There is a dirty little euphemism we all learn about in medical school called health care disparities. It seems the health care system is better at treating heart disease in men compared to women, hypertension in whites compared to blacks, and in keeping rich people healthier across the board in every category compared to the poor. The problem runs deep enough and fundamental enough that it appears no one is immune. It is the problem of poverty that I find particularly perplexing.
This phenomenon is evident across the globe as poor countries continue to see polio and the continent of Africa is ravaged by AIDS, while in the USA antiretrovirals and research, while not curative, have essentially put out the fire in our backyard.
This is a divisive and touchy subject for us physicians. The question of why these problems exist cuts right into basic conceptions and prejudices that we all have to some degree or another by virtue of simply being human.
To be fair, I don’t think any doctor goes into any situation thinking, “I’m going to give substandard care to this patient. I don’t like them.” It is never that simple. The problems are intrinsic to human nature, subtle, and impossible to root out entirely, try as we might.
Furthermore, the difficulties often run far beyond anything the doctors themselves contribute. Poverty interferes with making copays or travelling to appointments without transportation. Poverty makes childcare for siblings out of the question. Poverty makes paying for prescriptions near impossible.
Furthermore, recent studies show that poverty stunts brain development, not only by increased exposure to toxins such as lead, but simply by having parents who are too stressed and too without resources to interact with their children in a stimulating and reinforcing manner.
They live in a culture in which stopping an infant’s cry to soothe them is to weaken them. They live in a culture where the only good child is unheard and unseen, and fear or violence is used to achieve this end. Even in the office, I have witnessed parents or grandparents smack their children and tell them to “shut up” unapologetically. What is a good physician supposed to do? I still don’t know.
A recent This American Life podcast gave an insightful look into how this happens culturally. It vividly describes the difficulties, as well as an ingenious community program designed to break the generational cycle right at the level of the infant. The program has its own heartbreaking costs and realities, as anyone who listens will find out.
Poverty is a cultural barrier that doctors very often cannot comprehend. Most of us never knew poverty. The people of the slums and the rural poor just aren’t the demographic filling our medical schools.
I should know, I come from a poorer, much more rural demographic than most. I am generally intimidated by the lifestyle and background of most my colleagues.
Additionally, I served an LDS mission in more than a few of these poor inner city neighborhoods and experienced a culture shock most middle class white Americans will never experience, yet I can barely begin to comprehend what life must like for the poorest of my patients, or what I can do as a physician to help them.
On top of all this, at least where I train, there is the matter of race. It was in medical school that I learned of a group of scientists at the Tuskegee institute that took a group of black men with syphilis, and denied them treatment, once penicillin came along, because they wanted to learn the natural course of this brain rotting sexually transmitted disease.
My patients, on the other hand, learned this story on their daddy’s knee, repeated over and over. Knowing this history it isn’t hard to make other leaps, such as the idea that HIV was engineered to destroy the Black man.
There is a deep distrust in the black community for the health care establishment that undercuts the ability of doctors to properly care for them. It harms them in the long run, even if the view is not entirely without cause. Trust is vital to any healing relationship.
It has been my experience that these families are the most difficult to get consent from for any procedure. They are the last to agree to seizure medication and the first to go off of it without notifying anyone. They are quick to jump on mistakes, real or imagined. They are the last to unhook their loved ones from the ventilator when there is no hope of them ever waking up.
It is extremely tempting to blame these problems on the individuals themselves, to make them one of those people. Medicaid is a drag on the economy. In a market system it in completely unsustainable, simply because poverty increases the risk that you will need to use the system and spend health care dollars. It’s need grows as the economy tanks.
Wouldn’t it be nice if it was just a matter of having people forgo their cable TV, crack cocaine, and Ipods? While I have no doubt that some of this does and will exist, the truth is never that simple. The truth is that health care rationing is alive and well in America, a nation that spends far more on health care than any other nation. It is done by money and socioeconomic class, with the “working poor” being cut right out of the system.
While we continue to debate the ills of socialized medicine, single payers, market solutions, and whether health care is a right or a privilege, I hope that we can all at least agree that health care is a moral responsibility for all of us to somehow find an equitable way to share the finite resources, yet wonderful developments we have in medicine today. The way I see it, anything less is Unacceptable.
