(The Gutter, the Grave, the Glitter, and the Glory)

What follows are some of my thoughts on disparities in health care and how it relates to the concept of universal health care via HR 676. I will try to focus my discussions on health, but many of the issues involved in the sick non-system we have are tied into larger societal issues such as poverty, racism, segregation, lifestyle, pollution, alienation, greed, etc. I have been in something of a contemplative, reflective, retrospective mode lately, and will start with anecdotes, and lead into statistics and then comments.

I served my internship in the Public Health Service in Norfolk, Virginia in 1973. For two months, I was assigned to a rotation in the emergency room in Norfolk General Hospital. The ER actually consisted of two separate but adjacent operations. One was the ER for "private" patients--that is those with insurance. The other was the "public" ER for patients with no insurance. The private ER was staffed by trained, professional emergency room physicians and the public ER was staffed by the interns and residents in training. It takes little imagination to figure who the patients were, and the color of their skin in both locations. This was my first exposure to tiered medical care with insured people getting the superior care and people of color receiving care from lesser trained doctors. In the public ER, people were also sicker as they had postponed treatment. It was a good experience for the interns, as we saw meningitis, uncontrolled diabetes, asthma, etc. that should never have occurred. Oh, the stories I could tell.

I did my family practice residency at the University of Arizona in Tucson from 1974 through 1976. I also spent some time in a small town near Tucson where I witnessed prejudice as I never imagined existed. The most egregious situation was a doctor who performed a Caesarian section on a Mexican woman and unknown to her, he also tied her tubes. He did this because he didn't like Mexicans on welfare having babies. Although he tried to cover it up, I learned of it when a nurse who was present came sobbing to me to tell me what happened. The rest of the story is long, and the events related to this and similar conduct haunted me for seven years and cost much money in the court system. I was sued by a physician there because I was advocating for the patients and trying to address practice issues. Of note is that I finally prevailed but at the expense of my family and pocketbook. Oh, the stories I could tell.

Next I practiced for two years in a migrant farm worker clinic in Toppenish, Washington from 1976 through 1978. Overall, this was the most gratifying time of my professional career, and I reflect wistfully on those days of collegiality and service. I did see the results of many flaws of care delivery, but found joy and fulfillment in meeting the needs. Yakima County had the highest infant mortality in the state of Washington (17/1000) while the state average was 11/1000. The majority of the population in most areas was Hispanic or Native American. I have often wondered what happened to the infant mortality rate after we started our prenatal program. I also witnessed racism and medical malice mostly in the form of denying care. On one occasion, a woman presented with a ruptured tubal pregnancy to a hospital 60 miles away from us. They told her to go see Dr. Castillo in Toppenish as he speaks Spanish. When she arrived in Toppenish she was in shock and close to death. Oh, the stories I could tell.

I came to Corvallis in 1979 and have now been here 30 years. For the most part, Corvallis is served by many dedicated physicians. I still see similar problems here, the most notable of which is the system issue of access and tiered care. We have women presenting in labor with no prenatal care (mostly Latinas). The issues of bias are sometimes harder to discern because they are often more subtle. Nonetheless, they exist, and I hear of them more often than one would expect.

Several years ago I participated with a safety net group. We were able to get financing to establish a federally qualified health Center with Benton County. The clinic is perhaps five years old now and is doing well. Overall, I am proud of most everything the clinic does. I agonize somewhat over the concept of segregated care and will address this more later. As a family and community physician, I believe in integrated care. Regrettably, there is sometimes a need for clinics providing care to certain populations because the mainstream community is not meeting the needs (i.e. women's clinics, veterans clinics, farm worker clinics, free clinics, etc.)

The above are anecdotes but are consistent with the data on care for minorities. Consider that Blacks have 1.5 the death rate from heart disease, yet the rate of coronary bypass for Blacks is less than 50% of that for whites. It is well documented that Blacks who present with cardiac symptoms to the ER are treated differently than Whites. In the ER pain medication is given more often to White Non Hispanics (WNH) than to Hispanics or Blacks. Whites have colorectal cancer screening at a rate of 50% while for Asians and Hispanics, it is 35%. In 2005, African American women were 10% less likely to have been diagnosed with breast cancer, however, they were 34% more likely to die from breast cancer, compared to non-Hispanic white women. African Americans aged 65 and older were 40% less likely to have received the influenza (flu) shot in the past 12 months, compared to non-Hispanic whites of the same age group. Today, the infant mortality rate for Whites (WNH) is 5.6% and for Blacks, 13.6%. I don't understand why there is not more outrage at this statistic.

Defenders and apologists for these facts cite other intertwining factors as mentioned above, though sometimes deny bias, discrimination, and prejudice. The Institute of Medicine (IOM) did a study at the request of Congress to try to disentangle these issues. They separated out the broader issues of economic and social inequities and concluded the primary reason for poorer outcome was most likely related to access to quality care. The disturbing additional finding was that people of color do receive lower quality care even when they do get it. Contributing factors to this include bias, fragmentation of care, cultural and language barriers, and lack of continuity of primary care.

I mentioned cancer screening, and there is suggestion that we may be beginning to see the increased incidence of cancer due to lack of access. This obviously has significant implications for people of color. This may well be "the canary in the coal mine". A single-payer system would alleviate this. Most people I know, and surveys have confirmed this, favor a single-payer system. I do not believe this is a political or economic issue, but rather, a moral issue. However, we need political support. The Black Congressional Caucus as well as many Latino groups supports single-payer. At the risk of becoming political here, I will observe that many Republicans oppose the single payer concept with the argument that health care is a commodity distributed according to the ability to pay, and the free market will work things out. The Democrats make me angry because while they give lip service to the concept of health care being a right, they say such things as a single payer system is not "politically feasible". They are yielding to the tremendous economic power of the health providers including the pharmaceuticals, insurance companies, hospitals, and doctors. To me, this is the same as supporting racism for money.

Democrats tend to support money for FHC's, Medicaid, etc.. In fact certain federal clinics are paid more for seeing the Medicaid population. This further encourages segregation. At this moment though I support these clinics as I believe we have an emergency on our hands. Hopefully, healthcare will become more integrated, including that delivered by FHC's. A study in New York examining factors encouraging segregation called this phenomenon "Medical Apartheid".

In Oregon in the last year there was a decline in the number of lives covered by insurance companies. One in five Oregonians are rejected by the insurance companies for pre-existing conditions. While the insurance companies were insuring less people, the majority of industry CEO's all enjoyed substantial pay raises. HealthNet was caught last fall in California giving bonuses to employees for examining the files of patients who were ill and finding reasons to cancel their coverage. One woman with breast cancer had her coverage canceled because she wrote her weight down incorrectly on her application. The insurance industry engages in many other scandalous endeavors such as Medicare groups holding dances for the elderly to sell their policies or offering fitness club memberships. It's obvious whom they are soliciting. This policy of cherry picking and spitting out the pits has gone far enough. We can no longer sit by as the blood of poor people flows from the gutter to the grave while the CEOs run off with the glitter and the glory.

I am not so naïve to think that a single-payer system will solve all the problems for minorities and poor. Unfortunately, the disparities in care exist in countries with single-payer systems. However, the difference is much less by several magnitudes. I firmly believe a single-payer system will be a step in the right direction. How can a group of people ever hope to improve their lot with out their health and without starting out with healthy babies?