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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