Reflections on Treating the Poor

It is altogether curious your first contact with poverty. You have thought
so much about poverty — it is the thing you have feared all your life, the
thing you knew would happen sooner or later; and it is all so utterly and
prosaically different. You thought it would be quite simple; it is
extraordinarily complicated. You thought it would be terrible; it is merely
squalid and boring. It is the peculiar lowness of poverty that you
discover first; the shifts that it puts you to, the complicated meanness,
the crust-wiping.

– George Orwell, Down and Out in Paris and London


George Orwell’s 1933 memoir, Down and Out in Paris and London,
relates the clear-eyed experience of being homeless and penniless. The
novel’s protagonist lives in Paris giving English lessons and eventually
experiences a stroke of bad fortune and loses his job; money slowly but
surely disappears. He is overcome with “a feeling of relief, almost of
pleasure, at knowing yourself at last genuinely down and out.”

Imagine, Orwell asks of us, what this bad fortune means. You cannot send
letters because stamps are too expensive. At the baker, an ordered pound of
bread weighs in slightly more and thus costs slightly more — and you cannot
pay for it. You avoid “a prosperous friend” on the street so he
won’t see that you’re “hard up.” And you’re hungry. Wherever you walk there
are inescapable reminders of this: bakeries, restaurants, coffee shops.
“Hunger,” Orwell writes, “reduces one to an utterly spineless, brainless
condition, more like the after-effects of influenza than anything else.” Months pass by in between baths. Clothing is pawned. In the midst
of this scramble to live, however, one forgets that there is, indeed, a lot
of time with nothing to do at all: “you discover the boredom which is
inseparable from poverty; the times when you have nothing to do and, being
underfed, can interest yourself in nothing.”

Orwell based such descriptions largely on personal experiences. In 1927 he
spent time in the company of tramps and beggars in London, dressed in
worn-out clothing and sleeping in poor lodging-houses for two or three
days. He subsequently moved to Paris and subjected
himself to similar experiences. In doing so, he eventually brought
attention to the plight of the poor, providing an honest, unvarnished look
at what it was like to be down and out.

~

Rereading the book reminds me of Bellevue Hospital, New York City’s
flagship public hospital. Bellevue, or its progenitor, was originally an
infirmary in Manhattan in the 1660s and became the most well-known of the
public hospitals in the country (I have

written about it
 for Public Discourse). Here physicians treat the uninsured, the
undocumented, and the homeless. It is a rare day when a physician at
Bellevue does not interact with New York’s poorest residents.

Jim Henderson (Creative Commons)

Sometimes they come in search of medical care and sometimes they come in
search of a meal. They stumble in from homeless shelters or from street
corners, inebriated, withdrawing from drugs or alcohol, psychotic,
suicidal, deathly ill or sober. Occasionally they unknowingly enter the
emergency room with lice or bedbugs and nurses delouse them with multiple
layers of permethrin, an insecticide. The physician must approach these infested patients with
a hairnet, gown, and gloves — the lice crawl on the patient’s head, chest,
arms and bed sheets. The smell sometimes overwhelms the doctor or nurse,
too. It may have been months since the patient has bathed, and the odor
percolates throughout the room and the hallway.

As I wrote in my Public Discourse piece, the patient presentations
are frightening and remarkable:

Ride the elevator down, and you will stare in horror as an agitated drug
addict with an infection tries to punch a physician while bolting out of
his hospital room with security guards and nurses in pursuit. Next door, a
homeless patient lies in bed with heart failure. Next to him is a patient
who’s visiting New York from Africa with a raging AIDS infection. Peer into
another room down the hall, and you can watch patients withdrawing from
alcohol or heroin, thrashing about and screaming.

Physicians have the unique privilege at Bellevue to see poverty up close,
which so rarely occurs in upper and middle class professions. But as close
as we are, we don’t really understand the poor the way Orwell did. We don’t
live amongst them or feel the curse of extended hunger or the uncertainty
of when the next meal will come. We don’t experience that odd sensation of
boredom, where there is nothing to do because one has nothing to do it
with. And we cannot fully empathize with their fragile health.

