What is the best thing for an under-funded hospital to do with the little money it receives? This was the question I first asked in 2007, when I was studying abroad in Quito, Ecuador. And I still do not feel that I have a suitable answer. This post is more of a description of my despairing feelings than an offer of solutions. I know that many readers do not like such a lament. But I truly don't have an answer. My hope is that this will at least cause others to ask the same questions, and perhaps it may even inspire a spark of innovation to find an answer.
During the fall of 2007, I had the chance to visit Baca Ortiz Children's Hospital in Quito, the premier children's hospital in the country. It is very difficult to find specific information about the hospital, so I have scraped up what little I could locate to provide a general picture. According to "Volunteers Abroad," Baca Ortiz was founded July 14, 1948. Approximately 140,000 children are treated at the hospital annually. Families come from around the country to the facility, because it offers specialized treatment that is not available in other regions.
The hospital has a paid staff of doctors and nurses, as well as a number of volunteers with a range of skills, from medical professionals, to individuals who visit with the children, to those who help fund raise for the most needy families.
Although Baca Ortiz receives funds from the government, it is significantly under-funded, and families are therefore required to pay for the treatment they receive at the facility.
Based on the accounts of my friend who volunteered at Baca Ortiz regularly and based on the information I received during my time there, the facility itself has so few resources that it cannot stock basic supplies, such as soap, toilet paper, bandages, or medicine to keep on-hand, unless these happen to have been recently donated. If a child is admitted to the facility, his or her family is responsible for providing soap, toilet paper, and other supplies for the child's room. If the child requires any sort of treatment, the family has to go to a local pharmacy and purchase bandages, sterilized surgical instruments, oxygen tubes, anesthetics, sanitizing agents, antibiotics, etc. There is no surplus to have these items readily available.
For many families, this simply means going without sufficient treatment. According to the CIA World Factbook, 33.1% of Ecuadorians live below the poverty line. Many more make enough to be deemed above the line, but are underemployed and still struggle to provide for their families on a daily basis. Additionally, income disparities are extremely pronounced between various regions of the country and between different racial groups.
Families are also provided meal tickets to eat in the hospital's cafeteria a certain number of times per week. For some, these are the only meals they will eat at all due to general poverty or due to the costs of traveling to the hospital and paying for treatment. However, my friend who volunteered handing out meal tickets told me that she frequently ran out before every family had received their share, as the hospital was extremely over-crowded (see the image of children being treated in the hallway on the right due to room shortages) and had a very limited budget to prepare a certain number of meals per week.
Some families have little hope of paying for treatment once they have received a diagnosis, and they go home without assistance. Others may gain funding through organizations that donate specifically for their treatment, such as The Mashi Foundation, which used social workers to identify ten children of highest priority and funded the surgeries for those children in 2010. Assuming that 33.1% of the 140,000 children who visit the hospital in a given year are impoverished, as is the case with the general population, that would be 46,000 impoverished children who come through the doors. Ten funded surgeries is an amazing thing, but it is astonishing to realize that the figure represents only 0.02% of children who are likely too poor to afford treatment at Baca Ortiz. My understanding is that such donated funding is sporadic, at best. Since the need for this type of financial intervention is so overwhelming, the situation is quite desperate and the poorest may never obtain the assistance they need.
After visiting Baca Ortiz, I felt disheartened and confused. Where should the hospital direct its scarce resources? Medicine for those who cannot otherwise purchase it, without which children will suffer from pain or parasites, possibly die from cancer or even treatable infections? Soap to prevent the spread of infection throughout the facility? (It was hard for me to imagine how a hospital functions without having medical supplies on hand, never mind free access to soap? The basic act of washing one's hands is crucial to the prevention of infection, yet some families have to choose between sanitation and medication.) What about meals for those who would not be able to afford a stay without the provision of this sustenance? Without the meal tickets, many families would not only be unable to afford treatment, but could not visit at all due to the extreme hardship it would pose.
