How We Treat Our Fellow Americans

Review of Rachel Pearson’s “No Apparent Distress.”
by Danielle Ofri
New York Times Book Review

Just after residency at Bellevue Hospital in New York City, I worked briefly in a private practice in rural Florida. One afternoon, the ER called about a man with very high blood pressure — not high enough to be admitted to the hospital, but high enough to need prompt treatment. “Send him over to our office,” I said.

When the Mexican farmworker arrived, the office manager hissed at me: “You can’t just bring these patients here.” Initially I was perplexed; I was preventing an admission to the hospital, saving thousands of dollars. But then I realized — this office would not treat him because he lacked insurance and means.

As the only person in the office who spoke Spanish, I had to break the news. This was the lowest moment in my medical career and I vowed never to have to utter such words to a patient again. I scrambled back to Bellevue and never looked back.

Rachel Pearson repeatedly found herself in the same miserable situation during her medical school training in Galveston, Tex. The island city had been devastated by Hurricane Ike in Sept. 2008, just before Pearson arrived. There’s no doubt that the University of Texas Medical Branch (UTMB) took a financial hit from the natural disaster, but many suspected that the draconian cuts to charity care were already in the works; the hurricane was merely convenient cover.

“It was January when Susan’s patients began to die,” Pearson writes in her engrossing book, part med-school memoir, part probing moral inquiry. Susan, a cancer surgeon at UTMB, was unable to treat her patients after the medical center — without her knowledge — sent her patients a letter saying the doctor would be “discontinuing her professional relationship” with the people in her care. Without an operating room (and access to chemotherapy and radiation), the surgeon could only visit her patients at home and hold their hands as the disease killed them.

Pearson, who comes from a working-class family herself, finds her element at St. Vincent’s House, a social-services center in one of Galveston’s poorer neighborhoods, which were disproportionately devastated by Hurricane Ike and then disproportionately ignored during the rebuilding. At first, she is “under the impression that there was a safety net.” With the bare bones of donated supplies, the students diagnose cancer, heart disease and other standard medical fare. But they quickly learn that UTMB and other hospitals would not be stepping in to deliver medical treatment. A fellow medical student concludes bitterly, “I didn’t realize that we were the safety net.”

This is the blossoming truth of “No Apparent Distress” — that a segment of American society has been casually cast aside, left to scavenge on the meager scraps of volunteer health services, and failing that, left to die. Such abdication is no mere oversight, as Pearson outlines. The president of UTMB later publicly stated that medical care for those without means was no longer part of the school’s “core mission.” The same can be said for much of the United States.

Pearson describes a homeless man whom the students diagnosed with throat cancer. (Texas chose not to expand Medicaid under the Affordable Care Act so is now home to 25 percent of the adult Americans who fall into the coverage gap between private insurance and Medicaid.) It took eight cruel months until a hospital accepted the patient into its indigent program for treatment. To satisfy a requirement that the man live nearby, a relative was found who bought him a tiny trailer home. Just after the first scans were done, though, the hospital got wind of the trailer. This “asset” disqualified him as indigent and he was promptly kicked out of the program. The cancer was never removed or treated.

My first response, after reading this horrifying account, was, “How do these people sleep at night?” Who signed off on the discharge of a homeless man with a treatable cancer? Which soulless human being sentenced a fellow human to await the slow obliteration of his windpipe?

But of course it is not just individual people. In the name of liberty, choice, freedom — call it what you will — too many of those in Washington and around the country have decided that it’s O.K. to discard millions of our fellow citizens.

Pearson’s vivid writing sometimes lulls you into the trance of a good story — character, voice, plot, conflict — but there’s always the sucker punch at the end to remind you of the gruesome endpoint of the American health care system: If you don’t have money, you can be sent out to die.

Pearson also offers a nuanced analysis of medical volunteerism, raising the uncomfortable questions that haunt medical-mission efforts. “Why diagnose people,” she asks, “if we can’t make sure they will get treatment?” She wonders whether free clinics exist more to assuage the guilt of doctors (and provide training for medical students) than for the health of poor patients who often have no other options.

Books take years to write. Even then, it can be many more months until they roll off the printing presses into your local latte-serving bookstore.Pearson and her editor couldn’t possibly have known that “No Apparent Distress” would arrive on the scene just as a wholesale dismantling of our modest national safety net is being considered. The great state of Texas is a canary in the coal mine of unequal access to care. Some politicians might call this “choice.” A more medically accurate term would be abandonment.

Pearson was a writer of poetry and fiction before she turned to medicine, and her literary skill is apparent in her book. Her courage, honesty and doggedness are evident on every page. But what to do with the moral outrage after reading her book? My first thought was that I’d want to hammer a copy onto Donald Trump’s desk. But I know that he wouldn’t see it. That, too, is American freedom — the choice not to see.

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