Many Patients Don’t Survive End-Stage Poverty

[maestrob]

April 11, 2024

By Lindsay Ryan

Dr. Ryan is an associate physician at the University of California, San Francisco, department of medicine.

He has an easy smile, blue eyes and a life-threatening bone infection in one arm. Grateful for treatment, he jokes with the medical intern each morning. A friend, a fellow doctor, is supervising the man’s care. We both work as internists at a public hospital in the medical safety net, a loose term for institutions that disproportionately serve patients on Medicaid or without insurance. You could describe the safety net in another way, too, as a place that holds up a mirror to our nation.

What is reflected can be difficult to face. It’s this: After learning that antibiotics aren’t eradicating his infection and amputation is the only chance for cure, the man withdraws, says barely a word to the intern. When she asks what he’s thinking, his reply is so tentative that she has to prompt him to repeat himself. Now with a clear voice, he tells her that if his arm must be amputated, he doesn’t want to live. She doesn’t understand what it’s like to survive on the streets, he continues. With a disability, he’ll be a target — robbed, assaulted. He’d rather die, unless, he says later, someone can find him a permanent apartment. In that case, he’ll proceed with the amputation.

The psychiatrists evaluate him. He’s not suicidal. His reasoning is logical. The social workers search for rooms, but in San Francisco far more people need long-term rehousing than the available units can accommodate. That the medical care the patient is receiving exceeds the cost of a year’s rent makes no practical difference. Eventually, the palliative care doctors see him. He transitions to hospice and dies.

A death certificate would say he died of sepsis from a bone infection, but my friend and I have a term for the illness that killed him: end-stage poverty. We needed to coin a phrase because so many of our patients die of the same thing.

Safety-net hospitals and clinics care for a population heavily skewed toward the poor, recent immigrants and people of color. The budgets of these places are forever tight. And anyone who works in them could tell you that illness in our patients isn’t just a biological phenomenon. It’s the manifestation of social inequality in people’s bodies.


Neglecting this fact can make otherwise meticulous care fail. That’s why, on one busy night, a medical student on my team is scouring websites and LinkedIn. She’s not shirking her duties. In fact, she’s one of the best students I’ve ever taught.

This week she’s caring for a retired low-wage worker with strokes and likely early dementia who was found sleeping in the street. He abandoned his rent-controlled apartment when electrolyte and kidney problems triggered a period of severe confusion that has since been resolved. Now, with little savings, he has nowhere to go. A respite center can receive patients like him when it has vacancies. The alternative is a shelter bed. He’s nearly 90 years old.

Medical textbooks usually don’t discuss fixing your patient’s housing. They seldom include making sure your patient has enough food and some way to get to a clinic. But textbooks miss what my med students don’t: that people die for lack of these basics.

People struggle to keep wounds clean. Their medications get stolen. They sicken from poor diet, undervaccination and repeated psychological trauma. Forced to focus on short-term survival and often lacking cellphones, they miss appointments for everything from Pap smears to chemotherapy. They fall ill in myriad ways — and fall through the cracks in just as many.

Early in his hospitalization, our retired patient mentions a daughter, from whom he’s been estranged for years. He doesn’t know any contact details, just her name. It’s a long shot, but we wonder if she can take him in.

The med student has one mission: find her.

I love reading about medical advances. I’m blown away that with a brain implant, a person who’s paralyzed can move a robotic arm and that surgeons recently transplanted a genetically modified pig kidney into a man on dialysis. This is the best of American innovation and cause for celebration. But breakthroughs like these won’t fix the fact that despite spending the highest percentage of its G.D.P. on health care among O.E.C.D. nations, the United States has a life expectancy years lower than comparable nations—the U.K. and Canada— and a rate of preventable death far higher.

The solution to that problem is messy, incremental, protean and inglorious. It requires massive investment in housing, addiction treatment, free and low-barrier health care and social services. It calls for just as much innovation in the social realm as in the biomedical, for acknowledgment that inequities — based on race, class, primary language and other categories — mediate how disease becomes embodied. If health care is interpreted in the truest sense of caring for people’s health, it must be a practice that extends well beyond the boundaries of hospitals and clinics.

Meanwhile, on the ground, we make do. Though the social workers are excellent and try valiantly, there are too few of them, both in my hospital and throughout a country that devalues and underfunds their profession. And so the medical student spends hours helping the family of a newly arrived Filipino immigrant navigate the health insurance system. Without her efforts, he wouldn’t get treatment for acute hepatitis C. Another patient, who is in her 20s, can’t afford rent after losing her job because of repeated hospitalizations for pancreatitis — but she can’t get the pancreatic operation she needs without a home in which to recuperate. I phone an eviction defense lawyer friend; the young woman eventually gets surgery.

