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Columbia College Today May/June 2011 > Alumni Corner
Caring for Those Without Health Insurance
By Dr. Ralph Freidin ’65
In 1965, Medicare and Medicaid were passed, Martin Luther King Jr. marched to Montgomery, Malcolm X was assassinated, President Lyndon B. Johnson’s Voting Rights Bill became law, more troops went to Vietnam and many were protesting the war. This was the social backdrop of our class.
My years on Morningside Heights were a time of social change and student activism. The corner of West 116th Street and Broadway was as much a classroom as Hamilton Hall. Although pre-med, I minored in history. The highlight of my four years was Jim Shenton ’49’s renowned seminar “United States during the Era of Disunion.”
Professor Shenton wove the milestones of current American history into his seminar, leaving me with indelible lessons of the tide of American history.
I left Morningside Heights in June 1965. In September, I drove to St. Louis to begin my first year at Washington University Medical School. With Medicare and Medicaid promising access to care to millions previously excluded, I entered medicine believing that it would be a tool for social change.
Dr. Ralph Freidin ’65 examines a patient at a free clinic in Washington, D.C., last August.
PHOTO: CHRIS USHER
Quickly, I learned that the view from Morningside Heights was not that from the heartland. Columbia had prepared me well for medical school, but not that my profession’s vision of social responsibility started and stopped at the hospital’s door.
Starving for the pulse of social change, I heard the words of my Columbia swimming coach, Richard Steadman: “Defeat is not a discouragement but a call to be better.” I started thinking of ways to get the medical school and hospital to extend its services to the inner city three miles from its door. With the support of two young faculty members, some of my classmates and members of the Pruitt-Igoe Men’s Club, we established a health center in Pruitt-Igoe, St. Louis’ largest public housing project.
For the first 10 years after graduating from medical school, I taught and practiced primary care and internal medicine in municipal hospitals. By 1980, I had a family of two young children and a wife with her own professional career. The problems of people marginalized in our health care system were too taxing for this stage of my life. I left inner-city medicine and joined a small private practice in Lexington, Mass.
Last summer, I saw a report of a one-day medical clinic in New Orleans that had provided free care to almost 1,000 people without insurance. The clinic, spread across 102,000 square feet of a convention hall, was my small neighborhood health center on steroids.
Believing health care was a right of every American citizen, undoubtedly learned in CC, history classes and Professor Shenton’s Civil War seminar, I called The National Association of Free Clinics (NAFC, freeclinics.us). Two weeks later, I was on a plane to Little Rock. I was asked to triage the waiting line, looking for someone who needed urgent care. The people began to line up two hours before the doors opened at 10 a.m. By the time the first scheduled patient was seen, more than 200 patients were waiting.
More than 80 percent were working but none had health insurance. Some were self-employed but could not afford the premiums of individual policies. Some had several jobs, none of which provided health benefits. Others had been laid off and could not afford COBRA.
Few had seen a physician in the past year. Almost half had not seen a physician in the past six years. All had the same reasons for having neglected their health. Without insurance, they could not afford to pay for a physician visit. Without insurance, they could not afford to fill their prescriptions. Without insurance, they could not afford any surgical procedure. If they had been sick enough to need emergency care, they were then saddled with an enormous bill that discouraged them from seeking further care.
A man with a below-knee amputation was in a wheelchair. He hoped the clinic would help him obtain the prosthesis request his medical insurance had denied.
A woman grimacing in pain had cancer treatment two years ago but was unable to continue treatment without insurance.
Another woman was wearing a trench coat to cover her emaciated frame. She had had three seizures in the past two weeks. A local emergency room where she had sought help told her that the level of her seizure medications was “OK” and discharged her. No follow up was arranged. During her seizures she had bitten the inside of her mouth and tongue. She could not eat. When I told her that we would care for her and arrange for further care, I could not see an intact tooth in her broad but crooked smile.
A man with labored breathing and a sweaty brow was slumped in a wheelchair. His weak voice told me five days ago he was in the intensive care unit of a local hospital for “swollen legs and chest heaviness.” At discharge, he was handed a list of unaffordable medications that he did not understand. Continuing care was not arranged. He had unstable angina. I wheeled him to the front of the line and called the EMTs to take him back to the hospital.
Had the free clinic not existed and his daughter not insisted that he come, would the cause of his death been his heart disease or the failures of our health system?
It was not the spectrum of illness I witnessed that was different. It was the severity of illness. It was not just diabetes; it was uncontrolled diabetes with diabetic complications. It was not just hypertension; it was blood pressures of 190 over 120.
There were five patients sent by EMT ambulance directly to the emergency room who may well not have seen the next day were it not for this clinic. At the end of the day, I had spoken to several hundred people and heard their stories of living in the wealthiest country in the world without health insurance.
I was overwhelmed. Every patient’s story ended with the haunting refrain of the chorus of a Greek tragedy: “no insurance, no cash, no doctor, no medication.”
Before leaving, I was asked if I would be at the next clinic in Kansas City that was scheduled in five weeks. Without hesitating, I said yes and that I would travel to any clinic organized by the NAFC. I have been to Kansas City, Hartford, Atlanta, Washington, D.C., and New Orleans. My seventh and most recent clinic was in Charlotte, N.C.
I have no professional affiliation with NAFC. My commitment to it is personal. I pay for my travel and take time from my private practice to do this.
I thank my years at Columbia for fostering my social awareness as well as my preparation in the basic sciences and American history for my career in medicine that has continued to bring challenges and satisfaction.
Dr. Ralph Freidin ’65 has practiced internal medicine and primary care in Lexington, Mass., for the past 30 years. He blogs about health reform at theunseenpatient.blogspot.com.
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