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Income inequality is surging, and there are few countries where it is rising faster than the United States. The distance between rich and poor is greater in America than nearly all other developed countries, making the US a leader in a trend that economists warn has dire consequences. GlobalPost sets out on a reporting journey to get at the ‘ground truth’ of inequality through the lenses of education, race, immigration, health care, government, labor and natural resources. The hope is to hold a mirror up to the US to see how it compares to countries around the world.
An unmistakable disparity in life expectancy and access to quality health care have become hallmarks of the Washington, DC area.
Obstacles to Health
If you’re sick in Washington, D.C., treatment is available — it’s the making use of it that presents a problem. The city provides free health insurance to people making up to 200 percent of the poverty level, no questions asked. There’s a public hospital, and Unity serves patients in all eight wards — including at nine homeless shelters and in two jails.
It’s Unity that runs the clinic under the Center for Creative Non-Violence homeless shelter where Herbert has come to see a doctor.
The room Herbert waits in looks much like those found in doctors’ offices anywhere in Washington — a notice about patient confidentiality and a poster explaining sanitary food preparation on the walls, a television in the corner playing health and safety messages — except for a prominent sign warning, in capital letters, “DRUG USE IN THIS AREA WILL IMMEDIATELY BE REPORTED TO POLICE.”
Last year Herbert overdosed on heroin and received treatment at D.C.’s only city-run hospital. Thanks to free testing, Herbert knows he’s HIV negative — at one point, he reaches into his pocket and displays a handful of free condoms in candy-colored wrappers. He recently had a CAT scan of his liver performed at the George Washington University Medical Center and found out he does not have hepatitis C.
But today he might not get the treatment he’s seeking for his back. Unity’s staffers know their patients are savvy about obtaining painkillers, which they then re-sell on the street for ready cash. Playing cat-and-mouse over oxycontin prescriptions can strain doctor-patient relationships.
It’s not the only challenge of practicing medicine underneath a 1350-bed homeless shelter. Bill Harpster, a former army surgeon who has been practicing with Unity for 16 years, names another one: flooding. Disgruntled residents of the homeless shelter upstairs occasionally sabotage the toilets, flooding the health center below. At one point, the center was finding itself underwater about twice a month. The flooding forces Unity to divert patients to other centers and call in a mobile care unit.
Despite such obstacles, Harpster says D.C. does a good job providing health care to the poor.
But though care is here, D.C.’s poorest still face obstacles in accessing it that might not even occur to residents of Georgetown. Many who are eligible for free government insurance remain uninsured because they don’t know about their options, they don’t trust government, or they simply lack identification.
Herbert is not the only one who finds transportation to appointments to be an obstacle. Relying on transit is more difficult if you work an inflexible shift for an hourly wage, or if your shelter imposes strict curfews. So Unity offers patients transportation to appointments. But, as one Unity administrator points out, just going outside is difficult if you don’t own shoes.
So Harpster gets a lot of no-shows. “It does make the schedule chaotic sometimes,” he says, “but their lives are chaotic.”
Harpster’s patients are very sick — he estimates one in five are HIV positive — and managing serious medical conditions can be near impossible amidst such chaos. “If you have diabetes and hypertension and HIV, you have to take 15 medications a day,” he says. “I couldn’t do it.”
A lobbyist on K Street, with a stable family life and a new BMW, would be much better equipped to access and manage treatments for these conditions, but this is largely a moot point. Not many K Street lobbyists have diabetes, hypertension and AIDS.
Patient resting at the Howard University Hospital in Washington, DC. Howard University Hospital is one of America's best hospitals and dates back to 1862.
Regardless of access to treatment, Washington’s poor residents suffer from chronic conditions at a far greater rate than its rich residents.
Though at-risk groups like gay men and white intravenous drug user have turned the tide on HIV, it remains a public health catastrophe for the city’s poorest blacks.
And in nearby Montgomery County, Maryland, where many D.C. residents pushed out by rising rents have relocated, blacks visit emergency rooms for both diabetes and hypertension at three times the rate of whites, and they visit for asthma at more than four times the rate.
Obesity is a major risk factor for all three conditions. In Washington, only 8 percent of white residents are obese, compared 31 percent of black residents. In this, too, D.C. leads the nation in disparity.
These vast gulfs are not explained just by different health care systems — but different ways of living.
Abdo, 53, says he and his family enjoy a healthy and active lifestyle — “Doing as well as I am, I could live anywhere and get great health care.” He’s covered by Blue Cross, Blue Shield through his company plan and says he’s avoided serious health issues.
Abdo’s family enjoys biking, and he notes that his wife runs marathons.
The affluent clientele his properties cater to demand the amenities that allow them to live the same type of lifestyle.
“It was a tougher sell in the mid-90s as the city was not going through what it has in the last 10 years,” he says. “There weren’t the Whole Foods in the neighborhoods, there weren’t all the yoga studios”
And if you want to understand the roots of D.C.’s gross health disparities, a yoga studio is a good place to start.
In parts of Georgetown and Glover Parker, where health activist Sariane Leigh once taught yoga and pilates, there are four to a block. But when Leigh began teaching yoga in 2009 in the impoverished neighborhood of Anacostia, she was the only show in town. She still found herself unable to draw customers.
“The first person who showed up on one of my first days of classes was a white girl,” she recalls with a laugh. “I was like, ‘this is not for you!’”
Leigh says the black women east of the Anacostia River don’t value their health the way her clients in Georgetown do. They may spiritually recharge by going to church, or pamper themselves with a haircut or new purse, but devoting time to the health of their bodies is not a part of their lifestyle.
Abdo recognizes the District’s disparities in health care — “Unfortunately, the quality of it depends on income” — But he also remains upbeat about the city where he builds housing. “The opportunities to be active and stay healthy are abundant here, he says.”
For for his part, Abdo recommends early childhood education as a remedy to the lifestyle differences that afflict D.C.’s poor.
“We’re dealing pretty much with social determinants of health that are way beyond the capacity of health centers or one entity to resolve,” says Keane, Unity’s CEO, of the herculean task facing the nonprofit.
Thus its initiatives — like free transportation to appointments and education about healthy eating —aim to widen the services offered in support of well-being.
But the net can only be stretched so far. The doctors at Unity’s clinics can’t open grocery stores, or guarantee employment, or build new schools and run the health classes. Leigh can offer yoga classes, but she cannot force anyone to take them. These, and a thousand other things, are part of the real health care system supporting Washington’s affluent class. As long as they exist only west of the Anacostia River, D.C. will remain a city divided by health in a country it’s helped divide by class. And that’s bad news for the capital’s poorest.
Not that Herbert’s complaining. He does what he can to take care of himself but feels that what happens to him, like what happens in Congress, is ultimately out of his control. In the most powerful city on Earth, Herbert embraces his powerlessness, and leaves his health in the hands of God.
“I’m happy,” he says. “We go through life as He writes it.”