Going Third World

            When I walk along your city streets and look into your eyes
            When I see that simple sadness that upon your features lies
            If my spirit starts to sink it comes as no surprise
            It’s been a long way from anywhere like heaven to your town, this town
                                                                              –   James Taylor, Anywhere Like Heaven

Some years ago I worked at a hospital in a unique small city on the inner banks of North Carolina.  With a population of only about 30,000 and at an inconvenient distance from the more swank and upscale centers of the North Carolinian economic boom regions (Raleigh, Durham, Chapel Hill, Charlotte) the city had nurtured the growth of a very respectable hospital that served the needs of a population of 100,000 people.

The quality of care was really good, I would say better for many conditions than the quality of care in Cleveland, where I work now.  Although we could not offer certain services that were cutting edge and could not pretend to be a tertiary care center, the rapidity with which patients were sorted out and cared for was remarkable.  The hospital was also free from much of the political infighting and turf wars one encounters in the Cleveland area, and that was probably a reflection of the fact that all of us who were physicians and surgeons were stuck with one another and had to find the means to cooperate to the patients’ benefit.  The chief medical officer was not so much interested in whether you as a physician brought patients to the hospital or not. He had an uncanny way of addressing problems by systematically looking at them and bringing everyone who had a part in a solution together.   Performance and patient safety were valued above market share.

That said, the surrounding rural communities, particularly at the periphery of our catchment area, were medical care deserts.  Historically this region had always been poor.  Indeed, one local historian noted that at the beginning of the European conquest of the region it had tended to attract people with little cash and coin, because they could sustain themselves from the abundant aquatic life and the fertile soil.

So physicians in the countryside were always scarce and the poverty was remarkable.  Anyone who imagines that legions of poor people subsist on welfare checks for life should disabuse themselves.  For decades supplemental cash support for the impoverished has basically not existed and North Carolina appears to have taken a certain pride in how little it supports a public health infrastructure and how little it supports public education.  Obtaining medical insurance via Medicaid is very restricted and the North Carolina politicians have proudly refused to expand Medicaid coverage in spite of the fact that the Federal government would foot the bill for almost all of an expansion.  My sense of the general situation of the wealthy and poor in that region was that the very poor worked very hard just to be poor.

I experienced an evening of clarity regarding this when a friend of mine, a nurse in retirement, invited me to become the supervising physician of a free clinic run once a week in the county public health offices of a small community near the coast of the inner banks.  She had recently agreed to become the clinic director.  While I had to tell her I most likely would decline due to time constraints I did agree to drive down to see what one of their evening clinics were about.

It was in a community with a main street, down at its heels, a courthouse, some gas stations, some fast food outlets and empty buildings.  Like much of the housing in those environs, the trailer home is ubiquitous.  The landscape is flat and agricultural and from the road out of town the vista affords views of an occasional well-kept vegetable garden and seasonal roadside stand contrasting with collapsing old farmhouses beside questionably habitable trailers.

I arrived at a tiny set of offices jammed with people who were standing, packed in corridors, waiting rooms or smoking in the darkness of the parking lot, waiting for encounters with physicians who were all retired, one a robust man of 80 years.  I was much amazed at the sheer number of patients. Then they waited at the make-shift pharmacy run by a retired couple who were pharmacists and who had, as if by magic, stocked the room from floor to ceiling with common medications they had obtained through various connections with industry.  All medications were dispensed free of charge. The clinic had an agreement with the hospital where I worked in which lab tests and simple x-rays could be obtained via the hospital free of charge.

The people were pleasant and polite and racially mixed.  Their facial expressions were varied, but fatigue and sadness seemed predominant.  They were poorly clothed and their vehicles in the parking lot, essential property in a region with no public transit, had seen much better days. These were of the expanding class of American working poor.  Most of the patients were middle aged, most were there to control their diabetes, hypertension, asthma and heart failure.  The clinic was held at night because these were working people with no medical insurance to cover what they could not possibly pay for, and jobs which, I suspect, would not allow them a few hours off to see a doctor. Do not mention the health of their mouths or their eyes. Like many Americans these are people who almost never have dental disease treated.  For most of the patients whose oral cavities I examined it appeared that they lived most of their lives with a mouth of deteriorating, infected dentition.  Their plans for dental care were to wait for the day when they had the money for full extraction and the creation of dentures at one of the well-advertised denture clinics one spots on the highways.

I left that evening with both an admiration of what the community was trying to accomplish and a deep sense of dread, a sinking spirit, a sort of foreboding.  Before me there was fact, revelation that American civilization is fading, its multitudes of poor slipping into the status of the poor of what we used to call the Third World.  Like some community of the Third World, desperately this little community was trying to claw its way, in terms of basic medical attention, into the twentieth century, in the early years of the twenty first.

Civilization depends upon taxation.  In western culture this has been understood since the ancient Greek philosophers pondered questions regarding politics and citizenship.  From taxation flow the funds through which good governance provides for what our constitution names as a bedrock responsibility of the government it establishes—the general welfare of the people.  We have now arrived at a place where a tiny few enjoy unimaginable wealth and see their taxes dramatically diminishing.  For them the economic question might be where to buy their next extra luxury house.  For a growing multitude the economic question is more like where they might find the heaven of any decent dwelling, more like where they might find their next bag of groceries or when they might find the money to have all their teeth extracted.