What Growing Up In India Taught Me About Belonging and Social Determinants Of Health

I don't typically make New Year’s resolutions, but it felt right given the jolting 2+ years we have just experienced. While rummaging through the basement for Holiday decorations several weeks ago, I found this photo I took during the summer between high school and college. The picture is of the street I grew up on before moving to the US at seven.?Immediately upon seeing it, I was overcome with a strong emotion that I still can't seem to shake. I can only describe it as a mix of sadness, longing, hope, joy, and love combined with a fiercely overwhelming realization of the importance of belonging.

Let me orient you to the photo because it can be disorienting and perhaps shocking if you haven't visited or lived in a rural developing country.

To the left of the two men in the foreground on the right (the man on the left is my oldest uncle, and on the right is a close family friend) is the house I was born in; it's the family home where my siblings and I spent every summer until I started college. The blue window on the left looks into a small clinic where my grandfather, mother, and youngest uncle saw patients "after hours." My grandfather opened the first hospital in our town. It was a small hospital, but it ran like a machine and at a pace that could rival any episode of ER. It wasn't uncommon for my grandfather to be paid in vegetables instead of money; at times, he was paid in nothing more than genuine gratitude and heartfelt blessings. It's nearly impossible to witness that kind of love for patients and the people in your community and not have it surge through your blood. It's why so many of my family members and I decided to pursue careers in healthcare.

If you look down at the row of connected homes on both sides, you will notice that a few have stoops. The stoop on the furthest left was the nightly gathering place for all the women and girls to gather late after supper. After the rest of the street went quiet, many women congregated to share stories, sing songs, and gossip. I looked forward to those evenings because it meant I could stay up into the wee hours of the night and listen to "adult talk."

The light blue building on the top right is where the tailor lived; his daughters were close friends of mine and my sister's. My best friend Gita (the daughter of a farmer) lived behind us in a home built primarily of mud covered by a terracotta-shingled roof, much like the home you see across the street from mine where the blacksmith lived. The family that lived at the furthest end of the street on the right owned the pharmacy adjacent to our hospital. Their youngest son, a pharmacist, was my youngest uncle's best and lifelong friend. Relative to the others in the town, my family was considered affluent, so convention dictated that I shouldn’t be overly familiar with some members of the street. In truth, I had been inside every one of those homes and enjoyed humble meals in almost all of them at some point.

My intention is not to overly romanticize those years because negative aspects like poor sanitation and related diseases occurred in these living conditions. Every summer, it's like a switch inside me was flipped upon landing in India and didn't flip back until I returned to Florida. It was unsettling how my younger brother and I would board the plane feeling like important people (coming from America was a huge deal back then), but we returned to the US having completely forgotten how to speak English. After those trips, I distinctly recall thinking: "I cannot possibly describe how big my heart feels right now." I know now that what I felt was a strong sense of belonging to an intimate community, something much bigger and more powerful than myself.

I have believed for some time that the world is collectively suffering from a pandemic of loneliness, but what I really mean is that we are increasingly losing our sense of belonging. The issue of loneliness is a hot topic in healthcare; however, it's essential to point out that loneliness is not the same as being alone, one being a mindset and the other being a physical state.

Despite remarkable technological advances in healthcare, our impact on overall health outcomes could be better. The US spends more on healthcare than other developed countries, but our results are not any better, and, in many metrics like infant mortality or diabetes, we often perform worse. Since I started medical school 25 years ago, one thing has remained true. The clinical intervention (i.e., procedure/surgery, medication, medical device, telehealth, digital health, etc.) is responsible for only a small percentage of the eventual outcome. The more significant component (up to 80%) is this amorphous gelatinous matter that we cannot directly control and often lump into the social determinants of health (SDoH) category. I have heard some healthcare thought leaders declare that SDoH is just another way to describe poverty, but I have known from childhood that this is not true. I would argue that SDoH and vitally important issues like health equity are, at their root, a result of a diminished sense of belonging and connectedness to our community.

So, my 2023 resolution is this: I will embody, create, inspire, and be inspired to foster a sense of belonging — in my corporate roles, clinical work, personal life, and community. Wish me luck!?