We keep this love in a photograph We made these memories for ourselves Where our eyes are never closing Hearts are never broken And time’s forever frozen still. . .
— Giuseppe Conigliaro, Porto Empedocle, Sicily, circa 1962
I recently needed to go through hundreds of family photographs, some going as far back as the last 70 years. It was both sad and heartwarming to look at family and friends over the years, including those who have passed on and many still with me, but looking very different and much older today. I still can’t believe that I used to be that skinny! It was interesting looking at changes in people, fashion, environments, automobiles, and even photo-taking behaviors. No one from the 1970s made a contorted face or hand gesture. I went through black and white pictures of my parents and grandparents back in Sicily, our ancestral home, where my grandfather ran a small grocery store near the center of town. Years later, the whole family would leave Sicily for better opportunities in America. In the pile were grainy Polaroid pictures from vacations in the Catskills, Cherry Hill, New Jersey, and Valley Forge, the old house on 84th Street, pictures of Aunt Nellie, Nonna Alfonza, Uncle Guido, and so on. It was interesting to see that in many of the images that were taken before the 1990s, there were cigarettes in the hands of my dad, uncles, and some of my brothers-in-law. They smoked everywhere; outdoors on the beach, or other public areas, or indoors at a restaurant or at home with the rest of the family including around young children. There were also photos of people working in factories and in crowded rooms. Different social norms, different circumstances.
How does looking at a bunch of old photographs relate to general internal medicine? I think a lot. Photographs capture a moment in time and represent a still image of our lives. I wondered what the people I see in these photographs were thinking at the time they were taken. What were their hopes and aspirations? I feel that from my position, viewing their lives years later, and knowing what happened to them, I somehow, retrospectively, have a view into their future. A sort of retrospective cohort study by images. I look at these photographs knowing how things turned out for the subjects in them. Some turned out good, some not so good and others pretty bad.
Through these images, I also get a glimpse of the prevailing social norms and issues of the time. I now look at that through the lens of the concept of social determinants of health, the theme of this month’s Forum issue, and the upcoming SGIM National Meeting in Birmingham, Alabama. Photos of immigrants who don’t know the language of their new country, who I know faced discrimination, worked hazardous jobs under poor conditions, smoked, lived in substandard housing, and lacked access to affordable health care. These photos were taken at a time when the effects of the social determinants of health were not as well appreciated and the resources to combat those effects scarce or non-existent. They were also taken at a time when the United States was a land of opportunity and people from another country could come and improve their lives. It is imperative that we as providers became familiar with the social determinants and how to intervene.
This month’s Forum features articles on the social determinants. Dr. DeSalvo continues her series by celebrating the people of SGIM. In the domain of medical education, Dr. Cacace tells us how to incorporate into our clinic precepting and Dr. Agonofer and colleagues share their experience on how to get our learners to act on them. Our Morning Report from Dr. Holtzman touches on an aspect of social determinants as well. These should get you in the right mind set for Birmingham next month. In addition, we also include an update on E/M coding from Drs. Goodson and Miller, learn about knowledge and attitudes around marijuana by Drs. Knapp and Jindall.
See you next month!