Consumed In The City: Observing Tuberculosis At Century'S End

3 The Public Hospital: Battles on the TB Frontier

3 The Public Hospital Battles on the TB Frontier One doesn’t ask of one who suffers, what is your country and what is your religion? One merely says, you suffer, that is enough for me, you belong to me, and I shall help you. —Louis Pasteur, quotation written on a statue in front of County General Hospital in Chicago No matter how noble their intentions, medical institutions are not immune to social prejudice. Just as muscular, skeletal, and nervous systems are intimately bound within the same human body, so is the medical system embedded in a larger social body, and it is afflicted by the same problems that perplex the society as a whole (Freund 283). Among these are the everpresent maladies of poverty, race, and gender discrimination. Eli Ginzberg has written that: “. . . every nation’s health care system is embedded in its cultural, political, economic, ideological and social institutions , and . . . these must serve as points of departure for any meaningful exploration of health care reform” (Ginzberg 277). At the same time, medicine may also be seen as an ideologic institution which plays a role in maintaining social relations as they are (Waitzkin 1991, 17). Conflicts within medical institutions, therefore, also mirror those that exist in the surrounding society (Todd 1989). This chapter considers health care as a socially embedded practice, focusing specifically on the problematic relationship that often exists between medical institutions and poor people. I deliberately approach this relationship from the point of view of the patient, for two main reasons: (1) the dominant view in public discussion of health issues tends to be that of medicine and the doctor, while the patient’s point of view is often neglected, and (2) my research was conducted primarily among patients, and not among doctors or nurses. I cannot claim to adequately represent the viewpoint of doctors or other medical staff vis-à-vis these particular patients. Nonetheless, I believe that this is a valuable exercise, and may be helpful to medical professionals as well. In my role as a public health worker, I occupied a middle terrain between patients and a large public medical institution, and its bureau57 cratic workings often appeared as mysterious to me as they did to them. For example, I had little grasp of the ways in which doctors in the hospital divided up their time and duties, between interns, residents, fellows, attendings, and all the rest. I apologize for this ignorance, but I believe that in this case it is actually instructive: the comings and goings of different doctors are often a complete enigma to patients as well, and I found myself sharing their confusion, and identifying with it. Here is an example of one fifty-year-old black man’s impression of hospital procedure: Don’t nobody seem to know what they supposed to be doin’; they swoop down on you like vultures. I’m tired of sitting here waiting for them to see me, waiting for the shoe to fall. I can take my medicines if they just tell me when and how many . . . They want to do too much, too quick, they don’t have time to talk one-on-one to no patient. Your health is as important to you, as the next person they callin’ them to go see . . . Ten or fifteen doctors running around, some of them just listening, you think they your real doctor, but they just emissaries, messengers or something. Then one doctor come up out of twenty-five doctors, they tell me I got a hole in my lung. Why didn’t all those others say anything? This shows just how strange the routine world of the institution can seem. In the same manner, many poor patients bring baggage from the home, neighborhood, or street into the hospital, including expectations, prejudices, and problems that are quite mysterious to the doctors and nurses. Often these are attributed to individual personalities rather than to social factors or cultural differences, and this may alienate the patient. Tuberculosis patients in an urban hospital may suffer a double dislocation . Because they often come from extremely marginalized population, and a high percentage of urban TB cases are poor, homeless, and substance -addicted, they are especially vulnerable to medical neglect and paternalism. Secondly, the alienating and stigmatizing effects of the diagnosis itself can serve to reinforce their marginality, making them feel akin to criminals or outcasts. This chapter takes the vantage point of a sociologically trained public health worker...