Medical Problems of the Ghetto (1969)

Medical Problems of the Ghetto

by Joan E. Thomas, M.D.

AS 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.