~

This is why Orwell’s book is so enlightening. At least we get a description
of what some of Bellevue’s patients may go through; at least we get a
glimpse. It creates a little less space between the comfortable and the
impoverished.

But Orwell wasn’t wholly right about the poor. He wrote in Down and Out:

The mass of the rich and the poor are differentiated by their incomes and
nothing else, and the average millionaire is only the average dishwasher
dressed in a new suit. Change places, and handy dandy, which is the
justice, which is the thief? Everyone who has mixed on equal terms with the
poor knows this quite well. But the trouble is that intelligent, cultivated
people, the very people who might be expected to have liberal opinions,
never do mix with the poor.

True, there is a closeness between “intelligent, cultivated people” and the
“poor” simply by virtue of being human. However, there are deep differences
that would not disappear if the two simply switched jobs and clothing. For
instance, in 2016,
four percent of U.S. adults experienced a “serious mental illness.” This did not cover patients without
fixed addresses — the homeless. And     
approximately one fifth of the homeless in the United States
 suffer from a severe mental illness. Even if the definitions of “severe”
and “serious” don’t match up precisely, the difference between mental
illness among the homeless and other US adults is huge. And these
differences matter both to policy analysts and to physicians.

Two epidemiologists, Elizabeth Bradley and Lauren Taylor, have written a
thoughtful book dealing with the issue of rising health care costs entitled The American Health Care Paradox. In it they argue that our
skyrocketing health care expenditures (we spend

more than double the share of GDP
 of other developed countries on health care) and poor outcomes (we are in the high 20s or low 30s in rankings among OECD developed countries for maternal mortality, life expectancy, low birth weight, and
infant mortality) are not due to
overspending, but rather to underspending by the United States on social services — affordable housing,
education, access to healthy food, and so forth.

Bradley and Taylor
explain how this happens:

Several studies have demonstrated the health toll of living on the
streets; more than two-thirds of America’s homeless population suffer from
mental illness or substance dependency, while nearly half have at least one
additional chronic condition such as diabetes or hypertension. The high
costs of health care provided to people who are homeless have been well
documented. For instance, in one five-year period, 119 people who were
chronically homeless and tracked by the Boston Health Care for the Homeless
Program incurred a total of 18,834 emergency room visits estimated to cost
$12.7 million.

This makes sense. Many of our homeless patients deal with chronic diseases
like diabetes, mental illness, or congestive heart failure. We stabilize
them in the hospital and send them back to a shelter or the street. Often
they return the next week with exacerbation of their heart failure or
sky-high blood sugars or psychosis, even when medication is provided by the
hospital without charging the patient.

Thus a chasm separates our world and that of the poor, yet they are
entangled. How can you get someone to start eating vegetables and fruits
and whole grains in order to mitigate the effects of diabetes if they don’t
have money to buy these foods? How can you control a child’s asthma if a
family does not have money to clean their apartment and rid it of the
vermin, bugs, and dirt that pervade the nooks and crannies? How can you ensure a psychotic patient takes his medication when he can barely feed himself? The homeless
face a very different and more intimidating set of difficulties than the
wealthy. And these translate into challenges for physicians, who do
not have the time or skill to be both doctors and social workers.

We, as physicians, care for the patients until they are ready to leave the
hospital. Then they face their poverty on the street. Our view is but a
brief and skewed snapshot. In our myopic hospital world, the hospital
stretcher is detached from daily life. And this is necessarily so, to
a certain degree. Physicians can only do so much to fix societal ills — they cannot create a job, a safe home environment, or a loving family for
the patient.

Nevertheless, both wealthy patients and poor patients succumb to cancer,
strokes, and heart attacks. Both undergo the

humiliating process of death and dying
. In this sense, death and disease are often great equalizers. Neither the
poor nor the rich can escape them. They rapidly close the chasm between the
two classes. And at least in that vein, Orwell was right.

