Treating the Poor

FOR one-fifth of the U.S. population, the risk of dying before age 35 is four times the U.S. average. In this group, adults have four times as much disabling heart disease, ten times as much visual impairment, six times as much mental illness, mental retardation and nervous disorder. This one-fifth constitutes the nation's poor--40 million Americans, by the Government's admittedly rough estimates.

Despite good intentions and the Great Society, the health gap is growing. In 1940, the infant-mortality rate for nonwhites was 70% greater than for whites; now it is almost 100% greater--38.8 v. 20.6 per 1,000 live births. In some ghettos, infant-mortality rates exceed 100 per 1,000 live births--approaching the level of a Biblical plague. In Mississippi, the Negro maternal death rate is five times that of whites; 74% of these are, in medical opinion, preventable.

First-Hand Study. To correct this imbalance, a band of determined medical men, supported by funds from the Office of Economic Opportunity, has launched a counterattack on medical poverty in several severely depressed areas. The OEO has allocated $94 million to finance 51 neighborhood health centers, of which 33 are already operating and 18 are being organized. Unless it is caught in a budget squeeze, the OEO will start ten more centers early next year.

The idea for this program originated with Dr. H. Jack Geiger, 43, a onetime medicine reporter for the International News Service who decided that he could do more for his fellow men by becoming a doctor than by writing about doctors. While studying medicine at Western Reserve University in the mid-1950s, he read about medical centers for the poor that had long existed in Europe. Later he studied what he calls "social medicine" (the concept of illness as an environmental as well as a medical problem) at South Africa's only medical school primarily for blacks, at the University of Natal in Durban. In 1964, Geiger traveled to Mississippi for the Medical Committee for Human Rights, and with Dr. Count Gibson Jr., a Georgia-born internist, set up a small health center that lasted only a year.

As the two returned to Boston, Gibson suggested that Tufts University, with an expanding program of social medicine, might sponsor a health-center program. Within four weeks, the hyperkinetic Geiger had Tufts' approval and an associate professorship, then obtained funds from the OEO. Says Geiger: "We have known for a long time about the relationships between poverty and health without fully facing up to them. The poor are likelier to be sick. The sick are likelier to be poor. Without intervention, the poor get sicker and the sick get poorer."

Primitive Housing. To solve the urban crisis, Geiger believes it is necessary to work on both ends of it--the Negro ghettos in the North and the rural South, which is the source of 200,000 Northbound migrants per year. In the Deep South's black belt, he could find no place worse off than the northern part of Mississippi's Bolivar County: 500 sq. mi. containing 12,000 Negroes, with an average income of $900 a year for a family of five. Housing is primitive: 75% of the homes lack running water, 90% lack indoor toilets. Two years ago, Geiger moved into Mound Bayou (pop. 1,380), the oldest all-Negro town in the U.S. He converted a parsonage into a clinic, used a ramshackle theater as a school for health aides, a trailer for a business office, and a remodeled storefront for a prenatal-care unit.

This month the center moved from this conglomerate into a new $900,000 building with 24,000 sq. ft. of space. The staff is divided into three units, each with a family-health group assigned to cover one-third of northern Bolivar. Of the center's 120 staff mem bers, 100 are local residents. To bring patients in from the black bottom mud of the bayous, the center has its own ambulance and 20 other vehicles.

Touring the region, TIME Reporter David M. Rorvik "collected enough case histories to fill six depressing books. Here's a typical one: the case of Miss Jessie Mae and family, a mother and eleven children living in a burned-out, three-room shack off Highway No. 8. Mother was cut off from welfare aid when her last child (illegitimate) was born. She is a day worker, rotating between two white families. Earns $15 a week. Field worker went there because she heard one of the girls was having blackout 'spells.' Found seven children playing in the yard under the care of an eleven-year-old. Although the temperature was 40DEG, four of the children were without shoes or coats. Baby in a paper box was nursing himself on bean soup. A five-year-old girl had a nasty open wound on her foot, very dirty. Had hit herself with an ax. Miss Jessie Mae herself materialized about 40 minutes later to reveal that 1) she realized the baby needed better care, but she had ten others to feed; 2) she gave the children grits for breakfast, pecans for lunch, and rice, beans and greens for supper; 3) she didn't have money to see a doctor. The case worker administered first aid for the wounded foot, told Jessie Mae about the Tufts-Delta Health Center, explained exactly how to get help, and arranged for her and her family to be picked up by one of the center's cars."

