The veterinary health gap

Campbell,Courtney;

Barlow, a one-and-a-half-year-old neutered setter mix shuffled into the exam room. Almost apathetically, he stood in the center for a moment and then sniffed his way around the room. Once he found his preferred corner, he half-slouched, half-sat against the wall as if that brief walk had been a full-body workout. The client, a young Black woman with a slightly sallow complexion, followed him into the room.

The primary complaint was a 3-day history of loose stool and 3 episodes of vomiting in as many days. The client added that she had adopted Barlow after he had been found running loose at a dog park. Not only was this her first dog, but she was frustrated by how difficult it was to get to her appointment. Furthermore, her parents had warned her to be leery of medical professionals and their potentially dubious treatment recommendations. After briefly examining the dog, the veterinarian prescribed a 7-day course of metronidazole. With a perfunctory handshake, the client and her dog departed.

The condition of the dog and the woman deteriorated. Additional tests at a different veterinary hospital determined that the setter mix was suffering from more than just a gastrointestinal infection. Although neutered, he had never been vaccinated. He was diagnosed with parvoviral enteritis and ascariasis, which is unusual for a dog his age, and the client was also diagnosed with roundworm, whose zoonotic potential she had been unaware of. They were both treated and are now doing well.

The role of access to care in patient and client health

How much of the dog’s and his human’s diagnosis was due to their shared environment? Had social disadvantages contributed to their medical condition? By adopting this dog without any experience, the client had essentially jumped into deep water. She was drowning, and the metronidazole was supposed to be the metaphorical rescue rope. But wouldn’t it have been better to throw her the rope and teach her to swim? Why treat only her dog instead of trying to improve the circumstances that prompted them to visit the vet in the first place?

In the context of human medicine, social determinants of health (SDOH) are the conditions in the environment where people are born, live, learn, work, play, worship, and age that affect a wide range of health and quality-of-life risks and outcomes (Figure 1).¹ SDOHs have a significant influence on widespread health disparities in people. Because pets and their families are inextricably linked, it follows that human SDOHs have a major impact on the health, well-being, and quality of life of pets and on the human-animal bond. This creates the so-called veterinary health gap.

By and large, veterinary professionals are hard-working, devoted, and compassionate. As a group, we are able to reach beyond the exam room and improve the social conditions that are linked to poor pet health. To be sure, this is not an easy task. Exhaustion, burnout, and compassion fatigue are real concerns and oftentimes it’s difficult to incorporate “life” into work-life balance. However, all of us have the talent, expertise, and duty to commit ourselves to veterinary health, justice, and equity (Figure 2) and find solutions to the social and economic factors that diminish pet health.

Understanding the human-animal bond

The bond between pets and their families is influenced by a host of factors, including previous pet experience, familial influence, culture, socioeconomic status, employment, and many of the same variables that determine human health. Education and training about the social determinants of companion animal health will help veterinary professionals recognize their influence and empower them to make a positive change for their patients. Education about the social determinants of companion animal health can begin early in veterinary school and be emphasized throughout all 4 years. Likewise, such skills as the effective way to take a history (sidebar) and guide clients toward the social services they need can also be integrated into the curriculum.

Community

Social History

Purpose

Helps you get to know each client as a person and pet owner.
Helps client to feel more at ease.
Helps you understand risk factors and background.
Helps you understand how they acquired the pet, including rescue, breeder, previous behavior abnormalities, previous experience with animals, social events with animals.
Information may be key to developing an appropriate differential diagnosis for a particular patient.
If it is not obvious, ask the client what language they prefer to speak in. It is also helpful to know how familiar they are with veterinary medicine and animal health.
Understand diet and high-risk behaviors (ie, off-leash activity at a dog park or near busy highways, etc)

Approaches

Client-centered

“What do you feed him/her?”
“What medications do you give?”
“When was he/she last vaccinated?”

