I am a reader. Amazon knows what to feed me. I get notice of books about politics, especially ones critiquing President Trump and the current perils to the future of our democracy. Their computers know I am interested in inequality and behavioral economics. My appetite for these subjects has been whetted by two things:
- I fear the ultimate losses associated with the election of Donald Trump, and the threat he poses to the improvement of health in America. Indeed it seems likely that some of the progress of the last several years has been lost, and there is no end in sight to the potential losses that might yet occur.
- I have a rekindled awareness of the importance of the social determinants of health that is coupled with a renewed acceptance of the reality that we will never improve the health of everyone in the community for a sustainable economic expense without a more focused and effective approach to the persistent issues of poverty and the structural issues that are the origin of economic inequality.
Since 2008 my presentation about the future challenges of American medicine include a slide that I lifted from the 2007 Shattuck Lecture, “We Can Do Better — Improving the Health of the American People,” given by Steven Schroeder and published in the New England Journal of Medicine. The point of the slide is that if we want to improve health and reduce the cost of care we need to look to more than what we do in the hospital and the medical office.
“The Case for Concentrating on the Less Fortunate” is an important section of Schroeder’s discussion:
Since all the actionable determinants of health — personal behavior, social factors, health care, and the environment — disproportionately affect the poor, strategies to improve national health rankings must focus on this population. To the extent that the United States has a health strategy, its focus is on the development of new medical technologies and support for basic biomedical research. We already lead the world in the per capita use of most diagnostic and therapeutic medical technologies, and we have recently doubled the budget for the National Institutes of Health. But these popular achievements are unlikely to improve our relative performance on health. It is arguable that the status quo is an accurate expression of the national political will — a relentless search for better health among the middle and upper classes. This pursuit is also evident in how we consistently outspend all other countries in the use of alternative medicines and cosmetic surgeries and in how frequently health “cures” and “scares” are featured in the popular media. The result is that only when the middle class feels threatened by external menaces (e.g., secondhand tobacco smoke, bioterrorism, and airplane exposure to multidrug-resistant tuberculosis) will it embrace public health measures. In contrast, our investment in improving population health — whether judged on the basis of support for research, insurance coverage, or government-sponsored public health activities — is anemic. Although the Department of Health and Human Services periodically produces admirable population health goals — most recently, the Healthy People 2010 objectives — no government department or agency has the responsibility and authority to meet these goals, and the importance of achieving them has yet to penetrate the political process.
Ten years later that last statement, …no government department or agency has the responsibility and authority to meet these goals, and the importance of achieving them has yet to penetrate the political process…, is still true. Schroeder was aligned with Dr. Robert Ebert’s observations about healthcare:
“The existing deficiencies in health care cannot be corrected simply by supplying more personnel, more facilities and more money. These problems can only be solved by organizing the personnel, facilities and financing into a conceptual framework and operating system that will provide optimally for the health needs of the population.”
Compare Ebert’s wisdom to Schroeder’s assertion:
To the extent that the United States has a health strategy, its focus is on the development of new medical technologies and support for basic biomedical research. We already lead the world in the per capita use of most diagnostic and therapeutic medical technologies, and we have recently doubled the budget for the National Institutes of Health. But these popular achievements are unlikely to improve our relative performance on health.
Spending money on healthcare does not assure a healthier nation. We must pay attention to the needs of the poor. Fifty years ago in the fall of 1967, Ebert gave a speech that emphasized our inadequate approach to the needs of the urban and rural poor. It’s been ten years since Schroeder admonished us to pay special attention to the issues that “disproportionately affect the poor.” Why has there been so little progress? Whatever the reason for our lack of success, if we want to move closer to the Triple Aim we must continue to try to rethink our strategies to improve the social determinants of health. Just “knowing” that we have a problem is not enough. The question is where to start and what can any of us do since it is clear from reviewing Schroeder’s article and comparing where we are now to where we were in 1967 or 2007, not much has changed.
I have always been enthusiastic about “knowing.” What is bothering me more and more is the realization that what I know doesn’t do much good for anybody. I am not making a difference in anyone’s life if I just “know more.”
I am trying to move from knowing to seeing and doing. Last year a friend offered me an opportunity to join an effort in a nearby low income, high unemployment community working in an after school program. It has been both fun for me to participate in the activities, and participation has given me a little bit of insight into the impact of the poverty in this community on the children who live there.
