Poverty Medicine: Why we need the poor and the uninsured

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This past weekend at the Tacoma Dome, 1,500 uninsured people were seen for free health care by 1,400 volunteer doctors, nurse practitioners, nurses, dentists and others. They saw all of the patients in eight hours, and provided 3,000 free prescription medications for things like diabetes and hypertension. The National Association of Free Clinics and the Washington Free Clinic Association were joint sponsors of the event. Nicole Lamoureux, the Executive Director of the National Association of Free Clinics told the volunteers, “This event will change your life.” (KOMO News, 4-30-11).

I watched the KOMO TV news footage of this event, and besides spotting a few of my nursing students who were volunteers (way to go!), I noticed that the newscaster kept emphasizing that the patients that day were the working poor. They interviewed an older white woman who said she’d worked all her life but didn’t have health insurance and was too young to qualify for Medicare. She did not appear to have a serious mental illness or a substance abuse problem. The message was that they were only providing free health care to the deserving poor.

There are many useful debates as to the utility of such large-scale one-off medical missions (whether or not they are explicitly faith-based). That is old territory and I won’t address it here. What I am interested in is what these sorts of free clinics—and of poverty medicine in general—say about us as a society. Why are they a seemingly permanent part of our health care safety net and of our country?

Poverty medicine, by the way, seems to have been coined by a US family physician, David Hilfiker. I met him back in the 1980s when he was living and working with homeless people in Washington, DC at Christ House. As he states on his website, many people seek “life with the dispossessed as a pathway toward intimacy with God.” That can either be viewed as laudable or slightly sadomasochistic. Christianity does have a long tradition along those lines. Dr. Hilfiker is quite open about the fact that he was prone to severe burnout and deep depression through this work. He stopped work as a physician altogether many decades ago.

Besides possible feel good, life changing, spiritual awakening (or burnout and depression) by those providing poverty medicine sort of care, what other functions does it serve?

I reflect back on the sociologist Herbert Gans’ “The Positive Functions of Poverty” (AJN, 1972).  Among his many suggested positive functions of poverty, the following have pertinence to poverty medicine:

1)   Poverty makes possible the existence and expansion of respectable jobs, including social work and public health (and I would add poverty medicine).

2)   The poor support medical innovation by being “practice” patients at public hospitals and by being guinea pigs in medical experiments.

3)   The poor—the uninsured who have to turn to free clinics like the Tacoma Dome—make the rest of us feel better about our social standing: at least we aren’t that poor. Yet.

4)   And here’s one of Herbert Gans’ positive functions of the poor that can really make us squirm: “They also provide incomes for doctors, lawyers, teachers, and others who are too old, poorly trained, or incompetent to attract more affluent clients.” (p 280)

I have worked as a health care safety net provider for almost thirty years, so I am one of those people ‘supported’ by the existence of poor people. Thanks poor people. I made a purposeful crossover into “yuppie medicine” for several years just to see what it was like. In Bellevue, Washington I treated Microsoft lawyers with stress-related health problems and bizarre sports injuries from extreme yuppie sports like underwater hockey. I reassured the worried well and tried to talk them out of total body MRIs. I burned out on yuppie medicine and went back to working with homeless teens at a community health clinic. But then I began to realize that perhaps by working in the health care safety net I was just helping to perpetuate the problem. Nothing has changed in the thirty years I’ve been doing health care for the poor—if anything, things have gotten worse. I do still believe that the mirage of the safety net is better than nothing, but it also prevents us from making the fundamental overhaul of our health care system that is needed.

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