Healthcare system problems and public health solutions

A lot of the problems we see with crowded hospitals and inefficient healthcare delivery systems can be addressed through public health. But what happens when people don’t want to be helped? And what happens when the system is one big, huge mess?

My wife and I went to watch “The Waiting Room” tonight. It’s a movie about 24 hours in the lives of the patients and healthcare providers in a busy emergency department in Oakland, California. As someone who grew up on the Mexican-American border, from a poor family, I can attest that, yes, emergency departments in cities are filled to the brim with people seeking primary care. Things like common colds and strep throat are being seen in emergency departments best equipped to deal with multiple gunshot wounds and open skull fractures. In essence, true emergencies are only but a sliver of the care being given in emergency departments. True emergencies from an objective point of view.

From a subjective point of view, everything is an emergency. An emergency room physician in a panel discussion after the movie told us that he has to rule out absolutely everything when someone presents with “minor” things. Belly pain can be a ruptured appendix. Headaches can be aneurysms. Fevers can be sepsis. Or they can just be gas, tension, and a bad case of the flu.

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“The Waiting Room” shows us the complicated navigation that patients have to perform to go from the actual waiting room and into a room in the emergency department. One patient, a little girl, is there with her parents. She has a fever and swollen glands. Her heart is racing. Her father explains that he lost his job, and he has a hard time keeping up with the needs/demands of the family. (Hip-hop classes can be a need or a demand, depending on how you see it.)

We also get to meet a young man who goes to one hospital and is told he has a mass in his testicle. Because he doesn’t have health insurance, that first hospital discharges him, telling him he needs surgery as soon as possible because it could be cancer. So he goes to the hospital where the movie takes place. He doesn’t make an appointment with a physician to be evaluated. No, he goes to the emergency department. He is a student, unemployed, so a lot of his questions are about how he’ll pay for the treatment.

Another patient we meet is a man who is picked up off the street in a sort of crisis from drugs and alcohol. He has been in the emergency department many, many times, but he always goes back out onto the streets and ends up back in because of his addiction. Heartbreakingly, his pastor tells a social worker that the man is not welcomed back at the home where he was staying.

And on and on the stories go.

The main gist of the movie is that the healthcare system is broken. It is broken to a degree that emergency departments are now performing primary care that is not primary care at all. It’s more of a patch-and-go kind of place where you go in, get stabilized and get sent home. There is no follow-up. If you do get follow-up, it is because you were able to find a doctor to follow-up with and had the money to do so.

As I sat there watching the movie, I couldn’t help to think that a lot of the problems presented by the patients could have been avoided with proper public health interventions and proper access to mental health services. For example, there was a man in the movie who laid carpets for a living. He also tells us that his daughter just moved back in with him, along with her child, and that he only has $80 to his name. One of the people in the audience mentioned that the kind of stress the man was facing would be enough for him to feel the back pain that he was feeling. I know I would have all sorts of aches and pains if all I had was $80 and two mouths to feed.

There were also plenty of patients who were there as a result of complications of diabetes. There was a man with high blood pressure who had a hemorrhagic stroke (a stroke from a burst blood vessel). Too many of the patients shown talked about having diabetes. Too many of them were overweight or obese. And too many where shown having been shot or killed from a gunshot wound, including a 15 year old young man. And these were only the patients seen on day of a year-round, 24/7 operation.

It’s enough to make your nose bleed.

Yeah, it’s easier said than done to assume that public health and private practice, and mental health, can all come together and declare what is happening in this country a sort of national emergency. In terms of preventable deaths, we have about half a million from smoking and poor lifestyle choices. A couple of hundred thousand from respiratory diseases (lower and upper respiratory, influenza and pneumonia). Over 38,000 from suicide. About 16,000 from homicide.

And that’s just the deaths.

There are plenty of people with missing limbs from diabetes, poor respiratory function because of smoking or a lifetime of exposure to poor air quality. There are those who cannot work or be productive because mental health (e.g. depression) makes it hard for them to function in society.

I could go on and on.

Instead, I’m going to keep studying toward my comprehensive exams next week, reading up on all I need to know about public health practice, and wait for a national movement on par with the Manhattan Project. Except that this time we put all of our available resources to work against these preventable diseases and conditions. Not only do we inform people of what they can do, but we make it feasible for them to do it. We stop treating mental health conditions like curses from above and instead give people with those conditions all the help they need. And we make sure that public health and private practice work together.

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