Health Care Inequities: Up Close and Personal
So far, the avalanche of comments in this Healthy Ideas dialogue is dissecting the particulars of health care reform. It’s clear that “health reform” to date has not substantively addressed the fact that expanding coverage is not enough; there are underlying inequities across health services by race/ethnicity and income that will require major overhauls in attitudes and practices.
I’ve dealt with these inequities for years. As a second-year medical student allowed to deliver seven babies during a two-month OB-GYN rotation, all to single teenage mothers, while barely allowed to touch the “private service” patients. As a doctor at a federally-qualified New York City health center serving Harlem nearly two decades before Clinton moved there. As an adolescent medicine director at a foster care agency in the East Village before “gentrification.” And now as a researcher, teacher, doctoral program head and Center director. I’ve made it my life’s work to give voice to those usually silenced by our societal hierarchy and address the factors contributing to health status disparities. But it’s one thing to study the disparities, it’s another to experience them first-hand, to see them in living color. I can’t add much to the thoughts of my erudite colleagues in the health care debate, so let me tell you a story.
Several winters ago, my 83 year-old mother developed a simple urinary tract infection, and was taken by ambulance to a nearby community hospital. My mom suffered from Alzheimer’s and osteoarthritis, but was ambulatory with a walker, articulate and. having earned a master’s degree in education, generally able to mask her memory impairment to those who didn’t know her.
Although her current medications and primary care physician’s name and affiliation were communicated to the emergency room physician orally and in writing, after her arrival on the ward, her medications for mild hypertension and diabetes were arbitrarily changed, and no anti-inflammatory agent for pain was prescribed. Upon my return to Los Angeles from a trip abroad, I was shocked to find out that her neck was spasming, she’d not been helped out of bed for the entire week since her arrival, she was grimacing in pain and barely lucid.
The attending physician indicated that he was not aware that she was previously ambulatory, that her neck was not permanently in spasm, nor that she was usually lucid, and he felt no need to call her regular physician, saying he had treated her based on the clinical “signs.” He couldn’t have even pulled back the sheets, much less conducted a full physical exam, because few lay folks, much less trained clinicians, could miss the hallmarks of severe degenerative arthritis: grossly swollen finger joints and a two-foot long scar over a swollen and permanently bent right knee.
After transferring her to UCLA the next morning, she spent a week there and a full month at a rehabilitation center just to restore her to near her prior level of functioning.
My mother was fortunate that I returned when I did, and that I had access to medical information and resources that I could so quickly marshal. I can’t help wondering whether the fact that she was an elderly African American woman played into such dismissive care. I suspect that he presumed she was indigent, a fourth “strike” leading to abhorrent care. Certainly, her treatment was consistent with the racial inequities in health care and health outcomes we’re discussing. However, were race and income not at play, there’s ample evidence that these types of mistakes are all too common and are but a symptom of America’s severely overburdened health care system in need of a dramatic overhaul.
My mother, a native of Kansas City who passed away peacefully in her sleep on August 7, 2008, taught me while young about the challenges of prejudice but also stressed that “can’t” was a word our family did not use. She told me how Rosa Parks refused her “place” but she also invoked the “Serenity Prayer” when times got tough.
She is why I am where I am, doing what I do. And she, along with so many like her, is why we need to address not just how many people we cover with health insurance, but how we cover them with quality health care and caring.
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Dr. Yancey’s story about her mother’s treatment illustrates several frustrating aspects of health care. It’s too much or too little. Overuse of ambulances obviously contributes to high costs, and alternative modes of transportation should be available. Electronic tracking of patients, while it has its drawbacks, would help ensure continuity of care and communication between multiple caregivers, preventing snap assessments such as occurred in the E.R. in this example.