not doing well in terms of infant mortality, maternal mortality, chronic diseases, and life expectancy. If we know that community conditions impact health, then that’s where we need to put more focus.
Duke Psychiatry: Explain the term “social determinants of health” and give an example or two of how they impact our risk for chronic conditions such as heart disease and diabetes.
Bronner: In a nutshell, the social determinants of health are those non-medical factors that impact health, like poor school quality, unemployment, low-wage jobs with no benefits, housing instability, food insecurity, and lack of transportation.
For example, if you live in a poor neighborhood, and you don’t have transportation, and you don’t have access to a grocery store with healthy foods, then you might be relegated to eating food from fast food restaurants or corner stores. It’s going to be high in calories, fat, and salt, and that can lead to conditions like obesity, diabetes, heart disease, and hypertension.
Another way living in a poor neighborhood can impact disease risk is if you have poor school quality, you may not graduate from high school, or if you do, you may not be able to get a job—or you get a low wage job. Sometimes the stress of not being able to make ends meet can lead to depression, anxiety, and health risk behaviors like overeating or substance use disorders.
Duke Psychiatry: You wrote about the need to sharpen our focus on preventing illness. Why is that important, and what are a few strategies for striking a better balance between prevention and treatment of medical conditions?
Bronner: I think the first thing is cost. If we’re not preventing disease, then we’re treating it. A lot of money is going into treating the same people repeatedly, with many of them needing hospitalization and high-tech diagnostics and treatments.
The other thing is suffering. Why are we waiting until people get sick to try to help them? Once you get sick, you can be on a slippery slope of getting sicker and not being able to function.
I think affordable housing and access to healthy foods are at the top of the list of the things that we need to address. We also need to invest in early child development. If a person grows up under stressful conditions, their development is impaired from the very beginning. And I think we need to continue integrating healthcare services—like integrating mental health into primary care and obstetrics clinics—so we can start to really look at the whole person in terms of health.
Duke Psychiatry: In the book, you note that stress is at the foundation of most modern diseases. What are some ways stress leads to poor health outcomes?
Bronner: A little bit of stress is good—it helps keep us safe, and it helps us succeed in our work. But it’s a problem when it becomes chronic. If you have stress, epinephrine increases your heart rate, blood pressure, and respiratory rate to get more oxygen and nutrients to where they need to go in the body. And cortisol stimulates the liver, increases production of glucose, and facilitates the breakdown of protein and fats to be converted into usable energy.
If your heart rate and blood pressure stay elevated, you’re going to be at risk for high blood pressure and cardiovascular disease, including heart attack and stroke. And cortisol from stress can lead to weight gain, which can take you down the road of diabetes and cardiovascular disease. Stress can also increase your risk of dementia.
Duke Psychiatry: What’s your vision for the role of community health workers in improving public health?
Bronner: Community health workers are trained to understand the community, its needs, and the people in the community. There are two sides to community health workers. One is the medical side, where they are care coordinators. If you’re being treated for diabetes in a clinic, they may be available to provide education, make sure you get to appointments, or advocate for you in your appointments if there are cultural barriers. This role is important, but it doesn’t necessarily impact communities.
My thought is to embed community health workers in the community, through county health departments. They start to get to know people. They start to trust the community, and the community starts to trust them. They make connections with stakeholders, and everybody develops a vision together. Once you’ve developed those things, it is through sustainability where you can really have an impact.
Community health workers could also empower and mobilize the communities to persuade lawmakers and policymakers to address issues that affect community health outcomes.
Duke Psychiatry: What do you see as the book’s main takeaways?
Bronner: This book is about changing the narrative about health in this country from clinics and health systems to communities and policies. Community conditions like unstable housing and food insecurity are health risk factors that lead to chronic diseases.
In health systems, we must have a greater understanding about an individual’s social needs to better solve problems around those issues. It’s validating for the patient and can improve care.
And as health professionals, we need to better understand the political system and advocate for the policies that will impact the health of our patients.