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December 9, 2008 at 1:51 pm
disillusioned
You hit it on the head. I grew up at or below the poverty level…with my “bread-winning” parent employed by the beauracratic part of our shared religion. The only saving grace for this horrible part of the religion is it’s health care…of which cuts and “shared wealth” is still based upon prejudice and indifference. My mother almost died because of prideful physicians–but more so, because of prideful insurance companies and the employer, who passed the rule that a referral must be granted BEFORE CALLING FOR AN AMBULANCE IN AN EMERGENCY!!! I am pretty sure that such a rule was only held for those who could only afford the plan my parents could afford. Meaning that even those who earned more through the church, could be granted non-referreed medical care in an emergency, while my mother had to go seek a dr’s referral while bleeding internally, before she could go to the freaking hospital!
As someone who grew up in a “HUD” world—where everyone’s homes or apartments had at least at one time, been funded and assisted by the government…I live in a very different frame of thinking. I wouldn’t go as far as claiming I “came from the projects”, although some of my past friends acted as though I did. But, instead, I have found the marvelous blessings of my upbringing: that I understand and can comprehend MORE THAN ONE WORLD!!! And am seldom shocked by the poverty and lengths people go to in order to survive. Granted, working for a small while in Mexico still exposed me to an even more different world. But, I understand far better where these kids and families come from. Just the cost of physicians assists in creating the mistrust. I mean, why pay for some person’s services, when they “look down upon you” and just charge you more?
One specific area of distrust I share, is that of mistreatment because of body size. This runs rampant in the medical field. It is so frustrating, especially (will display a prejudice of my own here) from male physicians who truly have no idea what it is like to be female, child birth aged, and dealing with health problems. But, female physicians can be worse!!! And, I don’t even want to go into the problem that has always been true, of refusing medical care to those with disabilities. I mean, the recent upswing of “medical tests” during pregnancy, just to predetermine which fetuses are “worth” life or not is the tip of a huge prejudicial ice berg!
In education, we truly deal with the same problem—with little success. A few schools have done very well when dealing with huge amounts of diversity. Many others, have not. And, when a successful “middle class” school suddenly finds itself facing diversity it’s not prepared for, the outcomes are usually very negative.
I don’t know. I think the key, honestly, lies in the Gospel of Jesus Christ. Not in feeling sorry for others, and having pity for them…which is usually how professionals are taught to approach the problem. But instead, to help others empower themselves. The most successful “programs” and interventions I’ve seen have been just that….people learning to empower themselves in their own neighborhoods, schools, and dr’s offices.
One final note: I have to agree with this. Although I’m not for socialized medicine, and have seen and know the woes of Medicaid—I also have a nephew who is alive today because of Medicaid—and whose family still constantly experience employeer prejudice because of the amount of kids and medical care they deal with. This reality has showed me, that this LDS viewpoint that SO MANY HOLD SO TIGHTLY TO, that capitalism, with it’s inborn greed–is the only answer….is so terribly wrong. As the scriptures say, we (WE) must be willing to live in true equality….which I firmly believe that people will have what they need. Even if that means that my nephew gets the medical care he needs at other’s expense….because honestly, they were lucky enough to have healthy children and don’t NEED the extra money they cling so greedily to! I honestly am seeing more and more, especially once I moved out of the “Mormon Zones” (where I saw it so much too), that perhaps this clinging to “greed”, rather than “sharing the wealth”, will be the crutch and downfall of many…if they are not careful and truly look internally at THEIR own prejudices and assumptive beliefs about the poor, those with disabilities and high medical needs, and anyone who is different from themselves!!!
December 9, 2008 at 2:15 pm
Doc
Disillusioned,
Take a listen to the This American Life program I highlighted. It is an excellent example of a program that “empowers” children, which is exactly why it works. It also requires the parents to sign on, when it is really too late for them, which is heartbreaking.
While markets may work wonders for the price of socks and underwear, I agree that social goods and resources like health care and education can only suffer under the competition and deception encouraged by capitalism. “Caveat Emptor” should not have to apply to taking care of our health or our mind’s development.
December 9, 2008 at 3:34 pm
Di
Great post. So much food for thought. My residency training sandwiched me between NYC’s East Harlem and the affluent Upper East Side…both populations posed tremendous challenges (some different, some in common) as far as implementing care for children.
My current patient panel includes a mix of private insurance and Medicaid…the majority of them come from hard-working immigrant families. I will definitely take a listen to the podcast. Thanks for sharing.