Poverty Impacts Access to Health Care. These Women Are Trying to Change That.
This article is part of our Women and Leadership special section, which focuses on approaches taken by women, minorities or other disadvantaged groups challenging traditional ways of thinking.
In the United States, wealth buys health. Consider: In 2000, in Boston’s upscale Back Bay community, a typical resident could expect to live nearly 92 years. But just a few miles away in the South Boston and Roxbury neighborhoods, the average person could not expect to celebrate a 59th birthday.
Access to health care plays a big role in this disparity, said Howard Koh, a professor at the Harvard T.H. Chan School of Public Health who was an assistant secretary for health in the Obama administration. That’s why that administration pushed so hard for the Affordable Care Act, Dr. Koh said. “Poverty is the major driver of health inequities.”
But even in places where people generally have access to medical care, the differences in outcome remain stark, said Thea James, vice president of mission and associate chief medical officer at Boston Medical Center. People with low incomes face financial pressure from all directions: rent, food, transportation, co-payments. If it is a choice between buying medications or food, pretty much all parents would choose their children’s bellies, she said.
Race also plays a role in the outcomes. In the United States people of color are more likely to be poor. African-Americans with cancer traditionally fare worse than white patients, said Dr. Nina Bickell, associate director, community engaged and equity research at Tisch Cancer Institute, Icahn School of Medicine in New York. But, she said, “when black and white women are treated the same for the same disease process, the outcomes are the same for the most part.”
To explore the disparity in care, The New York Times spoke with three women focused on improving the health of people with low incomes.
Diana Hernández, 37, a public health researcher and New York native, sees housing as the centerpiece of a healthy life. Adrianne Lane, 64, a longtime nurse and nurse educator, addresses rural health from her home base in Indiana. And the surgeon Minerva Romero Arenas, 36, serves as a role model by providing care in McAllen, Tex., near the state’s southern tip.
Minerva Romero Arenas
Evidence suggests that patients of color fare better when they have nonwhite doctors. But only about 5 percent of American physicians are black, and in many specialties the numbers are even smaller. “African-Americans and Latinos are grossly underrepresented in medicine,” Dr. Romero Arenas said.
So, Dr. Romero Arenas, who is originally from Mexico City, has felt the need to pull others along with her. In 2016, she and some friends founded the Latino Surgical Society to provide mentoring and other support for peers.
Patients appreciate seeing someone they didn’t expect as their surgeon, said Dr. Romero Arenas, who has a specialty in endocrine surgery but has been confused for a sales representative, a nurse, a translator, and a member of the janitorial staff.
Because people in her part of Texas can’t afford preventive care, it drives up costs when they do seek treatment. “The majority of people down here are uninsured or underinsured,” Dr. Romero Arenas said. That means many of those she operates on have uncontrolled diabetes, high blood pressure or severe obesity, all of which raise the risk for surgical complications.
“If you’re already not insured, you’re going to let things get out of control until you really can’t tolerate them,” she said. She has had cancer patients defer surgery for months or sell their cars to fund co-payments.
Helping patients with so many complex needs can be wearying. Still, she wouldn’t consider moving. “I do feel very tied to the mission,” she said.
In rural areas, simply getting to the doctor can be a problem. Specialists are few and far between. Insurance coverage can be spotty. And driving an hour or two for care can be an insurmountable burden for some. “Cost, distance and fear,” Dr. Lane said, are the three major barriers to rural health care.
Dr. Lane, who lives in Greendale, Ind., and holds a doctorate in nursing, originally devoted herself to rural health to give something back to her community. She watched friends go off to college and never come back.
“I wanted to be able to stay where I’m at and use my blessings to help people,” said Dr. Lane, who has been a nurse for more than 40 years and teaches online through Northern Kentucky University. She also serves as president-elect of the Rural Nurse Organization, a national group that promotes and supports rural nursing.
Around 2000, Dr. Lane and her colleagues began providing mammograms and other breast information for rural women, sometimes setting up a mammogram van outside the local hardware store or a Moose lodge.
Small communities, she said, can be distrustful of outsiders. Once, Dr. Lane said, she was trying to get women in a small town to sign up for her mammogram service, but had few takers.
That weekend, she went to a community event to hand out fliers about the program — and got caught in a downpour. “The people laughed at me, tried to get me dried off — they thought I was just crazy. And we were full by Monday,” she said.
When Dr. Hernández was growing up in federally subsidized housing in the Bronx, she and her family grew vegetables in a community garden.
“There was something about working with the land and doing that as a family and as neighbors, and then sharing,” Dr. Hernández said. “It wasn’t just about us as a family, it was also about the community that was built around the garden.”
That idea of pairing community-building and healthy activities stuck with her. Now an assistant professor of sociomedical sciences at Columbia University’s Mailman School of Public Health, she sees health care as part of a larger picture: If people’s housing is unhealthy, they will be, too.
Dr. Hernández also views apartment buildings and housing complexes as opportunities, saying, “We think of a residential environment as a place where we can address multiple issues around health.”
Take smoking cessation. Last year the federal government banned smoking in all public housing in the United States. But quitting is notoriously difficult. Many designated smoking areas in and around public housing are unsafe, and many of the violators are guests, Dr. Hernández said. So it can be hard to stop someone from smoking in public housing or their housing units because it’s often a rational decision, despite the risk of eviction.
Working with affordable-housing providers in the Bronx, Upper Manhattan, Detroit and Newark, Dr. Hernández has partnered with groups to help resolve some of these problems: providing safer spaces and public health programming, and fostering the kind of community support that can make addressing the underlying causes of bad health easier. As a scholar, she has also been measuring these programs’ effectiveness.
Dr. Hernández said that reaching people where they live can provide a different kind of care than a doctor’s office. “When we think about health, it can’t just be about health care, it has to be about all these other pieces that really contribute to how people live,” she said.