The poverty rate has generally been between 10-15% since the mid-1960s, so this isn’t a dramatic trend, but there are obviously concerns that it could continue to rise over the next couple years due to the recession. Also, it is important to remember that the income levels at which poverty is measured are relatively low by today’s standards. For example, for 2008 a single person had to have an income under $10,991 to be considered poor, while a family of two parents and two kids had to have an income under $21,834. Clearly a much higher percentage than 13% of Americans are struggling to make it in this economy.

By the way, if you’re interested in how poverty is measured and current calls to update it to today’s realities, check out http://www.povertymeasure.org/

I tell you, I get back from a trip overseas for a couple weeks and when I get back it seems like the crazies have taken over the political scene.  We have 47 million people without health insurance in this country and all some people seem to care about is old, tired baggage about “socialized medicine”  and using any scare tactics necessary to make President Obama and the Democrats look bad.  It’s really just disgusting.  I’m personally ok with my health insurance, but I think it’s immoral for a rich country like the U.S. to not provide coverage for everyone. As usual, it’s the poor – and in this case uninsured – who don’t have a seat at the table and are thus left out of the equation.

One of the few sane voices I heard on the radio today was that of Wendell Potter, formerly a communications executive at two major health insurance companies and now a repentant advocate for health care reform (talk about a conversion experience).  Check out the interviews with him and testimony he’s given before congress.

As California continues to release more prisoners, most will return to California communities, bringing with them a host of health and social needs. This raises key public health challenges, especially because ex-prisoners are returning to communities whose safety nets have already been severely strained. The RAND Corporation has just released a report to help California policymakers better understand the health care needs of those returning from prison to communities, which communities are disproportionately impacted by reentry, and the capacity of the health care safety net in those communities to handle them.

The full report and a press release are available, but several key findings emerge:

• California inmates bear a high burden of chronic diseases like asthma and hypertension and infectious diseases like hepatitis and tuberculosis—conditions that require regular use of healthcare for effective management—and their drug treatment and mental health care needs are even more pronounced.
• Certain counties and communities within California are disproportionately affected by reentry, which has implications in terms of targeting reentry resources to these areas.
• Most parolees—and, in particular, African-American and Latino parolees—return to disadvantaged communities where their needs for healthcare, housing, and employment, among other services, will be harder to meet.
• There are important gaps in the safety nets in those communities to meet parolee health care, drug treatment, and mental health care needs.
• Safety net providers, especially community clinics, are an important component of the safety net for parolees.
• Funding more clinics may help fill in geographic gaps in services.
• There is a need to better integrate the different treatment networks that provide services to the parolee population, particularly those for mental health, alcohol, and drug treatment.

A new report from the LA-based Economic Roundtable attempts to meet those needs by providing a wealth of the most recent data on how the current recession is affecting everything from employment, income, housing, poverty and health in Los Angeles and the state. Using historical data on recessions and employment projections from respected forecasters, the report produces estimates for how residents will fare over the coming years. If you are interested in where we’ve been and could be going, check out Ebbing Tides in the Golden State: Impacts of the 2008 Recession on California and Los Angeles County.

In general, the report sees conditions continuing to worsen over the next year but then starting to improve steadily by 2011 or 2012. It even provides estimates of how much poverty and homelessness will increase or decrease. Are these accurate? Of course there is no way to know. As the Nobel Prize laureate physicist Niels Bohr said, “Prediction is very difficult, especially about the future.” At the very least, Ebbing Tides in the Golden State provides an important overall understanding of how deep the recession is affecting us.

I’ve been reading Mountains Beyond Mountains, a great book by Tracy Kidder about the work of Paul Farmer and Partners in Health recently. It tells the story of how the dedication of one talented person can mushroom into a global effort to heal the poorest and most vulnerable.

Today is Good Friday, when Christians around the world remember the death of Jesus, something I was reminded of when I read this recounting from the book of the horrible death of a victim of the political violence in 1992 Haiti whom Paul Farmer examined.

