Providing health care to human beings trapped in the poverty culture - Reconciling the Inner Self With the Business of Health Care

KEY CONCEPTS

* Poverty Culture

* Changing Mental Models

* Providing Care to Poor Patients

* Creating Healthier Communities

* Poverty: The Ultimate Barrier to Care

"Every life deserves a certain amount of dignity, no matter how poor or damaged the shell that carries it."

- Rick Bragg, All Over but the Shoutin' (1)

I recently completed my thirtieth year of a career dedicated to providing health care to people living in poverty. Significantly, my experience with poor people as a medical student at the county hospital was not a good one and coming out of my residency I had no interest in caring for them. Sometimes they did not smell very good. Often they seemed to be in a bad mood. Many were not compliant. Their problems were complex. It did not occur to me until later that much of this was a result of problems with the system, not with the patients.

I took a position as Director of HealthNet Community Health Centers in Indianapolis for one year while waiting for the group that I was going to join to build a larger facility. And I stayed, captured by the mission, in love with the patients, and stimulated by the challenges. It became clear to me very early that if we treat patients living in poverty with dignity, they respond as delightful, genuine human beings. They eat, breathe, talk, laugh, dance, and cry just like the rest of us. They cry because they hurt. And the hurt is why they come to see us. But the culture of poverty impacts everything our patients think and do--and they are trapped in it.

Pearls for the health care provider

While taking care of patients in the poverty culture is in many ways the same as taking care of anyone else, it is also totally different. The secret is in understanding the sameness and the difference. Peter Senge writes about mental models in The Fifth Dimension. (2) My mental model underwent a major transformation nearly 30 years ago. What follows are seven concepts important in building a mental model that will enable physicians to provide health care to patients living in poverty.

1. Poverty is the number one health problem

The vision of the Indianapolis HealthNet Community Health Centers is to create one of the healthiest urban communities in the U.S. However, we will not improve many outcomes if we do not ameliorate poverty. Poverty overlays everything we do--it is the ultimate barrier. All of the efforts to improve access, while noble and worthwhile, will have minimal health impact because poverty persists.

I'd believed that if I could help patients feel better and be stronger, they would be more successful in getting an education and a job. But there is more to it than that. I am not going to eliminate poverty with my stethoscope. Poverty is a culture, a mindset, a mental model. This sea change has to begin in the home, schools, and communities. Health care professionals play a role, but we cannot solve poverty. As long as poverty exists, it remains the number one health care problem. No matter what condition our patients present to us, it is complicated in ways beyond our comprehension by poverty.

2. We see the same diseases as everyone else

At first I thought our medical practice was different because we took care of the unique conditions of poor people. But there is no medical, pediatric or OB/Gyn textbook on the diseases of poor people. Diseases are all the same. We see a lot of congestive heart failure, hypertension, diabetes, and cancer. Our pediatricians have multiple cases of otitis media and attention deficit hyperactive disorder. We may have more cases of tuberculosis and HIV than in higher socioeconomic practices because of the environmental context in which our patients live. We see a lot of stress-related disorders, anxiety, and depression, but so do physicians who do not treat patients in the poverty culture.

While we see many of the same diseases, managing these conditions becomes more complex, challenging, frustrating, and sometimes discouraging. Take any disease, add to it the cultural and social complexities that are part of the poverty culture, and the management becomes a tremendous challenge. The lights frequently go off, the refrigerator is often empty, the heat is on again off again, the housing is substandard, moves are frequent, and education levels are below average. Survival is the priority, not health. These conditions have to be managed in the context of the whole person, the family, and the resources available in the community.

3. Patients are trapped in the poverty culture

People in the poverty culture have an acute, urgent, short-term focus- five years into the future is irrelevant. They live in the "here and now." They are in a crisis mode. The primary objective is to get through the day. And like it or not, health is way down on the priority list. Their behavior is driven by the culture, We should not expect middle class behavior. And the cultural differences are as real and startling as those found with migrants from Mexico, the North American Indian, or immigrants from the Middle East, India, or China. Our patients are from Indianapolis, but they live and think differently than middle class Americans.