Patient-centered

“Let’s start at the beginning. Tell me...”
“How did this pet come into your life?”
“How many pets have you had in your life? What species were they?”
“How much time do you spend together on a typical day and what do you spend that time doing?”
“How much human food do you feed him/her?”

Enabling families to have more control over their pet’s health by providing salient pet-health information is an excellent way to encourage healthy pet care choices. Knowledge is power, and information is liberating at the personal and community level. The bond between the provider and client can be strengthened through motivational interviewing and conscientious history-taking (sidebar).

Empathy from the health care provider can increase client acceptance of information, decrease mistrust, and improve adherence to life-style change recommendations. At the community level, connecting clients with humane societies, local rescues, and mobile veterinary services can improve companion animal determinants of health. Grief counseling, legal aid, and gerontological counselors are examples of nonveterinary services that can also decrease the veterinary health gap.

The third component of animal well-being is the health care workforce itself. Staff members who have secure employment, flexible schedules (within reason), and financial stability will have greater mental bandwidth to address the social determinants of health for their clients and patients. As the old saw goes, “You can’t pour from an empty cup.”

Diversity, equity, and inclusion

A veterinary profession that is reflective of the general population benefits pet-owning families, the veterinary workforce, and the pets themselves. A commitment to equity and justice is crucial for the preservation of a profession that serves an increasingly diverse population. A decade ago, veterinary medicine topped The Atlantic’s list of “the 33 Whitest jobs in America.”² Today, very little has changed.

To be sure, merely increasing the number of individuals underrepresented in veterinary medicine (URVM) will not by itself solve the veterinary health gap. But concerted efforts to increase URVM populations can benefit those groups, respond to shifting national demographics, and be a powerful recruitment tool that can in time address disparities in companion animal medicine. That is because diversity, equity, and inclusion affect pet health and wellness in various ways:

Access to care

Almost all veterinary professionals agree that there is a need for increased access to veterinary care. Structured programs and partnerships have shaped the field of veterinary social work, which focuses on the bonds between humans and other animals, the healing power of animal companionship, and emotional support for veterinary professionals.

According to a 2018 report released by the Access to Veterinary Care Coalition,⁵ the biggest barriers to veterinary care are financial; in fact, the demographic most acutely affected continues to be ALICE (Asset Limited, Income Constrained, Employed) individuals. This group of hardworking people earn enough to be above the federal poverty line but nevertheless struggle to meet their basic needs. Regrettably, there is a myriad of other barriers to veterinary care, including lack of transportation and transportation supplies (carrier), client reticence, and fear of judgment. Although the magnitude and extent of these barriers can seem overwhelming, there are many opportunities to make a difference.

Commitment to positive change and sustainable solutions

Every member on the veterinary team can drive change and advocate on behalf of everyone involved—families, pets, and the veterinary profession itself. Working for social justice in other sectors (education, government, housing, etc) will have a direct impact on veterinary medicine and animal health as will integrating veterinary health, justice, and equity inro the veterinary curriculum and advocating on the national level for any policy that would improve the social and economic conditions in which people live, particularly pet-owning families and prospective pet owners.

Conclusion

If social conditions affect the type and frequency of illnesses in the pet population, the types of illnesses we treat also shed light on society. Numerous facets of a person’s life (housing, experience with animals, socioeconomic status, cultural and familial experiences, and access to veterinary care) can have an outsized impact in the exam room. Only through a commitment to veterinary health, justice, and equity will veterinarians feel less like they are throwing a rescue rope and more like they are teaching their clients how to swim.

Courtney A. Campbell, DVM, DACVS-SA, is a board certified veterinary surgeon who specializes in orthopedic, soft tissue, and minimally invasive surgery. He practices at VetSurg in Ventura, California. Campbell is the host of 2 podcasts— Anything Pawsible and The Dr Courtney Show— and he also co-hosted Pet Talk, a first of its kind talk show on Nat Geo Wild.