In the U.S., wealth buys health. In 2000, in Boston's upscale Back Bay community, a typical resident could expect to live nearly 92 years. A few miles away, the average person could not expect to live to 59.
Access to health care plays a big role in this disparity, said Howard Koh, a professor at the Harvard T.H. Chan School of Public Health who was an assistant secretary for health in the Obama administration. That's why that administration pushed so hard for the Affordable Care Act, Koh said. "Poverty is the major driver of health inequities."
If it is a choice between buying medications or food, pretty much all parents would choose their children's bellies, said Thea James of the Boston Medical Center.
Race also plays a role in the outcomes. Dr. Nina Bickell said, "when black and white women are treated the same for the same disease process, the outcomes are the same for the most part."
To explore the disparity in care, the New York Times spoke with three women focused on improving the health of people with low incomes.
Minerva Romero Arenas
Evidence suggests that patients of color fare better when they have nonwhite doctors. But only about 5% of U.S. physicians are black. "African-Americans and Latinos are grossly underrepresented in medicine," the Texas surgeon said. So, she helped found the Latino Surgical Society to provide mentoring for peers. Patients appreciate seeing someone they didn't expect as their surgeon, said Romero Arenas, an endocrine surgeon who has been confused for a sales rep, a nurse, a translator and a member of the janitorial staff. Because people in her part of Texas can't afford preventive care, it drives up costs when they do seek treatment. "If you're already not insured, you're going to let things get out of control," she said. She has had cancer patients defer surgery for months or sell their cars to fund co-payments. Helping patients with so many complex needs can be wearying. Still, she said, "I do feel very tied to the mission."
Adrianne Lane
In rural areas, simply getting to the doctor can be a problem. Specialists are few and far between. Insurance coverage can be spotty. And driving an hour or two for care can be an insurmountable burden. "Cost, distance and fear," Lane said, are the three major barriers to rural health care. Lane — who lives in Greendale, Ind., and holds a doctorate in nursing — devoted herself to rural health to give something back to her community. Around 2000, she and her colleagues began providing mammograms and other breast information for rural women, sometimes setting up a mammogram van outside the hardware store or a Moose lodge. Small communities, she said, can be distrustful of outsiders. Once, she went to a community event to hand out fliers about the program — and got caught in a downpour. "The people laughed at me, tried to get me dried off — they thought I was just crazy. And we were full by Monday," she said.
Diana Hernández
When Hernández was growing up in federally subsidized housing in the Bronx, she and her family grew vegetables in a community garden. "It wasn't just about us as a family, it was also about the community that was built around the garden." Now an assistant professor of sociomedical sciences at Columbia University, she sees health care as part of a larger picture: If people's housing is unhealthy, they will be, too. Working with affordable-housing providers in the Bronx, Upper Manhattan, Detroit and Newark, New Jersey, Hernández has partnered with groups to help provide safer spaces and public health programming. As a scholar, she has also been measuring these programs' effectiveness. She said that reaching people where they live can provide a different kind of care than a doctor's office. "When we think about health, it can't just be about health care, it has to be about all these other pieces that really contribute to how people live," she said.
