Sermon: Holiness and Health

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Holiness and Health

By Charles Rush

September 6, 2009

[ Audio (mp3, 7.5Mb) ]

yone involved in health care these days knows just how difficult the situation really is. About 5 years ago, I attended a meeting with the Chief Administrator at Overlook Hospital in which we reviewed three different scenarios: bad, worse, and apocalyptic. It reminded me of a commencement address given by Woody Allen many years ago in which he told the graduates: “More than at any time in history, humanity faces a crossroads. One path leads to despair and utter hopelessness. The other leads to total extinction. Let us pray we have the wisdom to choose correctly.”

I started out in ministry as a chaplain in the emergency room at the University Hospital in Louisville, Kentucky, in the early eighties. It was colorful work. University was a public hospital and a teaching hospital right downtown. It was over a hundred years old when I worked there, designed for an era before electric lights, with large open wards that held up to a hundred patients. On those floors you had a little bit of everything. It wasn't unusual at all to see policemen with prisoners. The prisoners had their legs chained to the bed and the police guarded by setting next to them. There was always at least one indigent fellow that was on the ward drying out. Usually they had the DT's so bad that they had to be tied down to the bed with towels to keep them from hurting themselves or someone else. They had a low level moaning or kvetching or complaining that the staff was trying to do them in for good. Some of them could moan out for an hour at a time “help me, won't someone help me.” Help in this case would be a fresh bottle of MD 20/20 and a pack of smokes. No one on the ward ever had a spare bottle, least of all the chaplains, so we heard a lot of moaning. And there were a lot of people there that were seriously injured. We were a regional trauma hospital, so all of the accidents with 100 miles of Louisville were medevac'ed in to our emergency room.

I had a quick immersion into the health care in the life of the poor in our country that summer. Some of it was oddly humorous. The first week I was there, we had a woman that came walking into the ER covered from her head to her waist in blood. She stood about 6'3”, weighed in the range of 350 lbs., strode straight ahead and demanded instant service as she was in a hurry. When the staff saw blood everywhere, they panicked. It turns out they were all superficial wounds. One of her neighbors owed her $50. She sent her boys over to collect payment to no avail. She called him up and he stopped answering the phone. Finally, on Saturday night, she needed her money to get some Malt liquor and she went over to his house herself and began rapping on his door. And she rapped and she rapped and hollered at him for the whole neighborhood to hear. She wasn't leaving ‘til he came out and gave her some money. This went on for quite some time. I guess he had enough and opened the door with a shotgun. It was a very light weight gauge and apparently loaded with the lightest bird shot. She stepped back off the porch, he fired, she fell to the ground and jumped straight up. Unfortunately for him, it was only a single shot and she was on him before he could say boo. Got in quite a few good raps on his head. Now they were both in the ER, with neighbors and extended family. They called the Chaplain to keep the peace down in the waiting room. I'll never forget asking one of the residents exactly what I was supposed to do. He said, ‘keep them from stabbing each other.' The high and holy calling of pastoral ministry. Indeed, some of them were planning a bloody revenge. It was a long night.

Most of the time, there were just low-grade tragedies that you never really read about in the paper because these people aren't that interesting. One night, I got over to the hospital to meet the ER team. They were working on a guy about my age. At the time, I was 23.

He was laying on the OR table in the emergency room, completely red and the doctors were taping as fast as they could, while others were sewing. He had a gash that ran from the bottom of his big toe, up his leg to his hip, up his torso to his shoulder, up his neck and across his forehead. I asked the attending what happened. He looked back at me and said, ‘He wrestled with a saw and lost.'

His wife was in the waiting room, as tiny as he was big. She couldn't have weighed more than 100 lbs and he was my size. She had a baby with her and another one on the way. They were farmers from southern Indiana. He was a man of very limited education. She was a simple, country girl, poor, uneducated. I remember thinking that she was very accomplished but she had modest intelligence and minimal exposure to the world.

They rented their fields, which means that you work very hard all year and barely make more than your produce. In my brief time in the farming community, I used to think that sharecropping today is probably not much different than it was 130 years ago.

They were cutting trees on the property. Fortunately, she'd gone with him that day. He was on the tractor and was using a circular saw implement cutting trees. She was nursing the baby in the truck, listening to the country radio when she heard something awful down below.

She ran down the hill with her baby, found the tractor still running, her husband passed out on the ground. The circular saw had sheared a pin, the blade came loose, hit the soil, bounced toward her husband and essentially ran right up him, cutting him literally from toe to head.

I wish you could have seen this little woman. She was in shock but what a tough gal. Without wasting a minute, she put the baby down, picked her husband up, threw him on her back, leaned down, picked up that baby and carried her husband about 400 yards up a ravine to the truck. Somehow, she pushed him up on the hood of the truck, so that he rested on the windshield, and drove down a dirt road about 2 miles to the state highway. Did I mention that she was pregnant? Tough woman.

