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Health care and poverty: A long distance traveled, yet still so far to go
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“We want to move Johnny to a place where there are none but children; a place set up on purpose for sick children; where the good doctors and nurses pass their lives with children, talk to none but children, touch none but children, comfort and cure none but children. Is there really such a place?” – Charles Dickens, Our Mutual Friend, December 1864
“It does not at all follow that the intelligent physician who has learnt how to treat successfully the illnesses of adults, has only to modify his plans a little, to diminish the proportions of his doses, for the application of his knowledge to our little sons and daughters. Some of their diseases are peculiar to themselves; other diseases, common to us all, take a form in children varying as much from their familiar form with us as a child varies from a man.” – Charles Dickens and Henry Morley, “Drooping Buds,” Household Words, 1852.
February marks the 200th anniversary of Charles Dickens’ birth — Feb. 7, 1812. It might come as a surprise to current pediatric residents that the importance of child advocacy and the understanding of the medical consequences of poverty are not merely newly discovered areas mandated by the American Academy of Pediatrics to be incorporated into residency training.
After a season of viewing the many adaptations of Dickens’ A Christmas Carol, I am struck by how far we have traveled since the Victorian era and how tenuous the social realization still is of the true cost of poverty. Not to mention the humbling realization that a truly modern elucidation of the core of pediatrics as we know it was penned by Dickens more than 150 years ago.
As pediatricians, we can only hope to carry on Dickens’ success as both a social reformer and as an advocate for children’s health. Although Dickens was a great supporter of London’s Great Ormond Street Hospital, Dr. Charles West, a British physician with a particular interest in pediatrics, was its founder. Similarly, on this side of the Atlantic, while gaining support from Dickens, the founders of The Children’s Hospital, Boston (1869) were also physicians.
The birth of a new specialty
In both cases, the social context of the need for a children’s hospital far outpaced the medical need, particularly in gaining public and financial support. Pediatrics was not yet a specialty of medicine. The partnership was formed, however, of private philanthropy and physician direction and has done well by pediatrics. Our challenge as pediatricians is to continue to advocate for a model of care that supports the health care needs of all children — including a social contract that understands the role of poverty in child health.
Social responsibility is a constant theme in Dickens’ work. In tribute to him at this anniversary, I think about how to apply his keen eye to today’s health care debate. A recent editorial in The New York Times (To Fix Health, Help the Poor, Dec. 8, 2011) by Elizabeth H. Bradley and Lauren Taylor, both with Yale University, yields some clues. We are surely myopic in our considerations of health care reform in this country, applying focus on health care costs with obvious political and social blinders. Unwilling to fight another war on poverty, let alone acknowledge poverty’s continued presence (in fact growth, especially among children) — we have chosen to pretend health care exists as a solitary budgetary line item.
It is a given in our current debate that the United States spends more than any other country on health care, although managing to rank in the bottom half of industrialized nations in outcomes, such as life expectancy and infant mortality. The implication is that we in medicine are poor managers of the nation’s largesse. What Bradley and Taylor make clear is that this assumption depends on what we count as health care spending. Their research has shown that if one includes spending on social services — such as rent subsidies, unemployment and employment-training benefits, old-age pensions, family support and other services that can extend and improve life with health care expenditures — then the United States no longer spends the most money.
In 2005, the United States spent 29% of gross domestic product (GDP) on combined health and social services, whereas Sweden, France, the Netherlands, Belgium and Denmark earmarked 33% to 38% of their GDP. The United States comes in 10th in combined spending and is one of only three industrialized countries to spend most its health and social service budget on health care itself. We spend 90 cents on social services for every dollar we spend on health care; our peers spend $2 on social service for every dollar spent on health care. Those countries with high health care spending relative to social spending also had lower life expectancy and higher infant mortality rates.
Focus on quality, cost
Our attempt to reform health care to control costs will undoubtedly fail if we think of health care as a zero-sum game and define success as a line-item cost. We clearly need to focus on quality and cost in health care. But we do a grave disservice to our patients first, and to health care in general, if we single out only the health care system as at fault.
Health care reform is here. Organized medicine is still here, and there are far too many participants and administrators to let any changes prune their ranks. Adjustments mandated by both, to the education, training and practice of medicine, are filtering through the land. I hope we do not forget that as wrenching that some of the changes may be, we who provide care, and no one else, should be people directing the change.
However, an echo of Dickens would truly be revolutionary — maybe it is not health care that should be the primary focus, but the social fabric disrupted by poverty. Perhaps a ghost of social well-being past, present and yet to come should visit our current Scrooge(s) — politicians (and their enablers) all, I suspect.
William T. Gerson, MD, is Clinical Professor of Pediatrics at the University of Vermont College of Medicine and a member of the Infectious Diseases in Children Editorial Board. Disclosure: Dr. Gerson reports no relevant financial disclosures.