Their future is bleak. It is not realistic for them to be thinking about higher education, a good paying job, nice cars, big houses, or professional status. For young males, the macho image is the only hope for status and self-esteem. They smoke and drink with their friends. And "score" with the women. Motherhood becomes the means to status and self-esteem for women--so they have babies...early and often. They are all trapped by the poverty culture and have little hope of breaking free.

We have to understand this despair and behavior when thinking of preventive medicine, health promotion, or even expecting patients to keep a follow-up appointment six months down the road. We can't fight the culture, we have to work with it. Patients living in poverty respect their physician. But the physician visit is just another stop during the chore of getting through the day. We think our patients should have mammograms. But they are a lot of trouble and our patients already have enough trouble. Mammograms hurt, and our patients already have enough pain. They diagnose cancer, and our patients don't really want to know. While they are an excellent preventive procedure, our patients could not care less. Picking up food stamps is more important.

One of my first patients was a 40-year-old man who came in with chest pains. While I was thinking about ordering an EKG, he was explaining that in the past month he had lost his job, his wife had left him, he had been evicted from his apartment, and his son had been arrested for possession of drugs. That is enough to make any man's chest hurt.

4. The behavior is often manipulative

Our policy has always been that we "trust our patients." But the staff is frequently offended by the patients' manipulative behavior--they have learned to bend every rule and play on every emotion. They may not always be truthful and may take advantage in any way that they can. But manipulation is a survival mechanism. Our patients are dependent on the bureaucracy, on corporations with middle class values, and on us with our middle class understanding of the way health care should be delivered. Our patients do not choose to manipulate. Rather, it is the way things are done in their culture.

As physicians, we have to be compassionate in spite of sometimes demanding behavior, or what we may interpret as manipulative. Our patients come to us because they hurt. Sometimes the more they hurt, the more disruptive they are. We have to approach our patients with caring hands and loving hearts. We should become partners in helping our patients negotiate the system--a daily chore for them. We are here to help our patients become healthier, not to teach them middle class interpersonal skills.

5. Compliance is a unique challenge

Compliance is a priority--without it, physicians will have little impact on patients' health. This is always a problem in ambulatory care--the patient, no matter what the culture, has to remember and be willing to take the medicine. The patient has to do the exercises, follow the diet, get the test performed. In the hospital, we can make sure these things happen. This challenge is even greater in the poverty culture because of multiple distractions. Compliance is far down on the patient's priority list. We ask, "Why didn't you get your medicine refilled?" We know the answer: "It was too much trouble." "I feel okay." "Too many other things to do." And so we find ourselves making the same diagnosis, and dealing with the same problems that are not getting better from lack of compliance. This is frustrating.

Physicians need to work at partnering with patients to improve compliance by biting off short-term, manageable goals. It is not helpful to advise a patient to quit smoking and lose 50 pounds. Patients in the poverty culture think short-term. Let's talk about losing two pounds for the next month and celebrate the small victories. Compliance is a huge problem and challenge. We have to understand that it is even more so for those living in the poverty culture. We must be patient and we must never give up.

6. Patients have limited resources

The lack of financial resources compounds the complexity of patient care. Physicians have to be thinking about how to get the best possible job done with the limited resources. We have to use our stethoscope more and rely less on testing. We have to work up our patients one step at a time. We have to use generic drugs. Often, we have to use our second choice of drugs. We need to make sure that patients have shoes and clothes, adequate nutrition, sanitation and housing, and transportation to the health care provider.

We often hear that if these patients can pay for their cigarettes, they can afford their medication-an irrelevant argument that demonstrates a lack of understanding of the poverty culture. Poor patients lack competency skills. They are not ignorant, but are not well educated. Their approaches to many problems are unsophisticated or stem from an inability to do the effective thing. One patient told me that she had so many problems that she didn't know what to do so she started crying and went to bed. We need to work as partners with our patients in helping them to accomplish the things necessary for better health.

7. The ultimate contributors to poverty: unwanted adolescent pregnancy and substance abuse

Two ultimate contributors to poverty must be addressed to improve community health status: unwanted adolescent pregnancy and substance abuse. There is no end to poverty as long as they are rampant.

