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November 15, 1969 cover

Medical Problems of the Ghetto (1969)

From Our Archives

Joan Ellwood Thomas (1929–2011) wrote “Medical Problems of the Ghetto” for the November 15, 1969 issue of Friends Journal. She was a recent graduate of medical school and a mother of three young children when she began her family medicine practice in Louisville’s West End neighborhood. The West End was the site of riots, racial tension, and widespread “white flight” in 1968 after Martin Luther King, Jr.’s assassination. Hardened racial attitudes between white and black citizens exacerbated the scarcity of health care options for blacks that already existed. A founding member of Louisville Friends Meeting, Thomas continued her medical practice in the West End for two decades, witnessing to, and endeavoring to improve the lives of, thousands of her community’s least privileged individuals.

We present this piece as a historical snapshot as well as an opportunity for reflection around the topic of privilege. The tone and language in this piece are consistent with the time and the setting in which it was written, and some readers today will no doubt find them shocking. Feature articles and letters to the editor in Friends Journal in the late 1960s and early 1970s dealt regularly with such issues as racial justice and injustice, discrimination, and reparations. They used a different—some might say less respectful or politically correct—set of terms and reference points, but with a distinctly Quaker moral grounding that is as recognizable in Friends’ historical writings as it is in Friends’ writings today. This is the first in an occasional series of “Friends Journal Archive Selections.” -Eds.

Discussion Questions:

  • For Friends in healing professions such as medicine, mental health, and social work, what spiritual guidance does Quakerism offer in the practice of one’s vocation?
  • When our interactions (social, professional, and religious) span class boundaries, how can we recognize and transcend an “us‐them” dynamic?
  • How do we come to awareness of the realities experienced by those less fortunate than we are? What role do we have in sharing that consciousness with others?
  • What is similar or different about the health care system Joan Thomas portrays in 1969 and our current one?

You can share you thoughts on these questions in the Comments Section below.  You can download a scan of the original article here: Medical Problems of the Ghetto

Medical Problems of the Ghetto

by Joan E. Thomas, M.D.

November 15, 1969 coverAS A GENERAL PRACTITIONER in a slum in Louisville, Kentucky, I have had interesting and tragic experiences with the special problems of the poor. My office is between two poverty areas in which about 40 percent of the families, or more than 8,000 persons, live on annual family incomes of less than $3,000 a year. Nearly all my patients are poor. Nearly all are black. They are of all ages. About one‐fourth of them are children.

My patients have the same illnesses as the more affluent for the most part, but in some respects their medical problems are different. For example, about ten percent are treated for gonorrhea (I have been astonished at the frequency of this disease in stable, respectable patients). While I live in fear of penicillin reactions, many patients treat the whole subject with less concern than they do the common cold.

Most members of my patient population have characteristics that would be considered unhealthy in other groups. For example, nearly all are sensitive and suspicious in their perception of the thoughts and feelings of others. Obviously, knowing what “whitey” is thinking has survival value. This handicaps them in dealing with white society and is at least one root of black separatism, but can anybody honestly say that our social climate has improved to the point that correction of this trait is practical?

The diagnosis and treatment of psychiatric, and, indeed, all, health problems is handicapped by poor communication. Many of my patients have a hard time with words, a vague sense of time, and bizarre ideas of anatomy, physiology, and causation. Apparently the “strain” is no mere euphemism for gonorrhea, but is sincerely attributed to the effects of heavy lifting. One woman told me she had been overtreated for “low blood” (anemia) at a hospital, with the result that she had acquired “high blood” (hypertension). Patients with surgical scars frequently cannot tell what organ was removed or why. Even for a current illness, many are unable to give the details of timing, quality, and progression of symptoms that are essential to knowledgeable diagnosis. By the time that one young woman with acute gonorrhea complained that her womb was falling out, I was so weary of trying to made medical sense from nonsense histories that I failed to recognize her schizophrenia until the Mental Health Clinic got in touch with me.

If this is the quality of information coming my way, I wonder what goes back to the patient. How can patients who eat irregularly and ignore appointments be trusted with a potentially lethal drug like insulin, that requires measurement and timing? How can patients who share plumbing with other families effectively perform warm soaks or exercises that are beyond many middle‐class patients? The poor frequently require more instruction time, more followups, and longer treatment periods than middle‐class patients.

I suspect malnutrition is commonplace. I have many cases of anemia, poor healing, and infections, possibly related to protein deficiencies. Blood analysis of similar populations has demonstrated such deficiencies, and I do know that many of my patients in Louisville subsist largely on potatoes, macaroni, and bread. What can my instructions or medicines do for a nearly blind, toothless, illiterate 70 year old woman who lives on a pension of $100 a month, of which $60 goes for rent?

