Health Affairs, 24, no. 2 (2005): 506-510 doi: 10.1377/hlthaff.24.2.506 © 2005 by Project HOPE	New Online   House Health Reform Bill   Paying for Reform   Vetting AHIP's Report   HIV/AIDS Costs   Brief: Insurance Reform   HA Blog Top 10

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Narrative Matters

She Walked From El Salvador

PREFACE: Living in a diverse nation inevitably requires working closely with people from a variety of backgrounds. In medicine it means that physicians must care for patients whose race, ethnicity, and language are often different from their own. What does this do to the sensitive, often complicated interactions that take place between a doctor and a patient? Does the preponderance of non-black, non-Hispanic physicians in a country that is increasingly black and Hispanic explain the poorer health outcomes that are frequently seen in these populations? Glenn Flores, a pediatrician from the Medical College of Wisconsin, explores the varieties and effects of physicians’ attitudes in a short story about a recent El Salvadoran immigrant and her infant daughter. Attitude matters. Next, Alok Khorana wrestles with the "nonconcordance" between doctor and patient most often present in his own practice, pointing out that "I am neither black nor white. I am brown, but not Hispanic." Humanism, he would seem to conclude, is a more important factor than racial/ethnic concordance in the practice of good medicine.

"I couldn’t get much of a history," Jack added. "The mother only knows a few words of English. I had two years of high school Spanish. So we talked at a really basic level." The student wanted to be a pediatrician and knew that his evaluation by the attending physician would mean a lot.

Sitting across the table from him in the clinic’s common area was the attending pediatrician, Fred Appleton. "I wish these people would try to learn English—just once," he said. Appleton’s attitude was tough, even though on some level he had sympathy for the newcomers. "My grandparents came from eastern Europe, arriving in New York not knowing a word of English," he continued. "They taught themselves English by reading the daily New York papers and speaking nothing but English at the dinner table. It can be done." He paused. "I suppose you’re going to tell me the child doesn’t have health insurance?"

"No. I mean yes," Jack spluttered, kicking him-self for leaving out this crucial piece of history. "I mean, they are uninsured. What do we do now?"

Dr. Appleton’s Lament

Top Dr. Appleton’s Lament Dr. Cruz Steps In Juana’s Story Patient By Patient

 
What you do," Appleton replied, "is nothing. Illegal aliens are a major drain on our resources, and there’s nothing I can do about it." Appleton’s Division of General Pediatrics struggled to break even, caring for uninsured patients as well as many Medicaid patients whose reimbursement was pennies on the pediatric care dollar. Appleton wanted to draw the line at caring for poor Americans and not the whole world.

"It’s a hard choice," Appleton grumbled, "but one that has to be made. We have to make sure there’s enough money to provide care to Americans. The taxpayers just can’t bear the burden of paying for the health care of these illegals. Each one takes thousands of dollars from our country when they take advantage of welfare and free health care. So don’t do anything. Hopefully, they’ll get the message that the USA can’t afford to give them a free ride anymore, and they’ll go back to their own country, which ought to be taking care of them anyway."

Like many of his colleagues, Fred Appleton became a doctor to help people. But after he had spent fifteen years as a pediatrician in inner-city clinics, his attitude had hardened. He had come to believe in efficiency over everything. Public health programs should see people quickly if they were going to see them at all. He was personally troubled by the taxes he paid for what he believed was a wasteful system of health care for low-income families. He also was bothered because visits by uninsured patients took far more than the allotted seven minutes and produced no reimbursement. These longer visits also meant that he wouldn’t break his own clinic record of seeing thirty-five patients in the four-hour morning urgent care session. This irked him because the quicker patients were seen, the less they had to wait, the more children could be cared for, and the more efficient the system, which clearly benefited everyone.

What Appleton said was callous, but Jack supposed it made sense. There were only so many health care dollars to go around. "I’m not sure I know enough Spanish to tell the mother about vaccination side effects and when to schedule the next well-child visit," he said. "What should I do?"

"Interpreters take forever," Appleton answered. "I just saw the janitor at the end of the hallway. I think his name is José. Pull him into the room for a few seconds so that we can send them on their way. Patients are stacking up, so get a move on."

Dr. Cruz Steps In

Top Dr. Appleton’s Lament Dr. Cruz Steps In Juana’s Story Patient By Patient

 
Sitting at the same table finishing a patient chart was George Cruz, a pediatrician in Appleton’s division. Cruz hesitated to get involved since his own full patient panel was already backing up, but he was troubled by what he had heard. "Fred, I’d be happy to do the Spanish interpretation for this patient, if that would be helpful," he said. "Thanks, George, that would be great," Appleton replied. "Just keep things moving."

Cruz walked Jack into the hallway but stopped him short of the door to the exam room where María and her mother waited. "Jack, do you know what’s the fastest-growing racial or ethnic group in the U.S.?" he asked.

"No."

"Latinos," Cruz said. "They’re now the largest minority group in the U.S. They also are the most uninsured group in our nation. Over one-quarter of Latino kids are uninsured. That’s double the proportion for African American kids and triple the proportion for white kids. Studies show that Latino children are less likely than white children to get asthma medications, pain medications, and prescriptions overall. Language barriers and cultural obstacles are real for Latinos." Cruz knew what he told Jack might sound preachy, but the student needed to hear it. "So what’s the mother’s name?"

"I don’t know, I didn’t ask," Jack admitted.

"The first point, Jack, is that Latinos often place a high value on respect—that’s respeto in Spanish—and on formal friendliness—that’s personalismo. By not introducing yourself and shaking the mother’s hand, you probably put her off right from the start."

