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.

Leave a Reply

Your email address will not be published. Required fields are marked *