Poverty is Hazardous to Your Health

The four of us were just about to sit down to a delicious end-of-summer dinner of grilled pork ribs and corn on the cob when the phone rang. It was for my friend, Dr. Michele Barry, Yale medical school professor and chief of one of the teaching wards at Yale-New Haven Hospital, who was on call that weekend. "Tell me what's the matter," she said into the receiver, using her reassuring, unfazable doctor voice. "Hmm-hmm. And how long has this been a problem?" Michele left the room briefly to continue the conversation, and when she came back she was in full exasperated-at-the-system mode. The patient, mother of a month-old baby, was crying on the phone because for the past two days she had been tormented by head lice (Pediculosis capitis, if you really want to know). A simple problem, you might think--head lice is endemic among schoolchildren, as many a parent could tell you--and one that hardly needs a high-powered medical consultation. You just go to the drugstore, buy a bottle of Nix (permethrin) over the counter and spend a lot of time with that little plastic comb. But Nix costs $22.99, and this woman didn't have it. By then it was Saturday night, and the drugstores in her neighborhood were closed until Monday. Fortunately, there was an all-night pharmacy, so Michele prescribed her permethrin, which Medicaid would pay for. She does the same thing for women with yeast infections who can't afford $16 for the over-the-counter Monistat: She prescribes terazol (a much more expensive medication), which is covered by Medicaid.

You can see this incident as a tiny illustration of the penny-wise, pound-foolish complexities of our bizarre healthcare system, in which routine problems are treated as full-blown emergencies, and the government will pay for prescriptions but not over-the-counter medications that may be cheaper and work just as well. The President asserted that there's no healthcare crisis, because anyone can just go to the emergency room if they need care. He's wrong--ERs don't give ongoing or preventive treatment; they just patch you up in a crisis. But to the extent that ERs and free services like Yale's have become the family doctor or the CVS for low-income people, that is the problem, because they're incredibly expensive. This is the system its defenders claim we must keep because single-payer health insurance would bankrupt the nation.

But this is also a story about the way poverty and health are intertwined. If you are reading this, chances are good that you can put your hands on $22.99. It's not a huge amount of money--it's pizza and beer for two, a hardcover book, two tickets to the movies. But there are a lot of people like Dr. Michele's patient, for whom $22.99 might as well be $122.99. They just don't have it when they need it. Even the co-pays on lifesaving prescription drugs can be too much for them. "I have patients who say to me that they can't afford to get both the diabetes and the heart meds, so they're just getting one this month," says Dr. Mark Cullen, also a Yale professor of medicine, and Dr. Michele's husband.

Forget, too, the other things so necessary to good health that the rest of us take for granted. Fresh fruits and vegetables--try even finding these in an inner-city neighborhood. Clean air--poor neighborhoods are notoriously the most polluted. Safe streets. Housing in good repair. A life with no more than the ordinary amount of stress. Well, you'd be stressed out too if you couldn't afford to get rid of your head lice. What else can't Dr. Michele's patient afford if she can't afford that? Try school supplies and books for her child in a few years. Try vitamins and a good breakfast every morning.

We hear a lot these days about the struggles of the middle class. Remember M2E2--Medicaid, Medicare, education, environment--the mnemonic New Democrats adopted after the Republicans took Congress in 1994? Except for the minimum wage, even progressives now routinely frame their policies around middle-class concerns--homeownership, college loans, Social Security, affordable health insurance. (I'm not saying low-income people don't need these things too, just that they are politically salient because the middle class cares about them, as it does not care, for example, about the inner city, school integration or prison reform.) John Edwards is about the only presidential candidate who mentions the 36.5 million Americans--12.3 percent--who fall below the poverty line ($10,488 for a single person, $20,444 for a family of four), and the additional 19 percent who are what sociologist Katherine Newman calls the near poor--100 to 200 percent above the poverty line. Only Edwards talks about the need to eradicate poverty, which he claims would take thirty years. So far his antipoverty platform has mostly reaped him charges of hypocrisy in the media for having a big house and getting expensive haircuts, as if there has to be something fishy about a rich man who campaigns against poverty and asks for poor people's votes. It's as if all the media talked about in 1932 was FDR's cigarette holder. A cigarette holder! Who does he think he is?