I take a small sip out of the styrofoam cup and taste the familiar bitterness of black coffee. It’s 7AM in the middle of the week and the wards look like a beehive with various members of the healthcare team buzzing from room to room. Some carry food, others medicines and some, like myself, clipboards. I’m a senior resident now at this University Hospital and my responsibilities include supervising a team of interns and the medical students. I glance at the list of names that I’m now well acquainted with. It is the middle of the month and many of these individuals have been here for several days. They are your typical fare — some heart failure, a mix of infections, a few social admissions who cannot be discharged and at the bottom of the list the most familiar name of all. It belongs to a woman who has been in and out multiple times over my own short career (and I imagine many former). We call her a frequent flier. She belongs to a select group of patients whom the entire residency knows. They are the ones who end up in the emergency department that you do not need to look up because you’ve already taken care of them so many times before. They come in for different reasons. — this one in particular is a chronic alcoholic with liver cirrhosis and once again she has forgotten to take her medications.

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When people say there should not be universal healthcare because people don’t take care of themselves it always bothers me. They go on to say that those that would benefit most are the ones who eat poorly, rarely exercise and do drugs.

“Why should I have to pay to keep someone healthy when I’m working hard to do the things that they aren’t” I can hear someone shouting. “If I can skip fast food, keep alcohol intake to a minimum and force myself on the treadmill then those that can’t, well, deserve what’s coming. It’s not my responsibility”.

I knock on the wooden door outside this particular patients room, we’ll call her Sally, and ask if I can come in. She grumbles something that sounds like “yes” while she’s eating her breakfast and I walk inside. I exhale quietly and take in her features that I’ve come to know so well. Her hair is short and messy, her arms and legs are quite skinny, her complexion is tinged yellow and she is an expert in avoiding eye contact. The truth is I know exactly why she is here. She’s admitted with “hepatic encephalopathy” which is a fancy term for saying she’s confused because her liver isn’t metabolizing the stuff in her body like it should be. When this happens we prescribe medicines to keep that “stuff” to a minimum but the greatest trick is getting the patient to take it. It’s one that myself, and many before me, have failed to learn with this particular patient.

“Good morning Sally, I’m glad to see you eating. I’m not sure if you remember me, I’ve taken care of you before. You seem more awake today, you were actually pretty confused a few days back and we were able to get you better with a medicine called lactulose. You actually have this medicine at home, were you taking it before you came here?” Sally continues to stare at her breakfast plate now only half full with scrambled eggs, sliced fruit and a bright yellow lemon poppy seed muffin. She shrugs and says nothing. After a few seconds I sigh and continue with my line of questioning.

I’ve heard that kind of thinking over the past few years often enough; the idea that if one person can essentially overcome his or her own obstacles then why can’t everyone else? To be honest it has always rubbed me the wrong way. Why you ask? It completely ignores the historical, financial, social, political and economical complexities that make every person’s situation so unique. It pretends we’re all exactly the same and that simply isn’t true.

Let’s forget for a moment about whether or not everyone in the United States starts off on equal footing. Maybe it really does all even out in the end (it doesn’t). That’s fine because I have another question to ask. Do sick people deserve to die? If my neighbor can’t find the means to heal his affliction and continue working to feed his family should he, his wife and children die? Is all that’s left to be said about this scenario “If I could do it, why couldn’t he?”

Later that afternoon the social worker texts me and lets me know that Sally can go back to the shelter where she came from. I promptly forward this to my interns so they can prepare for the discharge which includes straightening out her medication, preparing her follow up and filling out paperwork. Nothing has really changed from this admission from the last few. Like clockwork she is admitted, we treat her, we find out she stopped taking her medications, we educate her as to why they are important and then we send her on her way. There’s no indication that this time will be any different from the last few and if I was a betting man I’d place my money on her being back sooner rather than later.

