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We Who Believe in Freedom Cannot Rest

By Dr. Zaneb Beams
. 1 Comment(s)

“Of all the forms of inequality, injustice in healthcare is the most shocking and inhumane.” Dr. Martin Luther King Jr.

On the day after the MLK JR holiday, I want to tell our readers about my experience of the injustice in our health care system, from a provider’s humble perspective. I’ve come to the conclusion, during my very short clinical career, that as long as we have two separate systems for two separate segments of our communities, health care delivery will be unequal, and therefore unjust. A clinical encounter I had several months ago (among hundreds of other such encounters over the past 12 years) illustrates our problem.

I have a patient who was born with a diaphragmatic hernia at 26 weeks gestation. His diaphragm was immediately repaired, he survived ECMO, and is now, for the most part, thriving. This darling 3 year old boy has had some simple problems. I’ve got his Chronic Lung Disease under control. He’s growing well. His speech is getting better with help from the Infants and Toddlers Program Early Intervention Program. But he has some significant obstructive sleep apnea, chronic sinusitis, and recurrent otitis media. When I saw him a few months back, I tallied up his episodes of otitis in the past 12 months, and given the overall clinical picture, I recommended Ear Nose and Throat consultation. Looking at the child’s registration information, I noted that he is covered through a state health insurance program. One of the more restrictive state plans, in fact.

 Some muscles in my chest tightened as I told this boy’s mother, “ Oh, you have XYZ insurance, so you should call and find out who you can see, and then let us know what paperwork needs to be done and we’ll help you in any way we can.” This mother looked at me. Her eyes were big, anxious, and sad. She knew what I was really saying.

“You are poor, and even though you work and dream and love just like any of us, you don’t get to choose which doctors you see. In fact, you don’t even get to choose whether you see a specialist or not. Because you are poor, and because your son was born poor, America has decided that neither of you deserve the same kind of access to care that half the kids in the waiting room deserve.”

Standing there in the hallway of my office, my head started to spin a little. I started thinking about Brown V. Board of Ed, 1964, and the fact that in education, we know that separate and unequal is WRONG.  In fact, we are so certain that separate and unequal education is wrong, that we have a proud legal history to prove it. Over the course of almost one hundred years, our nation finally came to accept, legally, that people of all races deserve to participate in all aspects of society equally. Sort of….

If we can admit this with respect to education, then why not also with respect to health care? In 1877 states were still arguing that as long as education was of equal quality, that it was alright, in fact, preferable, to keep different segments of society separate from each other.

The Morrill Act of 1890 stated the following:

“Provided, That no money shall be paid out under this act to any State or Territory for the support and maintenance of a college where a distinction of race or color is made in the admission of students, but the establishment and maintenance of such colleges separately for white and colored students shall be held to be a compliance with the provisions of this act if the funds received in such State or Territory be equitably divided as hereinafter set forth.”

Segregated states like Texas tried to keep Black students out of their graduate schools by promising to build, eventually, similar graduate schools for Blacks. (Sweatt v. Painter). But when challenged, the Supreme Court decided that both because of quantitative differences in facilities, (distance, accessibility), etc., and intangible factors such as peer interaction, that separate institutions could not meet requirements of “substantive equality”.

How can it be that with something as tangible as health care and health outcomes, we are able to accept significant differences in access? We all know that poor families wait longer to see a specialist and travel farther, at greater expense quantitatively, as well as subjectively.

The Supreme Court Stated in its decision re: Sweatt v. Painter, “We conclude that, in the field of public education, the doctrine of "separate but equal" has no place. Separate educational facilities are inherently unequal. Therefore, we hold that the plaintiffs and others similarly situated for whom the actions have been brought are, by reason of the segregation complained of, deprived of the equal protection of the laws guaranteed by the Fourteenth Amendment.”

Someone please explain to me, how is it different that poor families receiving state or federally funded health care can receive care only from designated providers in limited, usually inconvenient, locations?

I refuse to accept the argument that the cost of equalizing our systems is prohibitive. Here in Howard County, Maryland, we spend upwards of 60% of our annual budget on education. We spend a fraction of that on our universal health care program, Healthy Howard.

Nationally, we fret about spending 16% of GNP yearly on health care. On a simple pie chart, Education AND health spending are a sliver compared to defense spending.

I am losing sleep over this.

I’m not pondering the epidemiological implications or the accounting games or the legislative gauntlet that must be run. I’m thinking about my patients, the children who were born poor, and who deserve an equal chance at the brightest possible future. I’m thinking about that little boy who stops breathing every 30 or so seconds when he’s asleep, and then starts up again when the CO2 builds up in his bloodstream.

I’m wondering why I can call up any Ear Nose and Throat doctor in Maryland, and have my son seen within a week, and if we so choose, operated on, a week after that. I’m picturing that mother’s eyes, and that child’s innocent face.

And I am asking, how is it morally acceptable to work in a system that provides separate and unequal care to my community?

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  1. Lisa Plymate

    Separate and unequal is what we have had all my 30 years in practice as an internist. Even when poor patients are fortunate enough to have access to good primary care, through a community health clinic, for example, it is extremely difficult to get them in to see specialists. I worked for two years for the Yakima Valley Farm Workers Clinic in rural eastern Washington, and we often could find no orthopedists, ENT surgeons or even dermatologists to see our patients. As a federally-funded clinic, we could see patients without insurance on a sliding fee scale, but specialists were so concerned they wouldn't get paid that their receptionists often wouldn't even let me speak to my fellow physician to ask a question about the care of one of our patients. We often had to send patients 3 hours over a steep mountain pass to the University of Washington to get the care they needed. Thank goodness our state medical school also runs a consulting service that is free to providers all around the state, for that 'curbside consult' that I couldn't get from local specialists....

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