Recommendations of medical school faculties or lawyers for diagnosis and treatment sometimes seem irrelevant. Most of my patients expect even the most subtle problems to be managed by an off‐the‐cuff diagnosis and a “penicillium” shot. They fail to report for followup; they frequently go to some other doctor or General Hospital if my office is closed and then back to me when next they have a cold or some other discomfort entirely apart from their serious medical problems. The duplication of efforts and confusion of treatments increase expense and decrease effectiveness. Many cannot afford the X‐rays and tests required for scientific medicine. Only about 28 percent of my patients have private hospitalization insurance or Medicare. They are my rich patients. They are eligible for hospitalization and specialist referrals and I hope can afford the expenses of ordinary care.

About 40 percent of my patients have no hospitalization or medical insurance at all. Their incomes are above the Medicaid level but are not steady enough or in the right field to include insurance in the pay package. They range from the family of four trying to make ends meet on $3,500 a year to the young cat with genuine lizard shoes and a fat roll of $20 bills, but none of them can afford current hospital rates and few of them can scrape up the $200 or more required as a deposit for uninsured admissions. For people like these, the only recourse in serious or complicated illness is the clinic.

Many people who badly need service would prefer to die in a corner rather than go to a public clinic. At General Hospital, physical facilities are crowded, shabby, hard to sit on, even dirty. Overworked personnel are unable or unwilling to answer questions or arrange assistance. Appointments are not scheduled, so that even sick people have to wait for hours. Even the reduced fees of clinics may be formidable to patients who have no financial assistance from insurance or Medicaid.

Moreover, if I think the patient needs specialized General Hospital services, all I can do for him is to suggest that he go to a certain clinic; I have no way of arranging that he will actually be seen there. If he does not already have a hospital card, he has to be seen in the emergency room and take his chances of persuading a tired, harassed house officer that he is sick enough to bother with. Under such conditions acute fracture or hemorrhage is well handled; a possible heart attack or cancer is likely to be sent home with some pills. The medical school likes to sneer at general practitioners, but I feel that if they really cared about the quality of community medical practice they would permit private physicians to make specific referrals and be informed of the results.

The reason given for the poor performance of the clinics is lack of money. Up to a point this is true, but the large amounts of additional money from Medicaid and Medicare for clinic fees were used not to improve services but to reduce local government support. For example, the city/county share of the Louisville General Hospital budget has shrunk from 83 percent to 50 percent. I wonder how many other programs designed to help the poor result in hiring clerks and exchanging papers and money but no visible benefit to the client.

About 33 percent of my patients are on Medicaid. These are the poorest. In Kentucky, the state will pay on their behalf for specifically listed services in a doctor’s office, certain drugs, certain hospital expenses, and extended care services. The patient pays nothing; that I think is a mistake, since he then has no incentive to limit his demands to the necessary or to invest his own effort in therapy. For some services, payments equal private fees; for others, especially doctors’ services in hospitals, they are far less. The list of covered items is arbitrary and omits many services that I consider important, such as penicillin injections and children’s immunizations, but covers such exotics as total removal of a lung or internal repair of a heart. The drug list contains such duplications as four tetracyclines, four narcotics, and three oral penicillins, but no eye drops for glaucoma, no mood elevators for depression, no pediatric preparations for anemia or vomiting, nothing for local vaginal infections or ringworm. Payment to the doctor for a hospitalized patient covers three to five days of care, even if the patient requires weeks or months in the hospital. In short, the frustrations of the Medicaid program are such that most specialists are cool to referrals from a doctor who cannot balance the impositions with a suitable quota of middle‐class patients. So it is back to the clinics for these people as soon as they require more than routine care.

The converse of the fact that the poor cannot afford to pay for more than the most minimal services is that doctors in poor areas cannot afford to perform more than the minimum. Both government and private payment programs limit their support to the “usual and customary” fees in the locality. In a poor area, this level is set by what patients with tiny incomes and no insurance can afford—that is far less than among the affluent. So who is to pay for the services I perform for nothing or at half price?