On January 26, Chouchou, a handsome man in his mid-twenties, was scarcely recognizable. His face, and especially his left temple, was misshapen, swollen, and lacerated; his right temple was also scarred, although this was clearly an older wound. Chouchou’s mouth was a coagulated pool of dark blood; he coughed up more than a liter of blood in his agonal moments. Lower down, his neck was peculiarly swollen, his throat collared in bruises, the traces of a gun butt. His chest and sides were badly bruised, and he had several fractured ribs. His genitals had been mutilated.

That was his front side; presumably, the brunt of the beatings came from behind. Chouchou’s back and thighs were striped with deep lash marks. His buttocks were hideously macerated, his skin flayed down to the exposed gluteal muscles. Many of these stigmata appeared to be infected.

On this day, let us remember all who suffer all kinds of pain in this world.

The analysis is based on 65 specific criteria such as access to medicine, housing, family education, and support for National Guard members, and overall the news is not good. The U.S. gets a D, a rating that hasn’t budged since 2006. Across the states, the best grade is B (six states) while there are 18 states with Cs, 21 with Ds and six with Fs. The report includes detailed report cards and recommendations by state.

According to Michael Fitzpatrick, Executive Director of NAMI, “Too many people living with mental illness end up hospitalized, on the street, in jail or dead. We need governors and legislators willing to make investments in change.”

Hopefully, this report, and the imminent release of “The Soloist” movie will generate a national discussion on the need to de-stigmatize mental illness and get people the help they need.

The movie is based on a book by the same name written by Los Angeles Times columnist Steve Lopez, which I had put off reading until very recently.  It wasn’t because I thought I wouldn’t like the book; but rather because the story was so familiar.  The book emerged from a series of Lopez’s columns about the friendship he developed with Nathaniel Ayers, a mentally ill homeless man in Los Angeles.  As a loyal subscriber to the Times, and in particular a regular reader of Lopez’s column, I probably felt the book wouldn’t have much more to offer.  I’m glad I followed our rule of thumb, because I was wrong.  Whether you are familiar with this story or not, I encourage you to read The Soloist, a beautiful account of taking risks, learning, friendship, and personal growth.

Steve Lopez describes himself as a fisherman, constantly casting nets out for interesting stories which hopefully come back once in awhile with hidden gem.  He admits that in an industry that is crumbling by the day, he has a privileged position.  Like his heroes Mike Royko and Jimmy Breslin before him, Lopez plays the role of muckraker and storyteller for a city.  He enjoys “sticking it to the man” (Cardinal Roger Mahoney, LA Mayor Antonio Villaraigosa, and Gov. Arnold Schwarzenegger have been skewered on several occasions for what Lopez believes are both personal and professional transgressions) but also telling the stories of normal everyday people that have larger societal implications. None of his stories has had as much an influence, both to himself or society, as that which began as a chance encounter with the person he first calls Violin Man.

I’m on foot in downtown Los Angeles, hustling back to the office with another deadline looming.  That’s when I see him.  He’s dressed in rags on a busy downtown street corner, playing Beethoven on a battered violin that looks like it’s been pulled from a dumpster.

“That sounded pretty good,” I say when he finishes.

He jumps back three steps, eyeing me with suspicion.

….

I notice while talking to him that someone has scrawled names on the pavement where we’re standing.  Nathaniel says he did it with a rock.

The list includes Babe Ruth, Nancy, Kevin and Craig.

“Whose names are those?” I ask.

Oh, those people, he says.

“Those were my classmates at Juilliard.”

To a curious journalist like Lopez, those last words were a provocation to dig much deeper, and dig he did.  More than just the subject of a column, however, Nathaniel becomes a friend and teacher to Lopez, introducing him to the travails of mental illness, homelessness, and racism and taking him on a journey of self-discovery.