With appropriate modifications to meet local conditions, this is the pattern for health centers in 23 states and the District of Columbia. On Denver's teeming West Side there will soon be twelve neighborhood stations, tied in with two comprehensive health centers. "Anglo" doctors are expected to learn enough Spanish to communicate with their patients. In Minnesota, at the Chippewas' Red Lake Reservation, OEO doctors and nurses have at last coped with tribal rivalries enough to let them get on with the job of caring for the sick,

OEO centers are also caring for the white rural poor. In Hyden, Ky. (pop. 800), Dr. Mary Pauline Fox heads a corps of nurses who wear logging boots and drive Jeeps to get to Leslie County's one hospital, perched precariously on an eroded hillside. Long-unemployed coal miners have a high incidence of bronchitis and emphysema. The local mainstay is fried pork, the mountain people tend to be obese and suffer from high blood pressure and heart disease. Their children are anemic, infested with parasites. Mental and physical retardation are common, presumably because of inbreeding "back on the creeks."

Medical Labyrinth. One of the first and most successful centers treats the multiracial population of Columbia Point, a spit of land in Boston Harbor. For 150 years it was a city dump; now it has 26 buildings containing 1,504 apartments. The Point's 6,000 residents tend to feel left out of society. Two expressways effectively cut them off from Boston's center, and public transportation is so inadequate that it takes at least two hours, sometimes as long as five, to get to a hospital by bus.

But the Point's people--half white, half nonwhite--are hardly apathetic about health, Geiger argues. They prove the contrary by their nighttime use of emergency rooms in Boston area hospitals. There, he says, they find "the same piecemeal, episodic, discontinuous, uncoordinated medical care--but at least it's cheaper and faster than in daytime outpatient departments."

The O'Leary family is typical of Columbia Point. Jim O'Leary has trouble holding a full-time job because of a drinking problem. Kate O'Leary has had three children, all--until recently--anemic and in need of vaccinations, and she is pregnant again. The last time she was pregnant she did not see a doctor until she was in labor. She was then found to have a kidney disorder.

Lately, an OEO center worker visited Mrs. O'Leary. Once on welfare herself, the worker was able to find the words to persuade Mrs. O'Leary to go to the health center, only a few yards away, for a checkup, and to take the children' along. Jim O'Leary reluctantly agreed to go too.

At the center, the obstetrician checked Mrs. O'Leary; the pediatrician ordered iron tablets and vaccinations for the children; an internist examined Jim O'Leary, persuaded him to see the center psychiatrist for his "headaches." Learning Mrs. O'Leary would like to stop having children, the obstetrician made an appointment for her with a family-planning counselor. All of that in an hour.

Such a program actually saves money. Cut off from routine preventive medicine, poverty-ridden people tend to be extremely ill when they are finally compelled to go into a hospital. A sample of 54 Columbia Point families was found to have had a total of 200 hospital days in the year before the center opened. Two years later, because of better preventive care, this had dropped to 40 days--an 80% reduction. Hospitalization, at $50 to $100 a day in true costs, is the most expensive part of medical care. For these 54 families alone, the second-year saving in hospital costs may have been $10,000 to $12,000. Impressed after a tour of Columbia Point, Senator Edward Kennedy was able to get another $50 million added to the OEO appropriation. But no matter how far the OEO expands its health centers, they will not be enough to solve the nationwide medical problems of the poor. The effort to supply health care for maximum social impact will cost many more millions, and perhaps billions.

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