Through the Valley

Originally submitted as an assignment for my school's Community Health Component course:

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“Hola. Me llamo Peter. Cómo se llama?” 

That was about the extent of my Spanish speaking ability. We were at yet another colonia, a type of rural shantytown without adequate municipal services such as water, electricity, and sewage. These are places that even the government stays away from – that is, cities exclude these places from their city limits because the tax dollars generated would not be worth the municipal services they would have to provide. There is also no legal obligation for the county or state to provide such services.  

It was my fourth week at a colonia and I had finally gotten a sense of the work flow necessary to compensate for my inability to communicate with the patients. 

“Me llamo Maria.”

“¿Cuántos años tienes?”

“Cincuenta y cinco.”

I held up the blood pressure cuff and pointed to her arm. With an approving nod, I successfully avoided the first language hurdle. One hundred thirty-five over eighty. Not bad, considering her weight and the blood pressures I had seen throughout the day. Next, I pointed at the underside of my wrist with two fingers. She got the message. As I was trying to remember the words to test her blood sugar, she helpfully preempted me. 

“Sugar.”

Relieved, I took out the glucose meter and tested her. The first week, it had struck me as odd that a diabetic who was worried about their blood sugar would not have a home meter. It probably shouldn’t have. After a few seconds, the number “255” flashed on the screen. I showed it to her, causing her brows to furrow in dismay. I pointed to the table across the room. “Alright Ms. Maria, go see Dr. Patterson, he’ll help you out.”

However, even as I said that, I knew that the options were limited. The clinic discouraged the practice of managing chronic illnesses without the ability for consistent follow-up or laboratory tests. We would counsel most patients to seek a primary health provider and obtain laboratory studies. However, the patients’ lack of insurance and questionable legal status makes obtaining such services difficult. The cheaper alternative, the prescription of diet and exercise, is almost equally difficult. The abundance of tortillas, meats, and cheese is as much ingrained in the diet as it is in the culture. Even if patients were willing to make dietary changes, salads and vegetable dishes often do not exist in their recipe repertoire.

Later, after all the patients had left, the team reviewed some of the day’s cases. One man had come complaining of a headache. He revealed that he had actually been diagnosed with a pituitary tumor in a hospital, but could not afford the cancer treatment. He had come to the free clinic in desperation to look for other options. As none of us were capable of neurosurgery, the best we could do was to refer him to places that might do such a procedure for a reduced price. It is alarming that no current option exists for these patients. In the 1970’s, the Centers for Medicare and Medicaid Services (CMS) stepped in for end stage renal disease (ESRD) patients to pay for dialysis treatment in order to prevent hundreds of thousands of patients from otherwise certain death, but ESRD remains the only disease that is federally paid for. EMTALA, the Emergency Medical Treatment and Active Labor Act, which mandates the treatment of patients that arrive in the Emergency Department, only requires treatment for emergency medical conditions. For patients with a growing brain tumor, it would not cover the long-course care that would be necessary for complete tumor remission.

The social obligations and ethics of such policies are easily debatable in the boundaries of academia and politics, but much more disturbing when the face of the patient is sitting across from you. There is rarely an easy answer in the world of legislation, but there may be innovative alternatives.  One such hopeful effort by the director of the clinic is the implementation of mini health clinics at commercial establishments such as Wal-Mart. He believes that this would allow patients to access the continuity of care necessary to manage chronic conditions, provide preventative care, and manage costs to dramatically improve the health of local populations. Such innovation is a much needed glimmer of hope in a landscape where epidemic hopelessness risks ignorance and inaction.