1. Johnson, C. Erwin MD, EdM, MSc, FAAP

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Days after Hurricane Katrina struck New Orleans last August, media coverage gave us countless images of the city's poorer residents who, lacking means to evacuate, were left stranded for days on their sagging rooftops. As a pediatrician who provides care to many poor families, I was surprised to hear several colleagues respond with comments such as "I cannot believe how those people have to live" and "What a tragedy for those people." Yet most of my patients saw nothing new. They said, "This is how we're treated," and "What else is new? The government doesn't care about us." The disparity in these comments demonstrates a sharp divide in Americans' attitudes toward the poor. Too often, providers see patients through the distorting lens of their own class and ethnicity without considering the patient's.


I grew up in abject poverty in rural East Tennessee during the 1970s. I understand how poverty factors into the lives of my patients-and I have often witnessed how uncomfortable health care professionals can be with the poor, referring to such patients as "those people" and behaving differently with them (for example, using a patronizing tone). Moreover, according to recent U.S. Census Bureau estimates, more than half of the 37 million Americans living below the poverty level are racial or ethnic minorities.


Yet only 9% of physicians and 12.3% of nurses are racial or ethnic minorities, according to the Institutes of Medicine's 2003 report, Unequal Treatment: Confronting Racial and Economic Disparities in Health Care, which documented how providers' "stereotyping, biases, and uncertainty" create obstacles to the delivery of high-quality health care.


Too often, providers see patients through the lens of their own class and ethnicity.

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For the poor, vital resources-facilities, trained providers, and technologies-are often inaccessible, suboptimal, or both. For example, in a study recently published in Ambulatory Pediatrics, poor and low-income Latino parents identified 52 barriers to insuring their children, including misinformation from insurance representatives, bureaucratic inefficiency, and discrimination because of ethnicity or immigration status. Even when resources are there and when patients actively seek access and providers strive to deliver high-quality health care, the system tends to fail. Newsweek reported in its December 12, 2005, issue that, four months after Katrina, New Orleans's "fractured infrastructure" severely affected the medically fragile (such as people with chronic illnesses, a disproportionate number of whom are poor); the two largest public hospitals remained closed and "evacuees [were] swamping those facilities that [were] operating." Even in the best of times, our health care system is difficult to negotiate, ineffective, wasteful, and frankly an embarrassment to this resource-rich nation.


I recently heard Uwe Reinhardt, the renowned economist from Princeton University, speak about our nation's moral duty to improve the health care system for all, especially the neediest. He posits that the United States has sufficient wealth, creativity, and capabilities to accomplish this and that it's the right thing to do. It's the labor provided by the working poor-the janitors, hospital orderlies, bus drivers, Starbucks baristas, nannies, enlisted military personnel, construction workers, secretaries, and migrant farm workers, among others-that keeps this capitalist democracy running. Were it not for "those people," many of the services and luxuries most Americans take for granted would be beyond reach.


We must lobby our elected officials to support adequate funding for health care for the poor. We must work with policy-makers to minimize bureaucratic inefficiency and ensure better access to care for poor and working-class patients-by, for example, eliminating unnecessary paperwork and increasing support staff in practices and clinics that serve these populations. The education of all health care professionals should continue to include cultural diversity. And it must begin to address socioeconomic diversity as well.