Social Problems, Poverty Strain the System
Marshall Ingwerson, writer of The Christian Science Monitor, The Christian Science Monitor
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 anybody away."
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 poverty level.
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 them.
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 spiritual poverty."
One decision that closely corresponds with infant mortality in the statistics is unwed motherhood - even when other factors have been canceled out, says Mr. …