A more instructive opportunity came to me last fall. My minister asked me if I would participate in the eccumnical effort to address the acute issues of poverty in our community. I was apprehensive at first and told him that I would explore the idea. I met with the woman who was retiring as the “church nurse” and who had been involved in the effort for several years. After talking with her and a few others I decided to take the leap. The challenge was more than just joining a board. Board members rotate the responsibility of “carrying the phone” for two weeks. It is like being on call. The the phone comes with a big file of cards that contain information about recurrent clients. We meet once a month to discuss cases, review experiences, and try to improve the system within the means that are available. If you are interested, we have a website that describes our mission and also has links that explain “how welfare works in New Hampshire.” Our area is known for the expansive homes around the beautiful lakes. What you don’t see unless you look closely are the poor who live in substandard housing like the building in the picture that accompanies this posting. Follow many roads that go into the woods and away from the lakes and ski slopes and you soon discover rusted out old mobile homes and houses in various stages of disrepair where the poor and needy live in social isolation and out of site in circumstances that make some “urban ghettos” look high rent.
After attending four or five meetings, I had heard enough to be quite apprehensive about “carrying the phone,” but my buddy promised me that she would hold my hand through the process. It was just like being a frightened medical student leaning on the wisdom of an experienced resident. I realized that after four decades of medical practice I had never really been “to the gemba” of poverty and need. Some of my patients had huge needs but the focus was rarely, “What do I do now that they have cut off my electricity and the oil company won’t deliver more oil until I pay my bill, and I am out of firewood.” Pending evictions, no money for gas or food, a broken down car that prevents getting to work, dental infections without insurance or money to the pull the teeth are just a few of the problems that someone else always addressed while I was pontificating about avoiding salt and getting plenty of exercise.
I cringed this last week as I thought about all the things I didn’t understand about the real world while in practice. I got to know a man who was status post neurosurgery and a couple of strokes who is trying to live on $1100 dollars a month. He gets most of his food from a local food pantry, has several hundreds of dollars in unpaid pharmacy charges for his dozens of meds for his diabetes and hypertension. Although he was admitted to the hospital within the last month for an exacerbation of renal failure he has trouble staying on a low salt diet. When I talked to him it was Tuesday. He had no money. He had a couple of packages of ramen noodles and a can of Dinty Moore stew on his shelf. He had used his food stamps and the “food pantry” at the local church would not be open until Thursday.
I have a new appreciation for those who are in social services. While “carrying the phone” it is easy to see that success for any client is about getting a little bit of help from many different places. Working clients, and most of our clients are the working poor, are trying to juggle relationships with multiple agencies and programs. Forget efficiency. Check your privacy as you ask for a helping hand. After a week of carrying the phone, all I can say is that if anyone wants to talk to me about “welfare queens or the shiftless poor” they do so at their own risk.
Most of the people I have encountered are embarrassed about their needs and go to great lengths to avoid asking for help. KREM sees its mission as “… meeting the emergency needs of people in the Kearsarge/Sunapee region when other services are unavailable.” I am sad to say that I realistically expect that there will be a need for organizations like KREM long after there is moss on my tombstone. Our efforts to lift people out of poverty have been earnest but are almost always only band aids that are ineffective in eradicating the root cause problems. We should redouble our efforts and rethink our methods. We need more than charitable activities. We need to address the issues head on because we can. Dr. King talked about poverty a lot. In his acceptance speech for the Nobel Prize in 1964 he said:
“There is nothing new about poverty. What is new, however, is that we have the resources to get rid of it.”
We waste at least a trillion a year in how we provide healthcare. If we can stimulate the economy by giving hundreds of billions of dollars of tax relief to corporations and the very richest members of our society, we have the means. Why don’t we do something? My recent experience “carrying the phone” convinces me that King, Ebert, and Schroeder are right. If we are ever going to live in an America that is truly great we will need to take to heart the deep message Hubert Humphrey offered us when he said:
It was once said that the moral test of government is how that government treats those who are in the dawn of life, the children; those who are in the twilight of life, the elderly; and those who are in the shadows of life, the sick, the needy and the handicapped.
