WHOEVER walks into the Southwest Public Health Clinic, no matter
what their financial condition, can get medical attention.
"Bills are created," says David King, who practices internal
medicine here and at another clinic across town, "but we never turn
Even in poor urban neighborhoods like this one, lack of money
itself is not a major obstacle to health care, according to doctors
and medical administrators. Yet many of the poor, including
pregnant women, fail to seek any sort of health care until a crisis
comes and they land in an emergency room.
The reasons can sound trivial to middle-class ears: from lack of
bus fare to lack of a concerned relative to prod them. The result
is that the poor have worse health and eventually cost more to
treat medically than the rest of the population.
Some researchers believe that American health-care spending is
so much higher than anywhere else because so many American social
problems - from violence to homelessness to unwed motherhood - are
transformed into medical problems.
"We're fighting this thing at the wrong end," says Thomas
Chapman, president of Greater Southeast Community Hospital.
In the District of Columbia, along with a leading homicide rate
and a high child poverty rate, a greater proportion of babies die
during their first year than in any state or any other major city
in the United States.
The US infant mortality rate overall is more than twice as high
as Japan's, worse than most industrialized countries, higher even
than in Spain, where per capita income is below the American
The high US rate is not a medical failure, at least in the
traditional sense. When babies are born too small, too light, too
fragile, the American medical system is among the best at saving
The problem is that Americans produce a very high proportion of
high-risk, low-weight babies - a condition heavily affected by the
behavior of the mother. Smoking, for example, is responsible for 20
to 30 percent of low-birthweight babies, says Louis Sullivan, the
secretary of the US Department of Health and Human Services.
The sorrow of infant mortality is not spread about with an even
statistical hand. About half the states in the country have infant
mortality rates near the West European norm, as does the nation's
overall white population. Some of these states, such as Maine, are
relatively poor, rural states.
Inadequate family support cited
But in the federal district's poorest ward, Ward 8, which is 90
percent black and has the most teenage pregnancies, the infant
mortality rate is three times the national rate. Many social and
health problems - AIDS, drug abuse, high-risk babies, murder - are
concentrated in neighborhoods like this.
The health problems are not explained by poverty alone, and
money alone will not solve them, according to Mr. Chapman, whose
hospital lies in Ward 8.
"We know the problem isn't poverty. Poverty can be licked when
it comes to medical care," he says. The problem is that people are
not taking care of themselves when they have many kinds of problems
in their lives, poor family support, and the "abject frustration"
of social and economic depression.
"As a measured lack of household income, material poverty
doesn't go very far in explaining infant mortality," says Nicholas
Eberstadt, a visiting fellow at the Harvard Center for Population
Studies, who has just completed a review of the problem.
But, he adds, "you can also talk about behavioral or even
One decision that closely corresponds with infant mortality in
the statistics is unwed motherhood - even when other factors have
been canceled out, says Mr. …