To quote Paul Farmer, MD, “infectious diseases have a predilection for the poor.” The word “poverty” means “denied”, and it’s not hard to imagine that people denied access to clean living conditions, a solid education, a dignified job, and a genuine welcome into their community would be sicker than people with all of these things. In fact, science has demonstrated this to be true time and again. Science has also repeatedly demonstrated that exclusion from community has immediate, long-lasting, and potentially fatal ramifications for humans. There’s a concept called “allostatic load” that assesses the amount of stress placed on an individual beyond that which is healthy. For some people living with HIV, the allostatic load becomes overwhelming. The cumulative burdens of HIV, poverty, anti-blackness, and homophobia are simply too much and the only way out is to surrender.

We live in an extremely wealthy society notable for extreme disparities in healthcare outcomes, disparities linked to income levels, skin color, and even HIV status. The average age of death for a person living with HIV in the US is 52 years of age. As you will read in other sections of this blog, I call these stupid deaths.

Ours is a harsh, judgmental society, strands of which go back to the Puritanism of our ancestors. As a society, we don’t like people who we see as either physically “dirty”, such as those experiencing homelessness, or sexually “dirty”, such as homosexuals. Homelessness and HIV metastasize from addressable evidence of structural sin to public stains resulting from other people’s immoral behaviors. Looked at in this light, is it any wonder that the very people who most need to be welcomed into community retreat from all of the ugliness put upon them?

The challenge here is enormous, especially for clinicians. We are trained to focus on and treat disease, not prevent disease. Prevention of diseases caused by the adverse impact of the social determinants of health means changing society. That’s a very long-term proposition without guaranteed success.

What I can guarantee you is that people are stupidly suffering and needlessly dying today because that are put to the margins of our society and then discarded. These are the people I know how to help. I can’t change the big stuff, those are challenges for others. What I can do and what I have done is identify people suffering under the weight of too many life stressors, give them access to a community of helping hands, and empower them toward greater self-efficacy in a society where they aren’t valued.