Sorting out housing and insurance isn’t the best use of my skill set or that of the medical students and residents, but our efforts can be rewarding. The internet turned up the work email of the daughter of the retired man. Her house was a little cramped with his grandchildren, she said, but she would make room. The medical student came in beaming.

In these cases we succeeded; in many others we don’t. Safety-net hospitals can feel like the rapids foreshadowing a waterfall, the final common destination to which people facing inequities are swept by forces beyond their control. We try our hardest to fish them out, but sometimes we can’t do much more than toss them a life jacket or maybe a barrel and hope for the best.

I used to teach residents about the principles of internal medicine — sodium disturbances, delirium management, antibiotics. I still do, but these days I also teach about other topics — tapping community resources, thinking creatively about barriers and troubleshooting how our patients can continue to get better after leaving the supports of the hospital.

When we debrief, residents tell me how much they struggle with the moral dissonance of working in a system in which the best medicine they can provide often falls short. They’re right about how much it hurts, so I don’t know exactly what to say to them. Perhaps I never will.

https://www.nytimes.com/2024/04/11/opin ... pital.html

[Holden Fourth]

When we debrief, residents tell me how much they struggle with the moral dissonance of working in a system in which the best medicine they can provide often falls short. They’re right about how much it hurts, so I don’t know exactly what to say to them. Perhaps I never will.

It beggars belief that in a country as wealthy as the United States that this can actually happen. It doesn't happen here because we have a health system that despite it's failings is not really inequitable. Anyone who needs to go to hospital can do so and there are systems in place that try to ensure that those most in need are treated first.

Why should the US be different?

A death certificate would say he died of sepsis from a bone infection, but my friend and I have a term for the illness that killed him: end-stage poverty. We needed to coin a phrase because so many of our patients die of the same thing.

This was a major factor in many US Covid deaths. Many already unhealthy people exposed to a new disease probably accounted for the fact that the death rate from Covid in the US was significantly higher proportionally than its first world counterparts.

[Belle]

Our health system is 'equitable' only to an extent, but you'll still wait well over 2 years in the public system for those knee prosthetics - often in a lot of pain. Same with every other procedure. Where our public system is good is in an accident or emergency; private hospitals aren't really equipped for the demands of this kind of medicine. I had radiotherapy in a (once Catholic) publicly-funded hospital and the staff were second to none, especially the doctor.

Our daughter-in-law was admitted to a NY public hospital in 2017 with suspected food poisoning and had nothing but total praise.

At the moment if you can afford private hospital care and the doctor of your choice you'll get most procedures done very quickly because doctors remain financially motivated. You'll get some who won't bill for out-of-pockets and their waiting-rooms are full of patients! (Economies of scale.)

There was one false note, if you'll pardon the pun, in your comments; American is not a rich nation. It is POTENTIALLY rich but the reality is empire-ending sovereign debt. Eye-watering, in fact. When you live with that kind of debt it's a house of cards, as we've seen time and time again with financial collapses. Australia is also mired in huge debt and we have politicians and a demanding population who don't worry about burdening our next generations with the clean-up. It's not a problem for many as they virtue-signal their way through life's difficulties; real or imagined, fake or self-created.

[Lance]

This raises a very, VERY important question. As great as the USA is/was [and I love this country despite seeing the deterioration I view daily], we are deficient in many ways given our large population. We give a lot of money away for many things that are not as important as taking care of veterans and our older and sickly population, and those that are poverty-stricken. Long-term health insurance for catastrophic situations is near impossible to afford (unless you start providing for that after age 18) along with other "insurance" costs, especially towards the end of life, and what Medicare or Medicaid doesn't provide cost-wise. A huge percentage of monies we are "giving away" should go for care of our citizens who have been paying (sometimes extraordinary) taxes. I'm around many people who are now 80 years old or older, who have lived good, productive lives, and generous-to-other people, who are losing homes, dying, frightened ... I could go on and on. It's scary. The entire system has to be reworked and re-established. I now firmly believe that we certainly cannot take care of the entire world .... it is unsustainable and we will all lose. I wonder how I will end up because nobody knows for sure! While I don't enjoy getting into heavy politics, what I see is exceedingly disturbing and not much is being done to address important issues.

Why should the US be different?

[Belle]

This is very concerning, Lance. It's perfectly understandable that you love your country.

