Growing up in the border city of El Paso, Texas, I didn’t have to travel far to understand how unequal health care and services are around the world. The disparities there were self-evident. Within the limits of a bustling U.S. city were the colonias. Within these shanties built of scrap materials, Mexican immigrants were living without running water or sewage. Charities would go into the colonias to provide education on basic sanitation and health. People in El Paso would criticize the immigrants because they felt they were living off the fringes of society without paying taxes. Yet some of those same critics would hire them to work on their farms.
I think a lot of my inspiration as a doctor comes from the recognition of these disparities at an early age. I understood that the immigrants in El Paso wanted something better for their families. People from Mexico would risk their lives to cross the border to receive medical care in the U.S. They were doing what they thought was best, and they were hoping for better. I think that we all can identify with that basic concept.
I was a medical student at Boston Medical Center during the passage of Massachusetts healthcare reform. People in Boston had better access to care than probably anywhere else in the country at that time. Now, the Affordable Care Act reflects some of the concepts of healthcare delivery that began in Massachusetts. Yet I remember as a medical student we often struggled to discharge immigrant and low-income patients from the hospital. There were significant limitations for these individuals to receive the outpatient rehab or the mental health care they needed.
During my otolaryngology residency in Albuquerque, New Mexico, I learned particular skills working with poor and disenfranchised patients: how to choose the most effective yet least expensive medications and which pharmacies would provide them at low cost. I needed my patients to be able to take their antibiotics after being hospitalized for life-threating infections.
We cared for a large Native American population, plagued by obesity, diabetes, alcoholism, mental illness, violence and suicide, as are many vulnerable populations in this country. I remember seeing a provocative art exhibit by a prominent Native American artist in New Mexico. The exhibit displayed a traditional funeral and burial scene. Around the funeral setting were stacks of government surplus food, convenience foods and alcohol bottles. The artist felt that these outside influences had eroded Native American culture, leading to premature death and a loss of dignity.
As we struggle to fill the gaps in health care and eliminate health disparities, we need to go back to the basics and figure out how to best spend within the limits of the finite dollar. Many of you who have practiced medicine in other countries understand the waste and cost inflation occurring in the U.S. We need to find the middle ground. We are spending a lot of money on administrative costs, medical technology and imaging that may not result in improved outcomes or quality of life. We are providing expensive and intensive end-of-life care.
We are entrusted with great ethical responsibility as healers. Let us do our part to recommend the most effective and lowest cost interventions. Brand name drugs and expensive medical devices with questionable benefit ought to be approached with caution. People are counting on us as professionals to make the system better.