Book Review

Medical Care and the Health of the Poor

Mama Might Be Better Off Dead: The Failure of Health Care in Urban America

N Engl J Med 1994; 330:801-802March 17, 1994

Article

Medical Care and the Health of the Poor
Edited by David E. Rogers and Eli Ginzberg. 144 pp. Boulder, Colo., Westview Press, 1993. $49.50. ISBN: 0-8133-1720-7

Mama Might Be Better Off Dead: The Failure of Health Care in Urban America
By Laurie Kaye Abraham. 289 pp. Chicago, University of Chicago Press, 1993. $22.50. ISBN: 0-226-001338-5

As we ponder as a society and a profession whether we should undertake changes in our health care system, it is helpful to be reminded of why we are facing this decision. Two new books, one from the point of view of health care experts and the other from the patient's perspective, focus on access to care and the health of the poor. Each provides powerful arguments for fundamental changes in our health care system.

Medical Care and the Health of the Poor is a compilation of articles by eight medical experts. The strength of this book flows from the range and expertise of the authors, who comment on the relation between poverty and health. Drawn from the fields of economics (Victor Fuchs), sociology (Paul Starr), public health (Margaret Hamburg and Diane Rowland), and medicine (Douglas Black, Nicole Lurie, D. Arden Miller, and Mary Charlson), each author has made important contributions to studies of the health of the poor.

Why is poverty associated with increased morbidity and mortality? Several commentators acknowledge the lack of causal evidence linking poverty and health, but this book underscores the fact that the poor have poorer diets, work in more hazardous conditions, are more disabled by a given condition, and are less able to obtain medical care than the wealthy. Although all agree that health is not just a result of medical care, the authors describe numerous inadequately disseminated but efficacious treatments that can narrow the disparity in health between rich and poor.

The authors draw several conclusions about the state of our health care system and speculate about the future. First, the disparity between socioeconomic classes in health outcomes has grown to proportions that make a societal response inevitable. Second, judging from what has happened in other countries that have addressed the health disparities between rich and poor, the United States may not evolve a completely equitable system. Many democratic societies tolerate inequity in health care delivery provided there is universal access to services and that the base level of coverage is acceptable to the majority of the population. Many countries permit additional benefits for their wealthier citizens; however, if the base level of coverage is not acceptable to the majority and is imposed on a minority (Medicaid, for example), then there is a tendency for the benefits of the base coverage to decrease over time, and democratic principles of fairness are challenged. Third, even if universal access to health care is implemented, a strong public health infrastructure will still be needed to respond to population-wide health risks.

For those who are persuaded more by personal anecdotes than by the opinions of experts, Abraham's Mama Might Be Better Off Dead provides a dramatic picture of how America's health care safety net fails to address the problems of the poor. Abraham is a journalist who spent three years following members of a black family in Chicago's impoverished North Lawndale neighborhood, chronicling their health problems and efforts to get care. Her book uses the obstacles confronted by members of the Banes family to illustrate the problems inherent in our patchwork provision of health care for the poor. The book is accessible to a broad audience and provides extensive references to both the medical and health policy literature.

Some of Abraham's examples may startle even health care workers who work primarily with poor patients. On days when Jackie Banes, the central figure in the book, takes her grandmother to the doctor and is told that her blood pressure is “good,” she withholds the rest of her grandmother's antihypertensive medication for that day in order to save money, figuring that she only needs to give her the rest of the medication on days when her blood pressure is “bad.” Because Jackie cannot often afford the $75 for the van to transport her disabled grandmother to the doctor's office, she decides to skip alternate appointments to each of the two specialists her grandmother needs to see.

There are also numerous examples of the disastrous consequences of Medicare's policy of reimbursing for acute health problems but not for many chronic or preventable problems. Jackie cannot afford adult diapers for her incontinent grandmother, and Medicare will not cover the cost, even though it would cover the cost of a urinary catheter that could cause a bladder infection and sepsis.

Abraham does not ignore the need for people to take personal responsibility for their health. She is matter of fact in describing Jackie's husband's use of alcohol and cocaine even though he is a kidney-transplant recipient. She does not make excuses for Jackie's failure to obtain a free measles vaccination for her daughter during an outbreak in Chicago. Yet she shows us repeatedly how even the best efforts to obtain care are thwarted by the irrationality and inadequacy of the system. When these efforts are undermined by drugs and lack of education and the many other ills characteristic of urban poverty, good health appears very far out of reach indeed.

Both books make the case that reform of the medical system alone is insufficient to eliminate all of the barriers to better health that face the poor, but it would be a big step in the right direction.

Andrew B. Bindman, M.D.
Miriam Komaromy, M.D.
University of California, San Francisco, San Francisco, CA 94110