1. In our HealthNet centers last year we delivered 1,100 babies. Fifty percent of these mothers did not want to be pregnant, another 25 percent were ambivalent. Adolescent pregnancy and the resulting social and family chaos is the fuel that perpetuates the poverty cycle. Pregnancy is 100 percent preventable.

2. Substance abuse is everywhere--it destroys hope and potential in human beings and causes the impoverished community to devour itself.

Physicians need to be more creative and effective in making sure that pregnancies are wanted and are at the right time and that the problems of abuse of illegal substances are addressed.

Is it worth the trouble?

It has become clear to me that I am not the key to a healthier community. Physicians will not ultimately improve the health of impoverished communities. Leland Kaiser, PhD, said "if every physician retired, the health of the world would decrease only 1 percent." (3) The key to healthy communities is housing, jobs, and education. On the other hand, "a shovelful out of the mountain of disease takes a shovelful out of the mountain of illiteracy, or crime, or housing. They are all interrelated." (3) Helping our patients to be healthier is important. Our patients cannot get an education or job without health and energy. They cannot break out of the poverty cycle without an education and a job. But we have to understand that there is more to it than this.

Is it worth the trouble, the frustrations, patient after patient, year after year? After almost 30 years, poverty still lives in Indianapolis. Our communities are not the health-lest in the nation. The answer lies in the oft-quoted story about the boy on a beach littered with thousands of starfish washed up by the tide. He was picking them up one by one and throwing them back into the ocean. Someone said that he wasn't making much difference. He replied, "it makes a difference to this one" and he threw it back in. This is what can keep us going, realizing that we might "make a difference to this patient."

Conclusion

We must work at understanding our patients. We must respect them and the culture from which they come. We have to care. To be successful, we must create the right mental model. These seven concepts can help. But most importantly, we need to get to know the human being. Patients living in a poverty culture are for the most part wonderful, delightful, and genuine human beings. Getting to know them is an awesome experience. If you avail yourself of the opportunity, you will not be sorry. (1)

Resource

This organization offers excellent information on providing health care to people living in the poverty culture: The National Association of Community Health Centers 1330 New Hampshire Ave. NW Suite 122 Washington, DC 20036 202/659-8008

References

(1.) Bragg, Rick. All Over but the Shoutin Quote from the author's mother. New York. New York: Pantheon Books. 1997.

(2.) Senge, Peter. The Fifth Discipline. New York, New York: Doubleday. 1990.

(3.) Lee Kaiser. Personal notes. VHA Seminar. Austin. Texas. 1994.

RELATED ARTICLE: A Positive Impact:

The HealthNet Story

The HealthNet Community Health Centers in Indianapolis started out in 1969 as two storefront clinics with curtained off areas for exam rooms and a drug storage room in the basement stocked by raiding private physicians' drug sample closets. These clinics evolved into a network of neighborhood-based community health centers delivering more than 90,000 primary care medical visits each year.

HealthNet also has two dental centers, four school-based clinics, a community-based care coordination program for prenatal patients and infants that provides 700 home visits a month, a large homeless program, and a midwife prenatal program that delivered 1,100 babies last year. In addition, HealthNet offers pastoral counseling, social work, HJV detection, podiatry, a child abuse prevention program, and health education. Patients who are not on Medicaid are charged on a sliding fee scale. Obtaining grant funding is an ongoing, critical challenge.

HealthNet's mission is to provide health care to patients who live in poverty in the inner city communities in Indianapolis. The goal is to have a positive impact on the health of the community and the vitality of our city.

Dale S. Benson, MD, CPE, FACPE

Dale's Book Pick

Rick Bragg's All Over but the Shoutin' (Pantheon Books, 1997).

This Pulitzer prize winning journalist's book on growing up in poverty is powerful, compelling, and extremely well written.

Dale S. Benson, MD, CPE, FACPE, is Vice President of Physician Practice Management at Mercy Health System of Chicago and the Past President of the board of the American College of Physician Executives. He can be reached by calling 312/567-2375 or via email at dbenson@mercy-Chicago.org.

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