Lopez is fascinated with the story of how this talented musician, who overcame all sorts of odds as an African American male during the 1970s to attend Julliard, ended up on the streets of Los Angeles. He learns how quickly an illness such as paranoid schizophrenia can take someone with such promise and even family support down a path toward extreme poverty and homelessness.  Lopez begins to care about Nathaniel, learns about his past, develops a common appreciation for classical music, provides him with new violins and cellos that have been donated by reader of his columns, and ultimately tries to get him the care and housing he needs.  He struggles with the fine line between being a journalist and friend, whether by helping his new friend he’s putting him at risk:

Every time the phone rings at night, my stomach does a flip.  I’m always sure it’s the police, calling to say Nathaniel is hanging on by a thread after a mugging, and nice going Mr. Columnist.

In his columns, Lopez can at times come off as arrogant and condescending.  In this book, he bares his soul a bit more, detailing the ethical and personal dilemmas he faced in trying to help his new friend.  Is he exploiting Nathaniel for his own ends?  How can he help someone who so often expresses a distaste for wanting to be helped? Recounting the experience of receiving an award from the National Alliance on Mental Illness for his role in educating the public about mental illness, Lopez expresses his own inadequacies:

I don’t feel as though I’ve done much more than write about what people at the conference already know, and as I look at a crowd that is standing and applauding, I’m tempted to grab the microphone and ask if anyone out there can tell me what to do next.

It is clear to Lopez that Nathaniel needs psychiatric care and a place to live, and he tries numerous ways to entice his friend into both, usually involving using Nathaniel’s passion for music as bait.  He works with LAMP Community on Skid Row to create space for Nathaniel to practice his music.  He enlists musicians from the Los Angeles Philharmonic to provide lessons for Nathaniel.  He gets LAMP to reserve a room for Nathaniel to live in and bangs his head against the wall trying to get Nathaniel to stay there.

Ultimately, however, Lopez learns that this journey is not about himself.  Their relationship goes through many ups and downs, and it is after one of the particularly stressful times, when Lopez seem to almost have given up hope that Nathaniel makes the choice on his own to spend the night in the apartment.  Lopez recounts how he found out while driving around the streets looking for his friend and talking on the phone with LAMP staffer Stuart Robinson:

“Do you have any idea where he was?” I ask.

“Yes,” Robinson says. “He spent the night in his apartment.”

He what?

I pull the car over to avoid driving up on a curb.  Almost exactly one year after our first encounter, he did it.

Yes, he did it and thus begins a long process of recovery that continues to this day.  The two remain close and appear to be doing well.

I saw them at the launch of the Nathaniel Anthony Ayers Foundation, which was founded by Nathaniel’s sister to support programs for the artistically gifted mentally ill several months ago.  Mr. Ayers – as Lopez turns to calling him near the end of the book – played his cello as a surprise guest at the event, and the affection and respect toward each other was evident.  I have heard some question whether Lopez’s views on homelessness and mental illness are too colored by his own savior complex and relationship with Nathaniel Ayers, and whether he would have shown any interest in this person if he did not have a unique musical talent.  It’s a fair challenge, but one that I think Lopez is open to struggling with.  In the end, I think anyone can see that he has played a very important role in educating all of us through his writings.

About a quarter of homeless persons in the U.S. have a serious mental illness such as chronic depression, bipolar disorder, schizophrenia, and severe personality disorders.  That means there are about 165,000 people on our streets every day struggling with a serious mental illness.  What will it take for us to mobilize the dedication and patience to ensure that all of these people get the care and housing they need and deserve?

Hopefully the movie will be a great success and will generate a national, and even international, discussion to remove the stigma associated with mental illness and homelessness.  But, even more hopefully, people will read this book and wrestle with the challenges and hope it provides.

The Soloist: A Lost Dream, an Unlikely Friendship, and the Redemptive Power of Music. Steve Lopez.  G.P. Putnam’s Sons, New York NY.  2008. 273 pp. ISBN 978-0-399-15506-2

Access to health care to address all sorts of diseases is indeed a fundamental concern for millions of Americans and the source of household stress. What is often lost given current debates is the astounding progress made by modern medicine in addressing many – though not all – formerly incurable diseases. My father (currently retired after a long career in academic medicine and research) recently published a book highlighting these advances, as well as remaining challenges, in medicine.

