Caring and Health Care
Our health care delivery system is designed perfectly for the results we get (to paraphrase a saying attributed to Dr. Paul Batalden). As noted on the website of Physicians for a National Health Program, despite having the highest per capita health spending in the world, the U.S. health system ranks very poorly in international comparisons of quality, outcomes, patient satisfaction, and other measures. Administrative costs consume over 30 percent of health spending, most of it unnecessary. Nearly two-thirds of all bankruptcies are caused by medical bills. Three-fourths of those bankrupted had health insurance at the time they got sick or injured. Despite spending far less per capita for health care, Canadians are healthier and have better measures of access to health care than Americans. The uninsured do not receive all the medical care they need: one-third of uninsured adults have chronic illness and don’t receive needed care. Those most in need of preventive services are least likely to receive them.
Our country expresses its values in how health care is delivered. We spend more and provide generous profits to a few with increased illness, higher mortality, and the specter of financial ruin for too many Americans. There were 49.1 million uninsured Americans in 2010. Most medical bankruptcies occur in people who had insurance and found out too late that their health insurance was inadequate. While the Affordable Care Act (so called, “ObamaCare”) has made improvements and extends coverage, it firmly entrenches for-profit insurance industry at the center of medicine.
Dr. Danielle Ofri has an amazing viewpoint on medical care. She works with patients from all over the world in the clinics of the famous Bellevue Hospital in New York City. This book describes her quest to listen, to understand her patients, to connect with her fellow human beings by overcoming divisions of language, class, and circumstances.
Medicine in Translation relates the stories of Dr. Ofri’s patients. We meet Samuel Nwanko in her “Survivors of Torture” clinic. This twenty-seven-year-old struggled to get to the United States from Nigeria- where a beating and acid attack left him disfigured, traumatized and grimly determined to persevere. We learn about Dr. Chan. He is ninety-one years old. His slight build, debility, hypertension and diabetes does not diminish his care of his younger and stronger wife with advanced Alzheimer’s dementia. We confront the peculiar tragedy posed by Julia Barquerro—a thirty-six-year-old mother with a failing heart. Unable to be considered for transplantation because of her immigration status, Barquerro is unable to be with her nine-year-old son who is trapped in a detention center. We get to know Dr. Ofri’s patients, not as cases, but as people. She relates to her patients with dignified love—the respectful intimacy of an individual caring professional.
Language is how we connect with others. Dr. Ofri is not satisfied with her Spanish. In this book, the absence of spoken fluency is a barrier to human connection: “…like the time I’d asked a patient ¿Cuantos anos tiene? rather than ¿Cuantos años tiene? She was polite enough not to point out that I’d just asked her how many anuses she had rather than how old she was. Yet whenever I offered my patients a choice, they overwhelmingly preferred direct communication—even if somewhat flawed to the unnatural stiffness of an interposed interpreter.” The doctor overcomes the barrier with focused intention and effort.
Dissatisfied with her Spanish and pursuing a long-held aspiration, a now pregnant Dr. Ofri relocates to Costa Rica for one year with her husband, two toddlers and dog. Costa Rican medical care and culture contrasts sharply with that of the United States. “Having a new baby opened up another layer of Costa Rican society for me,” she writes. She encounters kindness and consideration for her and the new baby:
Over and over—Ticos offered to hold my baby and seemed to delight in it…. Suddenly, I was meeting people I’d never otherwise have engaged with. If I ever had another baby, I thought, I would surely do it in Costa Rica.
She is assaulted by the familiar grim demands when she returns to New York. Toward the end of her book, she reflects on the violent murder of her patient’s daughter, the prevalence of suffering, the professional challenges of caring for subjects of brutality, “…it dawned on me what a luxury denial was. A luxury that permitted us to impose an order-even an imaginary one- on an unpredictable life. I turned and joined the horde of commuters striding up the avenue. There was a comforting anonymity in the momentum of the crowd.”
The contrast between the culture of Costa Rica and the United States is an unrealized indictment. Her stories challenge us to embrace the humanity of her patients. The well-intentioned professional works without protest in a health system that prioritizes profit and accepts premature death for the disenfranchised. Dr. Ofri is an exemplary model of professional compassion. Her beautiful stories linger at the curtains of disease, of class and culture of life, and of inevitable death. The stories challenge us to create new narratives of caring and listening. Fluency in another’s language is a metaphor for caring. She is a doctor who is dissatisfied with her Spanish. She listens to her patients. But the interpersonal connections are tenuous. Our system prioritizes wealth over well-being. She fails to explicitly critique our health system. Her exceptional example is nearly eviscerated by our societal context.
She does not address the inhumanity of how our culture considers medical care as just another commodity to be provided for profit. Dr. Ofri is silent about the structure of the American health care system. She does not speak to interconnectedness of health and well-being.
Her failure to acknowledge our collective responsibility compels us to translate the language of caring into a language of financial empowerment of collective well-being.