You are so right that you cannot continue paying for the defense of the rest of the world. I think the international 'nanny' role has actually hollowed out your own prosperity. Trump was right; nations need to stump up the costs for this themselves.
The US health system is an enigmatic behemoth to those of us outside its purview. Plenty of people have proffered advice as to the remedy but it's so big that this makes a solution difficult. Add to that an influx of millions more 'asylum seekers' who haven't contributed to it via taxation and you can see the problem growing. All I can say is that there is an opportunity cost to this kind of 'generosity'.

You mention starting medical insurance at 18. Bingo. This needs to be rammed home from schooling years. Attaining 18 years is effectively adulthood and these kinds of responsibilities/decisions are part of that stage of life and start from Day 1. As soon as practicable after 18, if a student, these obligations should start. That's what we taught our (5) children. One took no notice; trouble is coming as sure as I'm sitting here!

As with everything in life it's all a matter of personal and national prioritizing and removing the sense that everybody is entitled, when they want it. Unfortunately that mindset is pervasive in the western world and depredation awaits. There can be no entitlement without our own roles in that 'bargain' which is a dual rights-responsibility paradigm. The person or persons who work that out early will be those who can make the system work for them.

[Lance]

Great comeback! Well, the immigration situation I see as totally out of control. Being the product of immigrants myself (from 1900 grandparents), I fully understand and appreciate why those in other places want to come here; I would, too. I still maintain, it HAS TO BE DONE LEGALLY, even if we have to quadruple staff to do it properly. So many people have come through now that we have no knowledge about who they are, which could well affect even the security of our nation, not even thinking about feeding, clothing, housing and medicating/hospital those arriving from other countries. I could certainly not expect to go to ANY country and just be accepted at the door, as it were especially "sneaking" in. [Could I just arrive on Australia's doorstep and expect to be allowed in knowing nothing about me?] Now, our own doctors and hospitals are not sufficient enough to take care of citizens. I am waiting five months now for just an eye appointment. My regular doctor canceled a March appointment and there is no call to when I can have an appointment, they are all overwhelmed. So, it's nice to be "generous," to people everywhere, but in the final analysis, things are going in a negative direction. Many of our fine CMGers will probably think I have rocks in my head in this thinking, but in living as long as I have, I see trouble coming big time and it is already big time. Our 25+ year olds cannot afford apartments or even think about acquiring a house. More and more companies are laying off employes, those that have worked for 20-25 years at the same place. California has raised minimum wage to $25/hour for restaurant workers, burgers are now heading for $25/USD or more. Living in California at $25/hour ($800/week) is still not enough for people to call it a living wage given the cost of living in that state (pretty similar to New York State). So now these restaurants are closing, workers going on unemployment insurance (where is all this money coming from: taxpayers who no longer work?). As I have said, I don't like opening up cans of worms on political issues being a peace-loving man, and for the first time in my own life, I am fearful of what's ahead, not only for me, but our children and grandchildren. "American Dream," they say? Hmmmm. We are already halfway down the toilet (pardon me!). We only have the other half to go. An in truth, America has done it largely to herself in so many respects. Much of it is pure greed. Money talks and ... •

This is very concerning, Lance. It's perfectly understandable that you love your country.

You are so right that you cannot continue paying for the defense of the rest of the world. I think the international 'nanny' role has actually hollowed out your own prosperity. Trump was right; nations need to stump up the costs for this themselves.
The US health system is an enigmatic behemoth to those of us outside its purview. Plenty of people have proffered advice as to the remedy but it's so big that this makes a solution difficult. Add to that an influx of millions more 'asylum seekers' who haven't contributed to it via taxation and you can see the problem growing. All I can say is that there is an opportunity cost to this kind of 'generosity'.

You mention starting medical insurance at 18. Bingo. This needs to be rammed home from schooling years. Attaining 18 years is effectively adulthood and these kinds of responsibilities/decisions are part of that stage of life and start from Day 1. As soon as practicable after 18, if a student, these obligations should start. That's what we taught our (5) children. One took no notice; trouble is coming as sure as I'm sitting here!

As with everything in life it's all a matter of personal and national prioritizing and removing the sense that everybody is entitled, when they want it. Unfortunately that mindset is pervasive in the western world and depredation awaits. There can be no entitlement without our own roles in that 'bargain' which is a dual rights-responsibility paradigm. The person or persons who work that out early will be those who can make the system work for them.

[Belle]

I've just been reading your comments while listening to Hamelin playing Kapustin!!

I share all your concerns because we have 5 adult off-spring (one of these is my spouse's). And, between us, 8 grandchildren ranging from 6 months to 34 years!! And, importantly, neither you nor they should ever have to apologize to anybody for holding those views, or any other.