Why do we pour so much money into healthcare and technology? I’ve always thought it was to improve the human condition. For those reading this on your laptop screens, wherever you are, what does the average human condition look like? Well, for starters, half the world’s population doesn’t even access to the Internet so if you’re reading this you’re already in the top half percentile. 757 million across the world can’t even read which is essentially the entire population of Europe and in the United States it’s one in ten people. Chances are if you are simply reading these words you are doing okay.

I bring up these examples because most people agree that these are obvious problems that need fixing. If you can’t read or have access to the Internet what chance do you really have to find success in this world? Healthcare is held in a different light however. Why? A few months after the UN reported that only half the world had access to Internet they also said the same for essential healthcare. In addition to that, 100 million people are pushed into extreme poverty each year because of their healthcare costs. If we think people should be able to access Internet and be literate why don’t we extend this to healthcare?

Afternoons in the hospital can certainly be calmer than mornings. Usually by now the important decisions have been made and work becomes less medical and more administrative. The lull provides an opportunity to practice, what truly is a rare commodity in this day in age, the art of medicine. For me on this day it means spending time talking to Sally. Unsurprisingly, because of her noncompliance she’s elicited a lot of frustration from the healthcare staff. I’ve felt it too. It isn’t frustration with her. It’s more with me. I feel like I fail, over and over again, without being able to really make a difference and this makes me feel helpless.

If you wonder why healthcare isn’t privy to the same reasoning as literacy or Internet access the answer to me is simple. If you read enough surveys, watch enough television or talk to enough people it always boils down to the same thing — we’re afraid. People surmise that somehow, if others have more, they will have less and what if that isn’t enough? We can sit here and talk about the facts. I can discuss how regardless of our per capita expenditure in healthcare (which is the highest) we rank last among other high-income nations. I can go on about how if you were to compare the top three performers the most striking similarity is that they endorse some variation of universal healthcare. These facts are well known; they’ve been in the media over and over again so if we haven’t changed our opinion now when will we?

Sally shrugs her shoulder, her most characteristic gesture. I’ve just asked if she knew why she doesn’t take her medication. It isn’t an unexpected response by now and I continue to stare at her face hidden by her messy blonde hair thinking of what else I could do or say.

“So what’s it like at this shelter?” I try in a last ditch effort to establish some connection. She eyes dart upward upon hearing this.

“It’s not that great”. As physicians we learn early when to shut up – now is one of those times.

“The people aren’t always nice there. Sometimes they steal my stuff. I have to keep a lot of it hidden but they find it anyway. I’m thinking about going somewhere else, maybe with a friend”. It’s the most she’s said to me since I’ve known her and even those few words drip with hope, dreams and humanity. I nod appreciably to her for allowing me a small glance into her world.

I don’t want Sally to die. Honestly, as I sit here reflecting on this moment and still feeling the impact of her words the last thing on my mind is how much it would cost to help her alive. Who is anyone to place a price on how much a life is worth? All I know is that no matter how many times she comes into the hospital I will do everything within reason to keep her healthy.

Maybe in a different set of circumstances she wouldn’t have succumbed to alcoholism and she also may have been able to hold a job. The truth is I don’t know what those circumstances are and I certainly don’t know what hers are today beyond the few pictures she can paint for me. I can’t judge her. The only decision to be made is whether I can find it in me to help her or not.

People often wonder if universal healthcare is needed in this country. They weigh the pros and cons and read various sources. I recommend an alternative approach. Ask yourself if sick people deserve to die. Also ask yourself if you would make a small sacrifice to help those less fortunate than yourself, those whose path through life somehow meandered into the unfortunate thicket they are now struggling to get through. If you answer yes then the only way forward is some form of healthcare in which we look out for one another. It also means you disagree with the notion that the wealthiest should live the longest or receive the best medical care. Health, like your ability to read and access the world’s knowledge is for everyone. If you, like me, think Sally does not deserve to die then you must certainly think that universal healthcare is necessary.

Patient and case details were changed drastically to protect the identity of those involved.

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