She parked her truck in the middle of the highway, got out, and stopped the next car she saw. They drove to the nearest farm, called 911 and they medevaced this guy 70 miles to the hospital. She was sitting in the waiting room all alone, telling me this story rather matter-of-factly. I know people that come completely unglued because someone cut them off on the Garden State Parkway. Country people often have this remarkable stoical way of handling these grave tragedies like this is to be expected as part of our living.

I could not believe that he could live. I could not believe you could lose that much blood. But somehow that incredible team of med students sewed and sewed. It was several thousand stitches but they sewed him up.

I saw her for the next several days, little by little, she would tell me about her situation. They rented. She had no people near here that could help them. His people were largely dead. She worked and was worried that she would lose her job at the grocery store because she had taken this time off. She didn't want to see a doctor but she was sore. She didn't have a doctor for her baby. She didn't know what she would do with her husband down.

He ran a fever from the beginning. It got worse, every day a little worse. The antibiotics could not contain the infection. I got a call one night and met her in the ICU with the doctors. He died. The resident and one of the interns were privately in a rage about the futility of the situation and feeling like somehow they had failed. She was just flat when we came to talk to her. She knew why we were coming together. We sat together for quite a while in silence. After a while, I walked her outside in the humid night air. We stood there for a moment and I asked her what she was going to do? “I don't know” she said. And she turned and walked away.

In a weird way, I liked University Hospital, mostly because everyone was there. In one afternoon, I met a biology professor that wanted me to read the book of Mormon with an open mind- and let me tell you that takes a very open mind- and visited with the Outlaws, the motorcycle gang, because one of their girls had been shot. Over and over in the midst of a religious conversation, I had to remind them, you can't smoke in the ICU hallway.

There are lots and lots and lots of people in our country that live on limited incomes, have special needs, were born with limited abilities. The ER in a major urban hospital is like jury duty, you meet all of them there. In a strange way, I like that, because for me, morally speaking, we all ought to have about the same access to health care.

That summer was the beginning of the era in which we now live. That summer a health maintenance organization, Humana, began buying up hospitals in Louisville. I believe there were 9 hospitals and Humana bought up 6 of them. You may recall that apocalyptic predictions were on the forefront of medical care in the early 80's. Costs for fixed care were projected to grow at double-digit inflation, the state born cost of covering indigent care expected to continue to grow to the point that we were predicting fiscal insolvency for most of our hospitals. Everywhere the cry was heard for controlling costs and this was the great promise that management teams like Humana promised. With wholesale scope for services and cutting unnecessary tests and procedures, health care premiums would be held in check and affordable for the broad middle class in our country.

At the time I was dubious about this approach and I continue to be dubious about it, though it is clear that we have a serious issue on our hands. I am dubious because of the original mission of our hospitals.

Up until the 80's if you went to the vast majority of the cities in our country, you could go to the University hospital, the teaching hospital. Usually there was also a General Hospital, often also the teaching hospital. Often there was a County regional hospital. And almost all the rest were religious. There was a Baptist Hospital, a Methodist Hospital, a Catholic Hospital, a Jewish Hospital. That is because health care was considered to be a mission outreach of the Church and Synagogue and if we'd had more Muslims settle our country, it would be an outreach of the Mosque too.

These hospitals had a mission of to heal out of spiritual convictions. Very often they took their mission statement as a version of our gospel story this morning. A man was sick and in need of healing. He couldn't bring himself to the healer, Jesus. So his friends carried him. The house was too crowded for him to get in, so they opened the roof. They got him what he needed. And this was the way that the administration of these hospitals ran. They had people in charge that were medically trained but also a lot of people with a spiritual disposition. The boards were comprised of good Catholics at the Catholic Hospital that thought about what they were going to do and not going to do in light of what it meant to be Catholic. And there were a number of Catholic volunteers in these hospitals who were there because Jesus taught us that being a good neighbor means binding up the wounds of those who are in need and that is what they wanted to do. No question, these hospitals didn't always live up to their mission statements but they had a mission statement and that was important.

After Humana bought up these hospitals, they changed their policy towards indigent care. Unless it was a life-threatening emergency, they stopped admitting patients who didn't have health insurance. Legally there was nothing to prevent them from doing that. There was nothing illegal about it but there was something profoundly immoral about it. Since they didn't advertise it, we first noticed it at University Hospital because there was a mild to substantial increase in our ER traffic. University Hospital had no choice but to admit all patients. We were a state hospital, not a private one. After a few months went by, University was swamped with indigent care and we began hearing stories from our patients that had been sent over to us in labor, with broken arms because they were uninsured and not eligible for Medicaid.