There's a huge irony in the unemployment situation; more people than ever before (in both our countries) are going to university. There isn't a concomitant increase in job opportunities for them, it seems to me. Quite the opposite; the growth in employment is currently found an the trades level where we just don't have enough people to build houses and university graduates cannot find work which pays them commensurate with their academic efforts. In spite of this students are still herded into universities. It's up to their parents to say, "enough". My son is studying law because he's going into partnership with his wife in her existing practice but if he was a university student of 18 he'd know the real outcome would be a low-paying start in a law firm, competing with thousands of other graduates for the same patch. My daughter-in-law went into politics, which is where she met my son. I remember her telling me how low the pay rates were in the legal profession compared to her salary as a political apparatchik. Supply and demand.

Same with housing. The immigration situation here in Australia is out of control, with people queueing whole city blocks to look for an apartment to rent in Sydney and Melbourne and 'cheap charlie' duplexes being built in my suburb to cope with rental demand (as I write this one is having a slab poured two doors down). The ponzi scheme successive governments have engaged in, trying to boost the economy falsely with the sheer weight of numbers, has an entropic slope. And what is that? No sustainable health services, no adequate suburban infrastructure, no social cohesion and no housing.

You get what you 'pay' for!! This cartoon says it all!!

[Lance]

IT SURE DOES! Applies on these shores, too.

You get what you 'pay' for!! This cartoon says it all!!

[jserraglio]

It is fascinating to hear from the pseudo-libertarian Right on this healthcare issue. They are the offspring of the very gaggle that bitterly opposed Medicare in the twentieth century and then savaged Obama/Pelosicare in the twenty-first.

They now presumptively proffer a fix for the real inequities that exist in America’s health system, while lauding their own socialist medicine regime and tirelessly parroting, without ever citing a shred of evidence, a xenohysteric falsehood about immigrants paying no taxes & leeching off the system.

An influx of millions more 'asylum seekers' who haven't contributed to it via taxation

You get what you 'pay' for!! This cartoon says it all!!

IT SURE DOES! Applies on these shores, too.

One might call it such cartoonish posturing Lilliputian hypocrisy!!

This [end-stage poverty] was a major factor in many US Covid deaths. Many already unhealthy people exposed to a new disease probably accounted for the fact that the death rate from Covid in the US was significantly higher proportionally than its first world counterparts.

Compounding the mistruths are the half truths, e.g., faulting inequities in the U.S. health system for its comparatively high percentage of COVID-19 fatalities while failing to acknowledge that a significant underreporting of COVID deaths took place in the South and West (certifying them instead as being from “natural causes”), caused by outright ignorance, willful resistance to taking preventive measures, and a MAGAean political bias against attributing deaths to the COVID virus. Note too the flip-flop from an earlier dismissiveness that characterized the COVID-19 death rate as a “storm in a teacup”.

[Belle]

You have one enormous chip on your shoulder. It comes across in everything you post. Bitterness is a resilient trait.

[jserraglio]

You have one enormous chip on your shoulder. It comes across in everything you post. Bitterness is a resilient trait.

How about presenting some hard evidence that shows immigrants to the USA to be freeloaders?

Until you do so, your inability to tolerate contradiction is just supersized self-puffery.

[barney]

It is fascinating to hear from the pseudo-libertarian Right on this healthcare issue. They are the offspring of the very gaggle that bitterly opposed Medicare in the twentieth century and then savaged Obama/Pelosicare in the twenty-first.

They now presumptively proffer a fix for the real inequities that exist in America’s health system, while lauding their own socialist medicine regime and tirelessly parroting, without ever citing a shred of evidence, a xenohysteric falsehood about immigrants paying no taxes & leeching off the system.

An influx of millions more 'asylum seekers' who haven't contributed to it via taxation

You get what you 'pay' for!! This cartoon says it all!!

IT SURE DOES! Applies on these shores, too.

One might call it such cartoonish posturing Lilliputian hypocrisy!!

This [end-stage poverty] was a major factor in many US Covid deaths. Many already unhealthy people exposed to a new disease probably accounted for the fact that the death rate from Covid in the US was significantly higher proportionally than its first world counterparts.

Compounding the mistruths are the half truths, e.g., faulting inequities in the U.S. health system for its comparatively high percentage of COVID-19 fatalities while failing to acknowledge that a significant underreporting of COVID deaths took place in the South and West (certifying them instead as being from “natural causes”), caused by outright ignorance, willful resistance to taking preventive measures, and a MAGAean political bias against attributing deaths to the COVID virus. Note too the flip-flop from an earlier dismissiveness that characterized the COVID-19 death rate as a “storm in a teacup”.