Historically, the slum doctor has managed by seeing a tremendous number of patients, offering a lick and a promise to each. Money can be made this way, but the quality is such that most doctors find it neither professionally nor personally satisfying. Except for a federally supported Neighborhood Health Center and myself, no new doctors have entered the poorest areas of Louisville for years. This is more serious than it would be in more affluent areas, because poor people frequently cannot afford car fare or are afraid to go to office buildings or hospitals for services. Even in lower‐middle‐class sections, a doctor may see 200 to 300 patients a week; several of the younger doctors have left or plan to leave for specialist training, not because they are so interested in the specialty but to reduce their patient load. So far, all the publicity given Medicaid payments has not enticed doctors into the ghetto.

It is hard to quantify the deficit of doctors in a limited area because of lack of information on movements of patients into or out of the area, rates of utilization of services, and proportions of hospitalized or chronically ill patients. I believe, however (after allowing for populations probably served by the Neighborhood Health Center and General Hospital), that about 99,000 persons in the poorest areas of Louisville are served by about 30 physicians. This means a ratio of 3300 patients per doctor. The national ratio of patients per doctor involved in patient care is 715: 1; the Kentucky ratio is 1020: 1; the Neighborhood Health Center 900:1.

The problems surrounding the training, distribution, duties, and organization of doctors are beyond the scope of this article, but I think it is apparent that improvement of the health care of the poor is tremendously more difficult than political rhetoric suggests. Not only is it foolish to make promises and appropriations without regard to the supply of services, but it is necessary to recognize that substandard socioeconomic conditions cause unusual illness, binder effective treatment, and obstruct the delivery of quality service.

Change is in the wind for private and public health programs, but let us study and plan these changes carefully. We need to experiment with efforts to improve the effectiveness and reduce the waste of health services at all social levels before we can unconditionally back or blame any single program.

This article first appeared November 15, 1969, with the following contributor biography: Joan E. Thomas joined the Society of Friends more than 20 years ago. She acquired her medical degree in 1966, despite heavy family responsibilities, and has been practicing in a poor section of Louisville for a year and a half.

Posted in: January 2013: Privilege

4 thoughts on “Medical Problems of the Ghetto (1969)

  1. rich says:

    I worked with black adults as a teen in the 50’s in my father’s junk yard. Later, in the 70’s,
    when I took over the business, I again worked with them.

    Although I didn’t discuss medical issues with the people, I did attempt to
    offer help with literacy. I wish now I had also thought about their medical
    needs.…..as a small business, we didn’t offer health benefits. Black people
    seemed to not need them.…..magically.…..no one advocated for them on that level
    and i was not imaginative .

    Were I a Quaker at that point, which I wasn’t, I know I would have had better
    sensitivity.

  2. Larry Ingle says:

    It’s a fascinating and rewarding article, but I want to deal with the brief editorial comment, “This article has been slightly modified for tone and consistency to match current Friends Journal style.”

    Perhaps as an historian, I am more sensitive than many to this kind of corruption of the original, but I find it almost unconscionable that the editors would distort what actually occurred in the past by changing either the wording or “tone” to reflect more contemporary usages. And to do this in light of the warning at the beginning that “some readers today will no doubt find them [tone and language] shocking” is to underestimate the sophistication and understanding of modern readers.

    I like the idea behind this new feature and the substance of what has been presented. I certainly deplore, however, the misguided effort to protect and shield readers from the reality of the past. Let’s have no more of this superior modern attitude/