I would be interested to hear if you know have ideas about how the hospital can best use its funds. What are ways this conundrum is being addressed in other nations? What has been proven to work? Do you have any novel ideas yourself?
I was recently lamenting to my friends that sometimes I wish this were a blog about politics so that I could rant and rave about the lunacy being spewed by the current presidential candidates. Then I decided that I could find a health-related theme for the subject about which I would like to rant as an excuse to do it anyway. So here goes my rant about Santorum's infamous recent comments about higher education.
Let me start by saying that I am registered as a political independent. I have voted for members of both parties, and it is rare that I agree with either party 100% on an issue. But on this particular issue, I don't see much room to argue with Obama. I know full well that education makes a difference, not only in lifetime earning potential, but also in human health!
For those who haven't heard yet, Rick Santorum called Obama a "snob" for reportedly "saying that everyone should go to college." This was hard for me to believe, but here is an actual video of the speech in Michigan.
Of course, after hearing such a strange insult to our president, I decided to find out what Obama actually said. According to a Politico article, the quote was, "I ask every American to commit to one year or more of higher education or career training. This can be community college or a four-year school, vocational training or an apprenticeship. But whatever that training will be, every American will need more than a high school diploma."
It's hard for me to see how this quote translates into liberal snobbery mandating that everyone must attain a degree. That is clearly a limited and disingenuous reading of what was said. Obama was discussing the fact that increasingly, we are competing globally with countries who are focusing on education. Years down the road, it may become more and more difficult to find a job with only a high school diploma. This is not to say that people who do not go to college are somehow less important, not hard working, or otherwise bad. It is simply to state the fact that job prospects are better for those who attend some form of higher education, and this is becoming more true with each generation.
Consider the current economic issues in our country. According to the Bureau of Labor Statistics, the average unemployment rate in 2010 was 8.2%. However, among those with a bachelor's degree (and no master's) it was 5.4% compared to 10.3% for those with only a high school diploma.
One article I read in the San Francisco Chronicle said that the median annual pay of those 25 years and older with a bachelor's degree is $56,472. That is 70% higher than those without a diploma. That means a person with a college degree may individually earn about the same as the average household income (presumably a measure of the total earnings of multiple persons living together) in our country. According to the same article, 30% percent of adults now hold college degrees, and 94% of parents with children under age 18 expect their children to go to college.
Now to be fair, I do think there are people who are prejudiced against those of a different social class or education level. It's great to speak out against that sort of intolerance. And I agree with Santorum that there are plenty of hard-working people at important jobs without one minute of higher education. I think many Americans, especially in small towns across the nation or in manufacturing centers like Detroit, would echo sentiments of pride in their communities, regardless of the average education levels in the areas. It is even true that some people have gone on to make millions without a degree (Bill Gates, for example - and for him, it was billions). As the Montgomery Gentry song, "Where I Come From," says, "That old man right there in the rocking chair at the courthouse square - I'll tell you now he could buy your fancy car with hundred dollar bills. Don't let those faded overalls fool ya'. He made his millions without one day of schoolin." Pride in your job and loyalty to your friends and family of all social classes are beautiful things. I agree wholeheartedly that education does not make one person better than another. The idea that our worth as a person is not determined by our social status, income, or level of education resonates strongly with my understanding of humanity. Amen to equality before God!
But the fact remains that statistics show average quality of life increases with higher education. No, that does not mean for every person every time. It means for most people most of the time. And I do not in my heart believe that Obama is among the ranks of the socioeconomically prejudiced for acknowledging this. I find it especially improbable that there is much truth behind the accusations of elitism given that Obama's life before running for Congress involved working with residents in the south side of Chicago.