Practicing Medicine Turns One

As I look back on the first year of this blog and reflect on my four years of medical school, I am amazed at how much I have learned and how much
I have seen. All of it has informed what I have written about here on Practicing Medicine. And many of the issues I have raised remain vital to my experience within the hospital.
Medicine forces physicians to ask questions; questions beyond which IV fluids to give or which antibiotic to use. Medicine demands that we ask the same
questions that any student of human history might ask: What makes us human? What is so humorous about human suffering and pain? Why
do we become numb to human forms of sufferingWhat is the process by which we die? And is it dignified?

How should we view the place of the mentally ill in our society
?

I have also made other, perhaps less broad and less grand, attempts at explicating the practice of medicine. My first post explained why I decided to blog and the awkward place
of medical students within the medical field. This piece
discussed the potent smells of the hospital — they are unavoidable and yet we adjust to them. Stepping into the ED for the very first time, I
explained how a trauma code works and the horrors that
trauma patients face. The kidney-failure patient also faces difficulties,
but they are of a chronic nature due to dialysis, a miracle of modern science with its own drawbacks.

I compared
George Orwell’s experiences in a French hospital in the early twentieth century to my own experiences in a hospital in the early twenty-first; yes, there are major differences, but there are also similarities. This is a pragmatic post on how we ought to think about
scientific studies and evidence-based medicine. I have written about depression and schizophrenia. And, in a more recent post that would have
pleased me greatly as a younger reader, I wrote about Sir Arthur Conan Doyle’s eponymous detective, Sherlock Holmes — it turns out his methods are relevant to physicians today.

Over the next year I hope to continue to write about the big questions and bring up others in relation to what I see and do. I also have a few bigger writing projects in the works, which I will mention here on the blog. If you have suggestions or
comments, please feel free to send them my way. My e-mail address and Twitter handle can be found at the right.

Denying and Romanticizing Mental Illness

Reactions to mental illnesses or disorders vary. (I wrote about some of them
in a 2012 essay in
the pages of The New Atlantis
.) I’ve noticed, however, that some of
the responses among physicians differ from their reactions to other medical
pathologies. There are several reasons why this might be the case, having to do
with the fact that psychiatric pathology is far more difficult to comprehend
and thus more easily misunderstood than the pathology of other diseases we
usually associate only with the body, such as cancer or pneumonia.

Image via Shutterstock

Unlike bodily illnesses, mental disorders primarily affect patients’
emotions and actions. As a consequence, our implicitly held beliefs about human
behavior, especially our views of free will, can color how we react to people
suffering from mental illness. A strong belief in free will helps validate a
sense of justice and morality: generally speaking, people choose their actions
and are thus responsible for them. So if a person with a psychiatric diagnosis
commits suicide, kills another person, or runs onto a highway screaming at
imaginary beings, it is easiest to hold the person morally responsible if we
believe he acted freely. Or, in the case of suicide, we might say that the
person “should have done” this or that to make life better: he should have seen
a psychiatrist, or he should have realized how wonderful his life was. We want
to hold the person responsible for his actions rather than deal with an illness
that so often makes people completely irrational and incapable of choosing
their actions.

Additionally, the fact that most medical pathology is visible to us makes it
simpler to understand. In the emergency room we easily see the
effects of a chopped-off leg
. We can feel
a large spleen
, hear an irregular heartbeat, or view an abnormal lab
finding. Psychiatric pathology, however, is not palpable in the same way. With
schizophrenic patients, for example, we cannot see the beings they see. We do
not inhabit the world they inhabit. Nor can we easily visualize their brain
chemistry. It is as if we are looking for the culprit in a pitch-black world.

With these difficulties in understanding psychiatric disease, some
physicians, patients and observers dismiss mental illness as a product of the
weak-willed or obstreperous. Or they romanticize it, focusing on the
interesting and provocative aspects of mental illness. These are minority
views, but they are not without influence — which is unfortunate, because if
they are followed, they can lead us to deny treatment to those who need it.

Dr. Robert Youngson, a British doctor-turned-author,
is an instructive example of someone espousing dangerous views of this sort. In
his 1999 book, The
Madness of Prince Hamlet and Other Extraordinary States of Mind
, he
writes:

Doctors and lay people talk, quite casually, of ‘mental
illness,’ the implication being that conditions like schizophrenia are much the
same as conditions like tuberculosis or meningitis. In fact, they are not.
Mental disorders have hardly anything in common with organic physical
disease…. The observable changes occurring in the body — including the brain —
in the course of organic disease are called pathology. So far as current
research can demonstrate, there are no corresponding organic changes causing
schizophrenia.

