“Alabama’s gotten me so upset
Tennessee made me lose my rest
And everybody knows about Mississippi Goddam”
– Nina Simone
A few weeks ago I found myself having drinks with a perfectly nice woman in one of those “mixology” bars that are sprouting up everywhere. You know, the ones that charge $15 for bizarrely colored drinks named after 50s movie starlets and pride themselves on only hiring bartenders with handlebar mustaches? Anyway, this woman had just graduated from university and was doing some variant of the Teach for America fad that seems to have swept our top-tier schools by storm. It turned out that she worked at one of those charter schools that have class six days a week, cut summer vacation in half and work their teachers like 19th century textile mill workers. Not surprisingly, she had been at the school two years and was already one of the longer-tenured teachers there. At the age of 24, she was already getting burned out and didn’t see herself teaching there more than a couple years longer. She seemed to think this was a brilliant business model: get fresh college grads looking for a resume builder, run them ragged for 2-4 years and swap in a younger, greener crop when they inevitably crash from exhaustion. It’s the educational equivalent of slash and burn farming. I thought that this was an absolutely wretched idea and told her as much. There was no second date.
I bring this up because the concept of worker replaceability seems to be a key theme both in the national economic narrative and the myriad social crises afflicting our country. In this Sunday’s New York Time’s Magazine, Suzy Hansen wrote a cover piece on the severe healthcare issues confronting the state of Mississippi and an unorthodox new strategy that has been implemented to increase quality of care. Mississippi has the worst healthcare in the nation, with 550,000 of the states 3 million residents living without insurance and a scant 176 doctors per 100,000 people. Hansen points out that the life expectancy of a black man in Mississippi today is lower than that of the average American in 1960. The state leads the nation in teen pregnancy rates and, as a result, spends millions each year on neonatal intensive care units for the surge of premature births that come with such a high percentage of teenage mothers.
Things are bad down in the delta and it seems like all of the money that’s been funneled in to fix the problem has only succeeded in stopping further deterioration. In Mississippi, as in other parts of the US with large percentages of uninsured residents and extreme poverty, the emergency room has become the people’s general practitioner. As a result, healthcare costs have skyrocketed as the efficiency and quality of care has plummeted. But, as it relates to my earlier point, hundreds of thousands of Mississippians don’t have a regular doctor. Their provider is whoever happens to see them in the ER on the day their health deteriorates to the point that they can no longer ignore it. Driving through the rural backroads of Mississippi, health clinics and doctor’s offices are few and far between. Hansen provides an anecdote about one client that is representative of the larger struggle within Mississippi. She recounts the story of a woman who had been to the hospital 20 times in the previous 8 months since she had a heart attack. Every time she had some sort of health issue she would call for an ambulance to take her to the ER because she didn’t have her own transportation and couldn’t afford to pay for a taxi. Since she wasn’t eligible for Medicaid she also went to the hospital every time she ran out of pills or inhalers because she couldn’t afford to get her prescriptions filled. She had $300,000 in medical bills that she would never be able to pay.
Healthcare advocates like civil rights pioneer Dr. Aaron Shirley and Jackson State professor Mohammed Shahbazi have looked to an unexpected source for inspiration in solving Mississippi’s healthcare crisis. They have headed to the “Axis of Evil” for guidance, using an Iranian healthcare system as the model for one they are implementing in rural Mississippi. Iran had an immense healthcare disparity between their urban and rural areas in the early 1980’s after the Ayatollah Khomeni’s return to power. Their solution to minimize that disparity was the creation of a system of “health houses” to serve as intermediaries for rural populations so that they weren’t constantly forced to flood the larger city hospitals with issues that could easily be dealt with at home. They actually look a lot like the Federally Qualified Health Centers that the Obama Administration and the Affordable Care Act are promoting, only there is an increased focus on localizing each health house. These centers are staffed with community health workers and provide basic services like nutrition, family planning, prenatal care and basic health measurements like blood pressure. If a resident has a need that cannot be met by the health house, he or she is then sent up the vertically integrated healthcare ladder to a hospital that can provide appropriate care.
Most importantly, the people who work at the health center are people who are a part of the community. Distrust of health officials is quite common, especially in the Southern black community where the sting of the Tuskeegee Experiments may never fully fade away. People are much more likely to tell the truth to someone who they know they can trust and who is a part of their daily life outside of a healthcare setting. This familiarity results in greater treatment adherence and cuts down dramatically on costs. Instead of having to go over someone’s chart every single time the walk into a hospital to have the on-call doctor acquaint him/herself with the client’s history, you have a staff who has been caring for an individual since they came out of the womb and who know what treatments have worked in the past. This quote from one of the creators of the Iranian system, Dr. Kamel Shadpour, is so great I have to print the whole thing:
“If you to one of these community health workers and ask him or her how many people they cover, they won’t tell you around 2,000…They will tell you exactly 1,829 people. If you take out the family file with the No. 62, he or she will know which family that is, and she will tell you that the father is this old, and they have five children, their ages, their vaccination, how they were doing family planning, everything.”
In order to have a community health center, you need to employ the community and you need to focus on health, not sickness. In this country, we have a healthcare system predicated on waiting until something is broken before we try to fix it. If our nation’s healthcare system was a car it wouldn’t bother doing anything if the check engine light started flashing. It would wait until the engine had fused itself into one smoking metal hunk and then spend 10 times as much money paying for the car to be towed and stored while every little part of the engine was replaced. It’s like the old Chinese proverb: “The superior doctor prevents sickness; The mediocre doctor attends to impending sickness; The inferior doctor treats actual sickness.”We are a nation of very skilled doctors practicing inferior medicine and getting very rich doing it.