Heidi Gullett, MD, MPH

Fellow Project 

Upstream determinants of health, such as poverty, cause inequities in health outcomes for individuals and populations. Poverty remains one of the most recalcitrant determinants of health, often layered with the complicated effects of systems and structures that perpetuate inequities around race, gender, sexual orientation, class and religion. Clinicians, working in a health system that increasingly commodifies care and actively discourages integrating functions, see the results of these upstream health determinants, but are not supported to meaningfully address them. As a family and public health physician, Dr. Gullett believes that it is vitally important to understand the root causes of the current fragmented system and to address the identified opportunities for integration of care to reduce the health effects of poverty. 

To that end, Dr. Gullett has been piloting a pragmatic program to address the conditions of both individual and community poverty known as Getting Ahead in a Just-Gettin’-By-World with patients in her clinical practice. This program is built on the framework of Bridges Out of Poverty, which enables people living in all 3 economic classes (poverty, middle class and wealth) to work together toward solving poverty through shared understanding. Getting Ahead consists of 16 three-hour sessions in which participating “investigators” – people living in poverty – simultaneously examine their own and their community’s experience of poverty while developing their own future story. Structured discussions consider historical and contemporary conditions, causes of poverty (individual behavior/choices, community conditions, exploitation and systems/structures), language, resources, and the hidden rules of class, among other topics.

During this ongoing research, Dr. Gullett has observed that Getting Ahead investigators frequently identify their primary care team as their (often sole) source of bridging social capital. Bridging social capital is a critical resource necessary for moving out of poverty. As a Nova Institute Fellow, Dr. Gullett is systematically building on this observation, using methods that enable understanding of Getting Ahead investigators’ life-course trajectories, to inform understanding of how individuals move out of poverty, and how primary care can be better understood and supported to serve as an impetus for movement out of poverty through bridging social capital. Elucidating the value of primary care in cultivating social capital as a means for movement out of poverty has the potential to serve as a key element of broadly characterizing and redesigning the role of primary care as a force for integration in the US health system.