    1. Ken Woerthwein says:

      As a retired family physician who treated pateints in lower income neighborhoods for years, I was greatly interested in reading this article, not only from an historical viewpoint but also because of my interest in providing care for low income individuals.
      From my experiences, I will try to address some of the issues that Dr. Thomas addressed in each of the pargraphs of her article and respond to the queries at the beginning of the article.
      I attended medical school in Chicago from 1965–1970. Through an AFSC program called PREP and through a summer health project funded by the War on Poverty, we became intimately involved with many families on the west side of Chicago in a cominuity called East Garfield Park. All of this occurred through a house owned by the AFSC called Project House. This community was primarily a low income black community.
      In 1970, we moved to York, PA following the riots in York in 1969. I began my internship in medicine at York Hospital. For my alternative service, I became the physician for the Community Health Center in York City and the rural communities of York Co. beginning in 1971. The establishment of this health center was a grass roots effort stemming from the riots in 1969. I continued to work at the Health Center through 1976, and then my partner and I set up a practice in the City of York with an intent to serve all ethnic, income and age groups with a staff that reflected our population of patients. We stayed in this location until 1996. The demographics of our patient population was similar but not identical to those of Dr. Thomas.
      I feel much frustration in the comments of Dr. Thomas — justifiably so.
      Many of our patients were poor and young, but in later years the average age of the patient became older.
      The difference in illnesses between the poor and the affluent were not initially similar. There was much venereal disease.
      There was some degree of suspiciousness of dealing with white medical structure that had been uncaring, but over time, trust between the patients, staff and doctors improved, I think primarily because we hired staff from the community to work in the health centers and so they knew the patients well.
      Although there was a barrier to communication between doctor and patient at times, I did not feel this was a serious barrier, because we were attuned to this fact and did our best to address it at each visit.
      I do not know how well the instructions we gave to patients were understood by them. We did our best to give instructions in the language and vernacular of the patient and community.
      We were fortunate that we had a good relationship with physicians at our local hospital who, for the most part, gave equal care to all patients. Our referral process went well, although the only resource to specialty care was through “clinics” at the hospital where patients did not receive appointments but had to wait in cue at the beginning of the clinic time. Speciality physicians in the community donated their time at these clinics.
      Many patients did not have health insurance or were on Medicaid. The reimbursement was very poor and inconsistent for all medical specialties to the point that many doctors did not make an attempt to bill for their services.
      If you were hospitalized, you were put on the medical or surgical ward where you were cared for by the doctors in training who were supervised by the attending physicians. This was not an ideal situation for quality of care and follow‐up on discharge from the hospital, but it was an improvement over what existed before 1970, and more frequently than I wish to admit, the physicians in training did not have proper trraining in cultural sensitivity.
      Over many decades, the State and Federal governents have realized that there is a need for better and more efficient ways of reimbursement for primary medical services.
      It has been my life long experience, that copayments by patients, whether low income or not, have not led to an abuse of the medical system through over‐utilization.
      Appropriate, generic drug formularies for Medicaid patients has improved over many years, and in my experience is no longer a major problem.
      Payment for hospital services for low income patients has always been insufficient but that is primarily because we as a nation are not willing to tax ourselves well enough to support these kinds of services for the low income. About $1,000 of an individual’s private health insurance annual premium goes to pay for unreimbursed or under reimbursed health care given through non‐profit hospitals.
      Many recent graduating physicians are employed by health systems for a variety of reasons, but one of the primary reasons is that the physician can provide equal care to all individuals regardless of their ability to pay because they are salaried by the health system that employs them.
      When I initialy began to practice in York in the 1970s and 1980s, there were a few physicians who saw a very large number of low income patients in a short period of time in order to maintain their income at the level they wished. We did not do this at our health centers nor in our private practice. The health center was initially funded with private and foundation monies and some fees for service through Medicaid and private payments, but when my partner and I went into private practice, it was a struggle to generate adequate income; we were able to do this eventually by performing medical services in a variety of settings for which we were paid.
      A comfortable patient load is about 1,000 patients per provider. 3,000 patients per provider is burdensome and hampers good care.
      Since the 1960s and 1970s, the way in which medical care is offered to low income patients has improved to some degree depending on where you live in the US. The major problems that remain, and have been so for quite some time, are availability of health care insurance, access to a primary care provider, ability to pay for medications, and transportation to health care offices. Hopefully the Affordable Health Care Act will address many of these problems.
      In York, we have been very fortunate that the medical community as a whole has assumed responsibilty for improving access to and quality of care for low income patients regardless of ethnicity. It has been a cooperative effort, that is not ideal, but is far better than it was 40 years ago.
      The spiritual guidance that I have tried to follow is that I do my best to listen to my patients; I do not rush them through the visit; I try to be aware of their personal, social and financial problems as I attempt to care for their medical problems; and I do my best to treat them as an equal person even though I have a great deal of specialized knowledge.
      I think we can attempt to transcend the differences between those in the health care profession and our patients, whether they are poor or not and regardless of their cultural or ethnic background, by deciding that we will stand shoulder‐to‐shoulder and walk hand‐in‐hand with them in attempting to correct the inadequcies of our health care system. In other words, we will be their advocates, and by being our patient’s advocates, we will speak out about the inadequacies in our health care system and for those solutions that will improve accessibility and quality of care for all of our patients.

      1. Ken Woerthwein says:

        I wish to make two clarifications in my long reply above.
        When I refer to “we” at the beginning of my reply, I mean my wife and me.
        When I talk about co‐payments for medical care, my point is that I do not believe that not having to pay a co‐payment leads to over‐utilization of medical care. I think it is a myth that co‐payments encourage patients to be more judicious in deciding when to seek medical care. It is more often that patients do not have the financial ability to seek care when they are in need of it, and therefore, having to pay a co‐paymnet only worsens the burden they have in having to seek and to pay for medical care.

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