Sunday, January 17, 2010



Today at 10:00 in the morning I am sitting at my computer putting together this week's laboratory medicine quiz for the pathology residents. Which of the following fluids may be transfused simultaneously through an infusion line with red blood cells? I don't actually know the answer off the top of my head, but that doesn't really matter. I just pick questions from a question bank, copy them to the body of an email and send them out to the residents. They have a week in which to send me the answers. At the end of the year the person with highest percentage correct answers will get a cash prize. Usually about $150, but it depends on how generous the attending pathologists feel when I make the rounds, asking for contributions. It's a bit of a pain having to go from office to office, knocking on the doors, asking for contributions for this year's laboratory medicine quiz contest, but in the end all of the pathologists are great about it. They like to see us engaged in friendly intellectual competition and they understand that this is a fun way for us to get ourselves to study some rather dry topics. We're all intelligent, motivated, successful young doctors, after all. Of course they don't mind putting $10 or $20 dollars in the pot for our collective educational motivation.


I go to the front door, dreading the possibilities. A pair of young, bright-eyed Jehovah's Witness missionaries for me to deflate with my superior biblical knowledge? A real-estate agent asking permission to post signs in our yard, directing people to his open house? A 2o-year-old single mother of three selling the latest, greatest cleaning supplies that are both environmentally friendly and sure to remove grease, rust, blood, and fruit juice stains from even the stubbornest of surfaces?


It's Ronnie.

Ronnie is a young man who lives in the neighborhood with his diabetic father. Ronnie works two part-time minimum wage jobs and does yard work and other odd jobs when he can find them. Ronnie's father is severely disabled, cannot perform any sort of manual labor, and has never been trained for any other type of work. Between Ronnie's meager earnings and his father's social security benefits, the two of them are usually able to pay for rent and utilities, with just a little left for groceries. Ronnie's father is on Medicaid and most of his medications are covered, but there is a $34 copay each month for the insulin to control his blood sugar.

It is winter here and it gets fairly cold at night. The bill for heating gas in the winter months can easily reach four or five times that of the summer months. When forced to choose between paying the gas bill and the copay for his insulin last week, Ronnie's father decided to keep himself and his son warm. He did not tell Ronnie that there had not been enough money for insulin. Ronnie only found out when he found his father on the floor, unconscious and barely breathing. Diabetic ketoacidosis. An ambulance trip. A day and a half of treatment and observation in the emergency room. A day of work lost for Ronnie. Ronnie and his father return home this morning to a house with heat and a little bit of food, but with no $34 for the insulin copay. They will not have $34 dollars again until Ronnie's next paycheck, five days from now.

Knock. knock. knock.

Ronnie hates doing this. He hates having to walk around the neighborhood asking for yard work. He hates knowing that all of us in our warm homes, happy and content with our own lives, will be made to feel uncomfortable by his neediness, by his very existence. He hates knowing that many of us will look through our peep-hole, see a slightly bedraggled young man, and automatically assume that he needs money for his next fix. Ronnie hates to ask for help. He also hates to see his father dying.

Knock. knock. knock.

Ronnie tells me about his last two days in the emergency room with his father. I already know why he is here at my door and I'm desperately trying to think of some odd jobs that I can have him do around the place. $34. On my resident's salary, that's about two hours worth of work. Can I find two hours worth of work for Ronnie to do? Two hours that he'll save me so that I can feel justified giving him the money to keep his father alive? Should I have him pick up the dog shit in our back yard? Should I have him pull weeds from the front yard that is going to be re-landscaped in a couple months anyway? Should I just give him the money and send him away so that I can get on with my day?

Ronnie and his father are a small but fairly representative sample of a huge and rapidly growing segment of our population: the underserved, underemployed, underpaid, and largely unheard poor. The poor. The poor without adequate access to healthcare. The poor without adequate government assistance for food and utilities. The poor who are reminded of how much it sucks to be poor in this country every time they have to ask for help. The poor who were born to the similarly poor. The poor who are marginalized when it comes to educational and employment opportunities. The poor who grow up undernourished because they're eating the shitty processed food that is less expensive per calorie than the healthy balanced diet that their developing bodies and minds really need. The poor who make the rest of us uncomfortable with their very existence. The poor who are desperate and sometimes steal to make ends meet. The poor who suffer at least as much mental illness as the rest of us, but who have virtually no access to treatment for such disease and must therefore self medicate with alcohol and illicit drugs. The poor who commit suicide far more frequently than the rest of us. The poor who are a nuisance to the rest of us, a problem about which we'd rather not have to think. The poor who turn to drugs to temporarily escape their poverty, only to find themselves enslaved to substances and dealers. The poor who cross an arbitrary line in the desert looking for employment, only to be arrested and deported... or to die of thirst under the hot sun when they've lost their way and are afraid to stay close to a road for fear of being arrested. The poor who have seen their mothers and older siblings beaten and raped and therefore figure that it's part of life and don't seek help or refuge when their turn comes. The poor who are far more likely to be murdered. The poor who join gangs and commit horrible acts of violence in an attempt to gain some sense of control and empowerment. The poor who rot in prisons for the rest of their productive lives while their families grow up, grow apart, grow old. The poor who bother us, interrupting our productive, healthy, happy lives by asking for help.

$34. A minuscule grain transferred across the fulcrum of economic disparity. A sick sad reminder of that day in the near future when the the situation will recur, when that $34 won't be available and the ambulance may or may not arrive in time. A reminder that the status quo just isn't enough when it comes to health care in this country.

Knock. knock.knock.

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