WHOEVER walks into the Southwest Public Health Clinic, no matter what their financial condition, can get medical attention."Bills are created," says David King, who practices internal medicine here and at another clinic across town, "but we never turn anybody away." Even in poor urban neighborhoods like this one, lack of money itself is not a major obstacle to health care, according to doctors and medical administrators. Yet many of the poor, including pregnant women, fail to seek any sort of health care until a crisis comes and they land in an emergency room. The reasons can sound trivial to middle-class ears: from lack of bus fare to lack of a concerned relative to prod them. The result is that the poor have worse health and eventually cost more to treat medically than the rest of the population. Some researchers believe that American health-care spending is so much higher than anywhere else because so many American social problems - from violence to homelessness to unwed motherhood - are transformed into medical problems. "We're fighting this thing at the wrong end," says Thomas Chapman, president of Greater Southeast Community Hospital. In the District of Columbia, along with a leading homicide rate and a high child poverty rate, a greater proportion of babies die during their first year than in any state or any other major city in the United States. The US infant mortality rate overall is more than twice as high as Japan's, worse than most industrialized countries, higher even than in Spain, where per capita income is below the American poverty level. The high US rate is not a medical failure, at least in the traditional sense. When babies are born too small, too light, too fragile, the American medical system is among the best at saving them. The problem is that Americans produce a very high proportion of high-risk, low-weight babies - a condition heavily affected by the behavior of the mother. Smoking, for example, is responsible for 20 to 30 percent of low-birthweight babies, says Louis Sullivan, the secretary of the US Department of Health and Human Services. The sorrow of infant mortality is not spread about with an even statistical hand. About half the states in the country have infant mortality rates near the West European norm, as does the nation's overall white population. Some of these states, such as Maine, are relatively poor, rural states.
Inadequate family support cited But in the federal district's poorest ward, Ward 8, which is 90 percent black and has the most teenage pregnancies, the infant mortality rate is three times the national rate. Many social and health problems - AIDS, drug abuse, high-risk babies, murder - are concentrated in neighborhoods like this. The health problems are not explained by poverty alone, and money alone will not solve them, according to Mr. Chapman, whose hospital lies in Ward 8. "We know the problem isn't poverty. Poverty can be licked when it comes to medical care," he says. The problem is that people are not taking care of themselves when they have many kinds of problems in their lives, poor family support, and the "abject frustration" of social and economic depression. "As a measured lack of household income, material poverty doesn't go very far in explaining infant mortality," says Nicholas Eberstadt, a visiting fellow at the Harvard Center for Population Studies, who has just completed a review of the problem. But, he adds, "you can also talk about behavioral or even spiritual poverty." One decision that closely corresponds with infant mortality in the statistics is unwed motherhood - even when other factors have been canceled out, says Mr. Eberstadt. Single mothers have low-birthweight babies 50 percent more often than married mothers, according to US Surgeon General Antonia Novello. In fact, for either white or black mothers separately, infant mortality rates are higher for unmarried women with college educations than for married women who dropped out of school.
Violence takes heavy toll among blacks A health problem even more concentrated in poor black communities is murder. Homicide is the leading cause of death of young black men and teenagers. The shooting death rate among black teens is eleven times higher than for white. Overall, the US homicide rate is five to seven times higher than that of Europe. As a medical problem, murder is the tip of an iceberg. For every homicide, 100 assault victims are admitted to emergency rooms, says Leroy Schwartz, president of Health Policy International, a think tank. Dr. Schwartz, a former pediatrician, believes that much of what makes American health care more expensive than in other countries is that these social problems land in emergency rooms. "Unless we reach out and touch some these problems, changing the [health-care] system will not help," he says. Chapman makes a similar point: "We could get national health insurance tomorrow, and it wouldn't do anything to improve the health care of the poor." Most would still lack incentives to take preventive care, he says. Chapman's hospital staff is testing ways of bringing better care to poor people by opening a clinic in a high-school, for example, or building a network of volunteer blood-pressure screeners at local churches. "The middle-class model of health-care delivery," where people schedule appointments and come in for check-ups, does not work for the poor, Chapman says. "Whatever you have to spend to get at these problems is far cheaper than not getting at them." Even the poor who actively seek medical care run into limitations. Dr. King at Southwest clinic notes that the budget for drugs often runs out before the end of the year, leaving patients to do without or use poor substitutes. Other patients are too passive, and will wait too long for appointments and operations. "Indigent patients don't realize how the system's supposed to work," says King. "There's a lot of room for them to fall between the cracks." These problems are worst in poor rural areas, where transportation can be completely unavailable, doctors or health clinics rare, and health is somewhat worse at each income level, according to the National Health Interview Survey. But in cities, medical care is largely available. "The poverty population is getting care," says Schwartz. "It's uncompensated care meaning that hospitals and clinics either swallow the cost or shift it onto the bills of patients with private insurance. And studies in Massachusetts have found that poor patients in hospitals usually stay longer and cost more than other patients. Most of the health problems and social problems concentrated among the poor in America are shared to some degree across the spectrum of incomes. In a speech at Yale University nearly a year ago, Secretary Sullivan stressed the links between behavior and health: "So many of these problems have their roots in the alienation, isolation, and lack of direction that follow from the collapse of societal standards, and the institutions that generate them."