We were incredulous. The whole system had worked in the past because each hospital bore some of the indigent care and absorbed it into their overall operating budget. The University Hospital always had most of the indigent care, but we didn't have all of it. For many of the physicians, it seemed tantamount to a gross violation of the Hippocratic Oath, which has a clear pledge to work for the social health of the community, not just the wealthy patients.

And for some of us, it was an ugly reminder of a by-gone Jim Crow era when black folks in the South were only admitted to colored hospitals. There were many tragic stories from that era, like that of the great Jazz Singer Bessie Smith, who was on tour with her band when they were involved in a terrible car accident. The white hospital wouldn't treat her for racial reasons. After a prolonged argument, she died en route to the colored hospital on the other side of town. It is just not right.

After a few months of this went on, University Hospital had a series of meetings because they were projecting that they would go bankrupt in a matter of months if nothing was done about the situation. Disaster was averted but a fundamental shift had taken place. Medicine was no longer a community wide spiritual mission. It was now simply a professional service that was offered on contractual business terms. It was a small step over a cavernous crevice from saying that medicine needed to reign in costs to deploying business managers to run the hospitals like corporations. The poor remain an ethical obligation, sure, but now the challenge is primarily understood as a legal liability rather than a mission. The difference is huge.

We remain in the midst of those throes into the foreseeable future. A couple years ago, I got a call from a friend of mine, a physician near retirement. He explained to me that his hospital recently got a grant from a family to renovate a whole floor in the hospital for what we might call Platinum service. Every room on this floor would be private, replete with a number of amenities not presently available- internet access, some valet services, a private Chef for the floor. The idea was to create a first class hospital experience. There would be a charge on top of your normal insurance payment that would come out of pocket. With the grant for renovation, the idea was to keep the extra daily rate slightly above the price for a premium hotel. Interest in the project was brisk.

He made an observation that I have heard repeatedly from people in the medical field who have been at the work for many years. We are rapidly moving towards a four tiered system of health care in this country. First, there are those that can afford to pay premium price, partly out of pocket. They have access to features that are simply phenomenal.

Secondly, there are those that are those that can afford the HMO benefits. In all ways, this group looks increasingly like the harried economy travelers on a marginal airline -- cramped seats, booked full, maybe a bag of peanuts, circling the Newark Airport for an extra hour and a half.

This group has to be advocates for their health care, particularly if they have specific medical needs. I've heard dozens of stories of Primary Care Physicians that refuse to refer kids with allergies to an allergy specialist, for example. Patients feel like they have to aggressively advocate their cause because Primary Care Physicians are rewarded for limiting the number of referrals they make. I don't know of anyone, patient or physician, that likes being in an adversarial,Helvetica position. As one writer for The New Republic put it months ago, any system that pits the economic interest of the physician against the medical needs of the patient is doomed to failure.

If you are lucky enough to actually get the service you need, most of the time you get a letter from your HMO listing a number of reasons that the care is not covered under your plan. It usually is, but in order to get the proper payment, you have to make half a dozen phone calls to the medical group back to the HMO. It is a bureaucracy that is byzantine to the point that it makes you long for the old Soviet Union. You can't make this up.

And then there are the abject poor that are covered under Medicaid. Their treatment is time intensive, inefficient, - often below what people should have to endure. But it is available and the costs are borne by the taxpayers. These folks swell the Emergency Rooms of our teaching hospitals and are the first patients our medical interns and residents get to treat- often outstanding care as a result of their care.

Finally, there is a class of people you might call the working poor. They do not qualify for Medicaid and they can only afford medical insurance for a portion of their life. It is not a perk for their jobs and budgeting for it requires them to forfeit something else that is dear. A sizeable portion of this group cannot rely on a steady income and thus periodically find themselves either uninsured or underinsured. A prolonged or serious illness would devastate their fragile economies. You know who these folks are. They clean your house. They cut your grass. We buy fruit from them at the little grocery in Manhattan on the way to the office. They push carts. They drive limos. They hawk tickets and ball caps at Madison Square, etc., etc. Experts who study this problem are worried that this group is growing too large.

I do not know what the answer to this problem is, though I spend an increasing amount of my time thinking about it. And that is not the point this morning. We have an issue on our hands that must be solved by this generation. In so many aspects of our world, we tend to presume that if we simply allow the logic of the market to run its course, a solution to our situation will eventually emerge that will sort the whole situation out. In this case, it would seem to me that the logic of our market forces is actually at odds with our spiritual and humanitarian impulses. And therefore, the solution to the problem will be complex and structural. I apologize, to you. I wish I could wrap this up neatly with a bow and I can't. I can only come back to our text which has a fresh poignancy in our era. We have friends who are in need of healing. We are going to have to carry them to where they need to go. And if need be, we may have to dismantle the roof of the building and lower them down so that they can get the healing touch that will make them whole. Amen.