Cruz knocked on the door, and he and Jack went in.

"Buenos días, Señora Rosario," Cruz said to the mother as he shook her hand. He continued in Spanish, periodically interpreting for Jack. "My name is Dr. Cruz, and this is our student doctor, Jack Parsons. It’s a pleasure to meet you and beautiful María."

"It’s a pleasure to meet you, doctor. My name is Juana," the mother said. "Ay, you speak Spanish! Thank you. Thank you."

Cruz took his time learning about Juana, María, their family, and María’s medical history. This was what he loved most about medicine: the gift of a family entrusting the intimate specifics of their lives to him. Jack felt a rush of adrenaline as he witnessed the rapport between Juana and Cruz quickly blossom. This was the kind of medicine he wanted to practice.

After talking for a few minutes, Cruz asked Juana where she was from. "I’m from El Salvador," she said. "I walked to the United States. It took me a year. Someone told me last week that I walked about 1,700 miles to El Paso, Texas."

Cruz was stunned. He translated for Jack.

"Please tell me more, Señora," Cruz said.

Juana’s Story

Top Dr. Appleton’s Lament Dr. Cruz Steps In Juana’s Story Patient By Patient

 
It was hard for Juana, but she told Cruz everything—how her parents and three sisters were murdered in front of her in one of the massacres by the army; her torture and rape by soldiers (she still remembered the metal taste of the rifle barrel they held in her mouth); being left for dead afterward, and knowing she was a dead woman if she stayed much longer in El Salvador. She described the walk through Guatemala, where thieves stole her rosary and most of her belongings, and the months it took to get through Mexico. She worked for a few weeks in a hotel in Acapulco, earning a little money by cleaning hotel rooms. She remembered one room with a closet full of beautiful men’s suits and women’s dresses, an open case of tequila, and dried vomit caked on the bathroom floor. She wondered how people could spew so much food from their bodies when she would go days wishing for a small scrap of tortilla to quell her hunger.

The father of her daughter worked at the hotel, too, as a gardener. She remembered the nights she spent with him in a hammock on the beach. Then one morning he was gone.

By the time she reached El Paso, she was six months pregnant, so pregnant she almost didn’t make it through the hole cut in the border fence. The Rio Grande was gorgeous but stank of raw sewage. In El Paso she saved up enough money cleaning hotel rooms to catch a bus to Boston. Some of the women she worked with at the hotel had told her the best hospitals in the world were in Boston, so that’s where she decided to have her baby. She was living in East Boston in a one-bedroom apartment that she and María shared with six other people. She had a part-time job at an airport hotel, but she sometimes had to go hungry so that she could buy baby food for María.

Jack was floored by Juana’s story. What could Cruz possibly do to help her? Juana and María clearly were doomed to a life of poverty—if they weren’t deported first. Jack looked on as Cruz examined María. The infant looked happy, oblivious to the misery in store for her.

Patient By Patient

Top Dr. Appleton’s Lament Dr. Cruz Steps In Juana’s Story Patient By Patient

 
Jack was astonished by what Cruz did after completing the history and physical. He informed Juana that because her family suffered past persecution and she had a well-founded fear of persecution in El Salvador, she probably would qualify for political asylum. María was born in the United States and therefore was a U.S. citizen. Cruz would help Juana get her daughter’s paperwork in order so she would qualify for Medicaid; in the meantime, she could get coverage under the state’s Children’s Medical Security Plan (CMSP). María had an ear infection, and Cruz gave Juana a prescription, explaining to her how to give the medicine and its possible side effects. He wrote down the name of a free adult education class where she could learn English, which made Juana grin. He told her that he needed to step out for a moment to call the hospital’s free food pantry to arrange for food and clothing for her and her baby, and to call WIC so that she could sign up immediately.

When they were in the hallway, Jack said to Cruz, "That was amazing. You changed their lives."

"Still, there’s so much more we ought to be able to do for families like the Rosarios," Cruz replied. "But the politicians have to help. There are budget cuts everywhere. The government is slashing the Medicaid budget. The president is trying to eliminate support for training minority health professionals. A federal agency recently produced a report concluding that racial and ethnic disparities in health care are national problems pervading our system at a significant personal and societal price. Before it got published, though, the Department of Health and Human Services edited out many of the conclusions and deleted the use of the word ‘disparity’ dozens of times. Only after major public outcry did the department finally release the original, more accurate version."

"So what can a pediatrician do?" Jack asked, perplexed by this avalanche of policy issues that he never heard about in medical school.

Cruz had thought about this question. "You just have to take it patient by patient, like we did with the Rosarios," he explained. "You school yourself on the resources and programs that are out there, and use them every chance you get. You work part time as a social worker and look for opportunities to advocate politically for your patients. When there are obstacles to taking care of patients, just remind yourself of Juana. She walked from El Salvador, and she did it step by step."

Jack watched as the pediatrician said goodbye to Juana and María. "You know, Juana," Cruz said, "maybe one day María will be a doctor, too."

Juana looked at María and said, "I would like that."

Editor's Notes

 
Glenn Flores (gflores{at}mail.mcw.edu) is an associate professor of pediatrics, epidemiology, and health policy; director of community outcomes; and associate director of the Center for the Advancement of Underserved Children in the Department of Pediatrics at the Medical College of Wisconsin and Children’s Hospital of Wisconsin. This story is fictional but is based on actual events and characters whose names and details have been changed.

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This article has been cited by other articles:

				G. Flores, S. C. Tomany-Korman, and M. Abreu Uninsured Latino Children: A Call to Action: In Reply Pediatrics, May 1, 2007; 119(5): 1034 - 1035. [Full Text] [PDF]

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