I think you may have missed the point of this cartoon. It is not suggesting refugees are freeloaders, in my view; it is a reference to Australia's housing crisis, which we would still have even with no immigrants thanks to a wide range of factors. Australia's housing, I read last week, is per capita the most expensive in the world.

Regarding the Republicans and America's medical plight, the GOP has blood on its hands.

[jserraglio]

I wasn’t commenting on the cartoon per se, I was taking issue with the xenohysteric hobbyhorse Belle rides about immigration, which is that immigrants are to a large extent freeloaders that don’t pay taxes, live on the dole and are a net drain on the public purse. Her words to that effect can be found once more in this very thread:

The US health system is an enigmatic behemoth to those of us outside its purview. Plenty of people have proffered advice as to the remedy but it's so big that this makes a solution difficult. An influx of millions more 'asylum seekers' who haven't contributed to it via taxation and you can see the problem growing.

The view that given the smokescreen of uncertainty obscuring U.S. health care, coloured aliens who pose as “asylum-seekers” (much like Oz’s self-proclaimed “aborigines”) can readily be singled out for blame, that they pose a problem, that they are little more than a dead weight dragging down the rest of the economy, is a dangerous form of scapegoating that at least two administrations in this century, both Republican and Democratic, have discredited.

[Holden Fourth]

I have two questions. I am a US citizen and I have no health insurance. If I suddenly fall ill and have to be taken to hospital, will this cost me financially? Will I owe thousands of dollars? Alternatively (my second question) will some form of social welfare system cover me?

I'm not asking these questions to provoke any form of discord. I'm just trying to shake off the stereotypes that I've heard about the US health system.

[jserraglio]

Health costs and the extent and amount of coverage by a social safety net will vary depending on who you are, where you live, and what choices you make.

Assuming you are not on Medicare (elderly) or Medicaid (indigent), the answer to your first question is “yes”, it will cost you.

If you choose to remain uninsured, the answer to your second question is “no”, there will be no social welfare system to assist you until you run out of money, and along the way it will cost you big time. Some states may even impose a tax penalty on you for declining coverage; other states will allow you to opt out of coverage without penalty, it depends on where you live.

If on the other hand, you choose to enroll in and pay for a private health insurance plan subsidized by both the federal gov’t and state gov’ts under the Affordable Care Act of 2010 (Obamacare), you would then be covered by a kind of social welfare system, so in that circumstance, the answer to your second question would be “yes”.

[Rach3]

The non - profit hospital tax scam:

https://www.statnews.com/2024/04/14/non ... e=hs_email

[jserraglio]

The non - profit hospital tax scam:

https://www.statnews.com/2024/04/14/non ... e=hs_email

Yes, but this is the price we pay for free-market medicine, for not living with medical care delivered socialist-style as they do in the U.K., Canada and Australia.

[Rach3]

The non - profit hospital tax scam:

https://www.statnews.com/2024/04/14/non ... e=hs_email

Yes, but this is the price we pay for free-market medicine, for not living with medical care delivered socialist-style as they do in the U.K., Canada and Australia.

Not to mention more costly, less effective here in the US.

[jserraglio]

The non - profit hospital tax scam:

https://www.statnews.com/2024/04/14/non ... e=hs_email

Yes, but this is the price we pay for free-market medicine, for not living with medical care delivered socialist-style as they do in the U.K., Canada and Australia.

Not to mention more costly, less effective here in the US.

Yes, but freedom does not cheap. Let the market work its will!!

[Holden Fourth]

The non - profit hospital tax scam:

https://www.statnews.com/2024/04/14/non ... e=hs_email

Yes, but this is the price we pay for free-market medicine, for not living with medical care delivered socialist-style as they do in the U.K., Canada and Australia.

You can add all the Scandinavian countries plus a number of European ones to this 'socialist styled' system.

[jserraglio]

The non - profit hospital tax scam:

https://www.statnews.com/2024/04/14/non ... e=hs_email

Yes, but this is the price we pay for free-market medicine, for not living with medical care delivered socialist-style as they do in the U.K., Canada and Australia.

You can add all the Scandinavian countries plus a number of European ones to this 'socialist styled' system.

What’s the world coming to???

Big Government, get off our backs!

Liberté et inégalité! Vive la différence!!

[Rach3]

A recent Brookings study per Axios:

" ...The paper compared poverty reduction efforts in the U.S. to other countries including Canada, the U.K., and the Netherlands, and found that the U.S. is the only one where working full-time at minimum wage doesn't lift you above the poverty line..."