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The Author's Last Word
It is only fitting that David Hilfiker have the last word: "I found the conference in St. Louis very stimulating. Particularly striking was the openness and genuineness of those who attended. The stories people told of their own work and the attention with which they listened to each other indicated a wonderful level of mutual concern."
Hilfiker acknowledges that clinicians who serve the homeless often don't see the results of their care. Many are young practitioners who tend to stay in the field for only a short time. Patients may not return to homeless clinics for a variety of reasons including transience, illness and death. Nevertheless, over a period of several years, practitioners do see some of the same people, over and over again.
"In health care for the homeless there are spectacular failures, but also spectacular successes - people who are alive and helping others because of the care they have received. An individual practitioner has a much greater impact on the health of the poor, who have few resources, than on the health of the affluent, who have many."
Hilfiker thinks physicians are even more limited in the feedback they receive from homeless patients than are other members of the clinical team. Office-based practitioners in homeless clinics should find ways to get regular feedback from someone who is regularly in touch with the homeless community, he says.
Moreover, although there are few seasoned practitioners of poverty medicine, young clinicians need mentors. Monthly meetings at which area practitioners share their experiences might help to address this need, he suggests. Such a mentoring program might be developed with support from the AMA Medical Education Society.
According to Hilfiker, "the single issue that dwarfs all others in American medicine today is the corporate takeover of managed care, which provides financial incentives for clinicians to withhold care, thereby removing their primary allegiance to patients.
"As health professionals we need to recognize that health coverage and health care for the poor and homeless are fundamentally ethical issues, not health issues." - David Hilfiker, MD
For mainstream medicine, these issues boil down to one question - whether or not to care for vulnerable people. Today, the answer is no. Until we acknowledge that fact, Hilfiker contends, nothing fundamental will change about the need for health care for the homeless.In Hilfiker's opinion, "you can't both save money and deliver good health care except with a single-payer system [financed by taxes]," in which the same basic care is universally available, so that political decisions about the system affect everyone. Such a plan is dependent upon a viable democracy, which he thinks is in jeopardy.
"As long as a huge gap between rich and poor in this country persists, there will be more and more pressure not to have any health care subsidized by taxes," he predicts. Nevertheless, if clinicians were united in favor of a feasible plan, Hilfiker is confident that they could have significant impact on public policy.
"If our democracy works, together we will decide whether or not we are willing to pay for any particular treatment. There is nothing wrong with distributing luxuries on the basis of income, but not necessities." David Hilfiker thinks our wealthy society can easily afford to provide for everyone, given the political will to do so.
Editor's Note: Hilfiker has published two books of particular interest to HCH clinicians: Not All of Us Are Saints, a collection of autobiographical essays (Farrar, Straus & Giroux: Hill & Wang, New York, 1994); and Healing the Wounds: A Physician Looks at His Work (Random House: Pantheon, New York, 1985). A seminal essay contained in that work, "Mistakes," first appeared in the New England Journal of Medicine and subsequently in On Doctoring (Reynolds & Stone, Editors, Simon & Shuster: New York, 1995).
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National Health Care for the Homeless Council, Inc.
HCH Clinicians' Network
P.O. Box 68019
Nashville, TN 37206-8019
Voice: 615.226.2292 | Fax: 615.226.1656 | Email: council@nhchc.org