Santorum also berated higher education for "indoctrinating" young people into liberalism. I would agree that there is a left bent in higher education as a whole, but there are a few things to point out here. (1) Not every professor holds the same views. (2) If conservatives do not obtain higher ed degrees, then they cannot become professors. So it stands to reason that if Santorum sees a problem of disproportionate representation among college faculty, he should be encouraging more conservatives to get degrees, not fewer. Hey, if there were enough of them banded together, they could even start new colleges. (3) As my husband intelligently pointed out to me the other day, colleges not only produce liberal thinkers, they also produce deeper conservative thinkers who are able to counter balance the arguments of liberalism. Without a strong understanding of politics, philosophy, economics, and the like, it is pretty difficult to make a believable case against an expert in one of those fields. Please do not mistake me for saying that education is the sole predictor of good ideas. That is certainly not true. But how does Santorum intend to fight "elite leftist" ideas if he has not also read the same texts, analyzed the same arguments, etc.? How can a person condemn a book he or she has never seen? How can an individual make a point against a philosophy he or she has never heard? We need more thoughtful thinkers of all political persuasions, not fewer.
So you may be wondering what this has to do with "mind and body musings?" Well, I found something that clearly justifies this entire rant! Education is also a predictor of....drum roll....health! According to the National Poverty Center, better educated people have lower morbidity for many chronic illnesses and higher overall life expectancy. The NPC also states, "Health behaviors alone cannot account for health status differences between those who are less educated and those who have more years of education." The policy brief I read suggested that some likely contributing factors to the health gap are complicated relationships between education and family background, effects of poor health in childhood, greater resources associated with more education, a learned appreciation for positive health behaviors, and social networks, among other mechanisms.
As I discussed in a previous blog post, education is also related to health literacy. To reiterate some of the statistics from that piece, the National Assessment of Adult Literacy targeted a portion of its latest assessment using health care related questions. The study found that among adults who never completed high school, approximately 49% had below basic health literacy, compared to 15% of adults who completed a high school diploma with no post-secondary education and just 3% of adults with a bachelor's degree. Low health literacy can inhibit someone's ability to read health pamphlets, follow medication instructions, make medical decisions when caring for a loved one, understand post-operative instructions, or complete other similar tasks.
In another related post, I described some of the connections between food insecurity and obesity. Since food insecurity is a socioeconomic issue, and lack of education is a predictor of lower earnings, these problems are a likely link between education and health. Some of the issues I discussed in more detail in that post include fewer full service grocery stores in lower income neighborhoods, lower quality produce, a greater prevalence of fast food, fewer parks or recreation centers, and less access to health care, among other concerns.
I believe that Santorum was misguided in his Obama name-calling on the higher education topic. He was speaking to a crowd in Detroit, and it seems likely to me that he was catering to his audience. I'm not even going to get into Santorum's campaign goals from past years related to higher education (but please do Google the topic - he used to think college was a good idea). Suffice it to say that a quick glance at Santorum's own life and credentials makes it clear that his education got him where he is today and that he intends to provide the same for his children (just like 94% of parents hope for their own kids, as mentioned above).
As LZ Granderson of CNN put it, "Granted, some of us are gullible enough to give each other high-fives because Rick Santorum called Obama a snob for promoting a college education. But the rest of us look at 'Slick Rick's' college degree, law degree and MBA, and the fact that he's sending his kids to college and owns at least six properties, and has earned millions, and wonder - What is he talking about?"
After my posts on Jamie Oliver and McDonald's, a doctor I know asked me why so many of her young patients from lower income families are obese. "Many of these families struggle to provide three square meals a day," she said, "so where are the calories coming from?"
According to a 2010 Los Angeles Times article, which summarized a study from the journal Health Affairs, nearly one in three children currently has a body mass index above what is considered healthy. The study also found significant discrepancies between children of different racial groups, socioeconomic groups, and regions of the country. According to the article, these factors are not necessarily independent. For example, the article says, "In Alaska, poor children were only 1.2 times more likely to be overweight or obese than better-off children. But in Arizona, the difference in rates was 3.8. Why would it be different to be poor in Alaska than Arizona? That's basically what it amounts to - it's not the same being poor in one state as it is in another."
According to the Food and Research Action Center's (FRAC) page on poverty and obesity, "obesity rates increased ten percent for all U.S. Children ten to seventeen years old between 2003 and 2007, but by twenty-three percent during the same time period for low-income children."