Dr. Youngson goes on to assert that we classify schizophrenia as an illness
in order to maintain a society of “normal” people. He claims that British
psychiatrists “carry out a tidying-up function much more closely equated with
that of the police and the judiciary than with that of the medical profession.”
Then he asks, disturbingly, whether there is “really any difference between
what happened in Russia, when political dissidents were deemed to be mad and
were incarcerated in mental hospitals, and what happens in Britain and America
when people who do not conform to current social mores are legally certified
and locked up.”

For support of his position, Dr. Youngson refers the reader to the work of the
late Thomas Szasz, who,
as a professor of psychiatry at the State University of New York Upstate
Medical University at Syracuse, New York, published a number of controversial
books arguing that mental illness is a myth. The status quo of medical practice
that considers mental conditions like schizophrenia as illnesses, Dr. Youngson
writes, is a “convenient fiction about a state of the mind.” (A critical essay
about Dr. Szasz appeared
in The New Atlantis
in 2006.)

But Dr. Youngson’s premise, that schizophrenic patients lack cerebral
pathology, is wrong. We know, for example, that patients with schizophrenia
have a disruption in certain neurotransmitters in their brains. Dopamine is
increased in patients with schizophrenia, and this possibly relates to the
effects of genetic alterations. There are specific (and multiple) gene
variants associated
with this disease. Furthermore, medications do sometimes
work, as I explained in another
recent post
. They inhibit dopamine’s actions on certain receptors in the
brain and, despite their side effects, can rid patients of awful and
belligerent visions and voices. If there were truly no pathology, why would
blocking receptors work? If there were truly no pathology, why would there be
significant elevations of certain neurotransmitters? There is indeed pathology
here — Youngson apparently just chooses to ignore it because it contradicts his
preferred explanations.

Dr. Paul McHugh, a
professor of psychiatry at Johns Hopkins University School of Medicine, wrote
about this particular topic in a 1995
issue of The American Scholar
. He argues that “the context of a life
should not be confused with the cause of all mental disorders or made the sole
focus of therapeutic attention as though guidance were always synonymous with
cure.” Unfortunately, “the assumption that something must have happened
if a mental disorder is present has provided an entry for zealots and
charlatans into psychiatry.” If we believe that mental disorders like
schizophrenia or depression are always rooted in life experiences and never in physical
pathology, we can easily misunderstand patients, their families, and the
possibilities for therapies. Not only is Dr. Youngson’s view wrong; it is injurious
to those whom it is meant to help.

Dr. McHugh also addresses the romanticization of depression in a 2005 Commentary
essay
(which I quoted in another
recent post
). McHugh reviews Andrew Solomon’s book The
Noonday Demon: An Atlas of Depression
(2001), in which Solomon writes
about his own experiences with depression. Solomon, McHugh argues, romanticizes
depression by making it seem mysterious like sex and curable most effectively
by a sheer act of will. Similar to Dr. Youngson, Solomon mischaracterizes a
terrible sickness. As McHugh writes,

the particular disorder at issue here is a disease,
an affliction that disrupts a natural function of emotional control. This
disease, like other diseases both physical and mental, renders the afflicted
person impaired in ways that are essentially the same from case to case….
[Depression] is not a you but an it, a thing unto itself and not
just the dark side of human emotion.

Again, depression, like schizophrenia, clearly involves pathologies in the
brain. It is a real disease that tears apart human lives.

What’s so striking about these cases is that those who are denying or
romanticizing mental illnesses are familiar with the diseases. Surely, Dr.
Youngson saw schizophrenics in his family practice. Solomon experienced
depression himself. And Dr. Szasz also saw patients with these disorders.
Seeing or experiencing the illness, then, is not enough to understand it. An
understanding of disorders of the mind requires that we not only learn about
symptoms, social context, and pharmacology, but also that we understand the
underlying pathology.