Whom the Gods Love Die Young explores the history of disease and medical care through the lives and deaths of ten famous people who passed away before the age of 40. Most of the people are from the arts (Robert Burns, Lord Byron, Charlotte Brönte, Stephen Crane, Rudolph Valentino, Jean Harlow, and Mario Lanza), but also from politics (Princess Charlotte and Eva Perón) and sports (Lou Gehrig). It is part biography, part medicine 101, and part medical prognosis. Though I am not unbiased in this case, I found the book engaging and well-written (not surprising given that the author corrected my grammar countless times at the dinner table as I was growing up).

In nearly all of the cases in the book, if these persons were alive today they very likely would live much longer due to advances in modern medicine (the possible exception being Lou Gehrig, as ALS continues to confound researchers). That is, of course, if they lived in the developed world or had financial resources to ensure access to the best health care. As highlighted in the book, deaths from diseases such as malaria (Lord Byron), tuberculosis (Stephen Crane), cervical cancer (Eva Perón) and death in childbirth (Princess Charlotte) have plummeted in the U.S. and much of the world but continue to plague poor countries and people.

For example, maternal mortality declined more than 99% over the last half of the 20th century, but rates in developing countries can be more than 150 times that in the U.S. Cervical cancer rates in the U.S. fell by two-thirds over the last 50 years due to improved screening (and hopefully helped recently by a promising new vaccine); but these interventions are much less readily available to the poor in our world. The advances of modern medicine have undoubtedly saved lives and improved the quality of life overall, but if health care is a right, we should strive to made this progress more universal.

Whom the Gods Love Die Young: A Modern Medical Perspective on Illnesses that Caused the Early Death of Famous People. Roy Macbeth Pitkin, M.D. RoseDog Books, Pittsburgh PA. 2008. 183 pp. ISBN 978-1-4349-9199-7

• More than 1.5 million children are homeless annually in the United States—one in every 50 American children.
• 42 percent of homeless children are younger than age 6.
• Homeless children have twice the rate of moderate to severe health conditions compared to middle class children, and twice the emotional problems.
• More than 1 in 7 homeless children have moderate to severe health conditions, such as asthma.
• Homeless children struggle in school, with an average 16% lower proficiency in math and reading, and an estimated graduation rate below 25%.

The report includes data for all 50 states along four major domains (extent of child homelessness; child well-being; risk for child homelessness; and state policy and planning efforts) and rankings by state, as well as a policy platform to address the problem of child homelessness.

There is a wealth of information on the report and the Campaign to End Child Homelessness at http://www.homelesschildrenamerica.org

We don’t go bowling anymore, but I think the most important thing that I had to give up was doing without my medication, because I don’t have insurance now. I can’t afford to pay for my medication for my rheumatoid arthritis. And before my daughter got her insurance, it was either I buy my medicine or my daughter’s medicine, who has a heart condition and epilepsy. And her medication is $180 for one bottle. So I gave up my medicine to be able to buy her medicine.

You can read, view or listen to how layoffs are affecting people here.

Also highlighted in the clip is analysis supported by the Henry J. Kaiser Family Foundation, which found that:

A one percent rise in the nation’s unemployment rate is projected to lead to 1.1 million additional uninsured and 1 million new Medicaid enrollees (600,000 children and 400,000 adults), increasing overall state Medicaid spending by $1.4 billion while tax revenues fall 3 to 4 percent.

For more information on that analysis, go here.

According to the Bureau of Labor Statistics, the unemployment rate in the U.S. went up 1.6 points from September 2008 to January 2009, which would mean according to these estimates that the number of people without health insurance increased by about 1.7 million. Clearly, the economic meltdown is affecting all sectors of our society and placing strains on already-overburdened safety net systems.