One thing that is important to note is that the stereotype that virtually all low-income people are obese is not true. The Food and Research Action Center (FRAC) also shows that the link between income and obesity has actually been weakening over the past few decades. But the question still remains, why do the statistics show a link at all?
For answers, I turned to the FRAC page on food insecurity and obesity. Most of the information I am going to mention below is from this website, and the authors of the studies are specifically mentioned there. For me to put a citation after every sentence would make this post very long, so please refer to the FRAC food insecurity and obesity link for the authors of the studies and facts mentioned.
One of my friends, Sara, commented on my McDonald's post that many families live in "food deserts," which is actually one of the main points FRAC makes, as well. According to multiple studies, low-income neighborhoods often lack a full service grocery store where families can purchase fresh produce, whole grains, and low-fat dairy. Instead, many residents rely on small convenience stores, which do not carry the variety of healthy and low-fat options available in larger establishments. Low income communities, especially areas near schools, are also more likely to have fast food restaurants. Frequently eating fast food has been linked to high-calorie, low-nutrition diets, which may lead to weight gain.
According to other studies cited by FRAC, fruits and vegetables in low income neighborhoods are often of poorer quality, thus making it less likely that residents will be prone to purchase them. Furthermore, healthy food, such as fresh produce, whole grains, and low-fat options are often more expensive compared to more processed fats and sugars. Many families trying to stave off hunger look to purchase the maximum calories per dollar by buying energy-dense foods, which provide the calories a family needs, but not necessarily the other nutritional components of a healthy diet. "Feeling full" may be the priority for a family who is unsure when the next meal will be available, especially when it comes to preventing feelings of hunger in children. Carbonated beverages, such as soda, for example, will make a child "feel full," even if they do not provide any other nutritional value.
In addition, chronic ups and downs in the availability of food may encourage people to eat more when it is available. This can lead to general over-consumption or even metabolic changes that affect fat retention.
According to FRAC, the problem is not just about food consumption. Low income communities also have fewer resources for physical activity, such as parks and recreation centers. Even in communities that do have open space areas, they may be less attractive due to trash, noise, traffic, and criminal activity. It makes sense that parents would not want their children to play at the park in a particularly dirty or high-crime neighborhood. This puts children at a higher risk for staying indoors and living a sedentary lifestyle. According to other studies, lower income children are less likely to participate in organized sports or to have access to/participate in physical education classes and recess.
Additionally, the financial and emotional pressures of poverty may have a serious impact on both adults and children. Stress can contribute to unhealthful eating behaviors, hormonal/metabolic changes, and even chronic anxiety or depression, which have all been associated with adult and childhood obesity.
Many low income families also lack access to quality, affordable health care. Chronic illnesses that are related to obesity may not be diagnosed. Furthermore, families may not realize their child is overweight. For example, according to Strong4Life, an organization fighting childhood obesity in Georgia, 75% of parents of overweight or obese children in the state did not believe their child had a problem. I recently read an article saying that even among families who do have access to health care, less than 25% of parents of overweight or obese children recall a doctor telling them their child is overweight. If even medical professionals are unwilling to confront or acknowledge the issue, how can we expect households who have less access to health education and basic health care to recognize obesity and take action steps to prevent or correct it?
To me, the fact that obesity is inversely related to income is further support that the socioeconomic disparity in our society is not just a matter of money, but is linked to a complex set of dynamics that affect all aspects of life.
So what can be done to stave off the obesity epidemic in lower income communities in particular? I would suggest communities can start with the specific issues mentioned above, by bringing farmers markets to lower income neighborhoods, investing in community recreational centers and low/no-cost sports leagues, requiring schools to provide more hours of physical education, providing free health education for parents and kids, offering free classes on how to manage a tight food budget, focusing efforts on preventive health services (including attention given to decreasing stress), among other actions.
I have tried to lay out some of the reasons for the weight disparity, but I think it will take a lot of people with a lot of brain power to improve the health future of all our nation's children. If you have other ideas, please share!
According to a 2010 