By Thomas L. Fisher
Washington Post
Sunday, July 1, 2007; Page B02
CHICAGO At 4 a.m., the ambulance rushed the driver in a single-car accident to the emergency room where I was the attending physician. The victim, a man in his late 20s, had been knocked unconscious when his head slammed into the windshield. The paramedics handed me two-thirds of his scalp in a plastic bag.
That sounds horrible, of course, but modern medicine can do a lot in such cases — if it has the chance. Our team worked to stabilize the patient and to save his scalp. Human tissue can die in a just few hours if it’s cut off from its blood supply. So to avoid a disfiguring injury, our patient would need the care of a specialist who could reattach his scalp’s blood vessels. Unfortunately, my hospital didn’t have such a surgeon; the closest one worked at a sibling hospital in a more affluent neighborhood 15 miles away.
We raced against time to avoid permanent tissue damage. I called and called and called, searching for a physician willing to take care of our patient. But no one would accept him. After 40 minutes, we flew him — and his dying scalp — by helicopter to a hospital 45 minutes away.
The patient should have been recuperating after a close call. Instead, by the time he was whisked away from me, he was facing lifelong disfigurement. This is the reality I see every day as an ER doctor: Large groups of people — mainly those from communities of color, and also those who are poor and uninsured — are not receiving basic care that can make all the difference.
Many Americans have been talking more about health care these days because of the buzz around Michael Moore’s new documentary, “Sicko,” a polemical look at unfairness in the nation’s health care industry. However, the types of communities I care for are barely addressed. Moore says up front in the movie that he is not focusing on the nearly 50 million people who have no access to care at all. His decision to concentrate instead on the substandard care given to the working and insured is an understandable attempt to touch the heartstrings of Middle America. Unfortunately, by giving cursory treatment to race and class, he avoided tackling the most intractable problems in this country’s health care system.
Here’s the view from the front lines: Hospital waiting times of 10, 12 hours. Emergency rooms so packed that ambulances must be turned away. People suffering from ailments ranging from organ failure to psychotic breakdowns, all preventable.
These issues affect not only individuals, but whole communities and the health outlets serving them. I sympathize with those who are unhappy about the quality of their insured care, but I’m more worried about those with no insurance at all. The bigger problem is that we all want the finest of health care, and as a result, many of us — largely black and brown — are left with nothing.
One scene in “Sicko” does deal directly with race: A white woman questions whether her husband, who is black and has kidney cancer, would receive better care if he were white. I can’t speak to their situation, but my experience is that the influence of race and racism on health care is rarely that obvious. But it is unmistakable, nonetheless.
For instance, the young driver in the car accident essentially had the misfortune of getting hurt in the wrong part of town. At the time, I was an emergency medicine physician fresh out of residency, working in a community hospital system in the Midwest that consisted of two very different hospitals. Hospital A (where the patient started) served a blighted, post-industrial city of about 100,000 residents, about 85 percent of whom are black and largely poor and uninsured. Hospital B (the one we couldn’t get him into) is 15 miles away, in a more affluent community of about 30,000 people, about 70 percent of whom are white. Although technically the two comprised a single hospital system, physicians were allowed to choose to work at one or both of the locations. Most chose Hospital B, leaving few specialists on call for emergencies at Hospital A. By dumb luck, my patient wound up at the wrong hospital, and that made all the difference.
The reasons behind the two-tier structure weren’t malicious. In most hospital systems, physicians are not direct employees but instead have privileges to deliver care through the facility. In this structure, the patient receives one charge from the doctor and one from the hospital. That means there’s less of a financial incentive to work in communities with many uninsured members. Many specialists did not want to leave their neighborhoods and their families in the middle of the night and disrupt their upcoming workday schedule to care for a patient who may not be able to pay but could nevertheless file suit over care.
It’s honest to say that most poor people — not just those from communities of color — suffer from inadequate or nonexistent care. But I’ve found that decisions that seem race-neutral at face value can systematically hurt such groups. These decisions create racial disparities in health care that go beyond what can be explained by class alone. The challenge presented by that emergency case at 4 a.m. was determined by the earlier decision not to require physicians to provide care at both hospitals. The difference in care between these two facilities went beyond just a single car-accident victim and wounded the entire community that Hospital A was supposed to serve.
These are the kinds of systemic problems that lead to widespread racial disparities in health. Consider the medical picture for my black male peers. According to the Henry J. Kaiser Family Foundation, black men are the least healthy ethnic group in the United States. Their death rate (1,282 per 100,000 in 2004) outstrips that of all other ethnic groups, including non-Hispanic whites, 949; Native Americans, 750.2; Hispanics, 702.7; and Asians, 534.1. Black men also have higher rates of heart disease, HIV/AIDS and certain kinds of cancer, including prostate, lung and colon.
Such statistics send a larger message about medical care and race: The lack of equity seen in wealth, income, education and insurance has considerable impact on health.
On balance, the middle and upper-middle classes are relatively healthy, as evidenced by their lengthening life spans and rising quality of life. Meanwhile, the bad outcomes disproportionately affect the poor, including many working-class and poor whites but more often people of color. In these populations, health and health care in the United States are not dissimilar to the standards in some developing nations. For instance, in 2005, the average life expectancy for black men in this country was 69.2 years; according to CIA estimates for 2007, the life expectancy for all Iraqis is 69.3.
Health care is not a run-of-the-mill service like an oil change. It’s a massive industry that shapes our lives and sometimes saves them. But our health care options are more than just commodities. That being said, providing health care to the underserved alone will not solve every problem — broader issues of equity will need to be addressed.
Many Americans oppose a single-payer health care system. My support of this initiative has grown from witnessing inequities daily through years in an emergency room.
I hear the concern about such a system; people worry that they won’t get what they need, that the government will ration health care. But in fact, that’s exactly what we have right now. It’s just a little more subtle, a form of rationing that’s based on a person’s ability to endure hours of anxiety in the ER, to wait for the next medical appointment, to afford high-quality insurance.
So how can we have a public discussion about this subject? This country has limited resources to devote to health care. But it also is saddled with an inefficient health care system that gives advantages to the privileged and well-off while ignoring preventive care and abandoning those most in need.
In some ways, given escalating costs, health care is a zero-sum game. So what are people willing to give up, and what care should be provided to all? Many middle-class Americans take comfort from knowing that their health care is covered. But all those little choices add up to big society-wide choices and market incentives for drug companies — and produce an America where one man pops his Medicare-covered Viagra pills while another can’t get life-saving cancer medication.
Many Americans do get the Mercedes-Benz of health care. But given the scarcity of resources, they may be doing so at the expense of many others. Ultimately, we will need to find a middle option — providing all Americans with the health care equivalent of a Prius, a vehicle that will take efficiently to where you need to go and is affordable enough that nobody will have to walk. Because you never know what neighborhood you may wind up driving in.
tfishermd@gmail.com
Thomas L. Fisher serves on the faculty of the University of Chicago’s Department of Medicine and practices in the emergency room at the University of Chicago Medical Center.