Class Consciousness!

May 15, 2007 at 2:51 am (Michael's Posts)

Huh! What is it good for!

Well, I don’t know yet. However, I’m reading a book by Sydney Lewis about Cook County Hospital (It’s called Hospital. I added it to my book list post) and various people have brought up the issue of class.

Even though this book is about a hospital in Chicago, this question applies to all of the work that we have talked about in this forum. It’s an uncomfortable question (talking about money is never easy) but it is really necessary to address for all global health folks.

A lot of people have said that the issue of class in this public medicine mecca is always there. This may seem obvious, but it’s important (maybe?) to remember. The interns are mostly from the middle or upper class and surely the doctors are mostly from a similar background. Class awareness plays a prominent role in the questioning of new interns, according to one attending physician who discussed the important questions for candidates for residency. He wants people to at least be honest and aware of the fact that there is a huge gulf between provider and patient.

Some of the time the question of race division is raised and people choose to rephrase it as a matter of class. I think that in America the two are linked deeply, if not inexorably. So we must address both and we ought to understand that they ought to be addressed together. Or must we? In my experience, it’s been a mixed bag as far as what works the best as an approach to these issues. However, I have been finding (and other race-conscious white folks I know find this as well) that if you look through all that stuff and simply be in contact with the humanity of the person you’re talking to, it works pretty well. But does this mean ignoring the differences? Does it mean discounting them?

As far as provider-provider divisions are concerned, it seems that the bottom line for the black people I have read interviews from is whether or not the white intern or doctor or fellow nurse has a funky attitude or not. I find this to be true in my own experience as a volunteer.  However, I have witnessed otherwise and I’ve talked to some of the attendings I work with now about a racial division in the clinic. They have said it’s alive and well and troublesome.

Are these divisions important to recognize? Well, doctors from well-to-do backgrounds can think that a patient’s inability to rustle up bus fare or find a caretaker for a child are poor excuses for missing a clinic appointment. In reality, these are life truths for the patient that appear as very real barriers to getting care. According to some of the health workers interviewed in the book, poor people complain about discomfort less than the more well-off. This might contribute to a tendency to report feeling “fine” when they are in pain, which in turn can make it hard to know if a medicine is working or appropriately dosed. In these cases, a class awareness contributes to respecting and working with a patient’s life difficulties instead of getting impatient with them for missed appointments.  It also helps a doctor think about how to ask better questions of their patients so as to get the best information from them.

I have also been reading that people are people are people and that we should treat everyone like a human being.  With equal compassion and care, is all this discussion of class really all that important?  That sounds flip, but if we really think about it, what part of the class discussion do we need and what part do we not need?

I’ll probably post on this more as I read and think.  Please comment!!



  1. Christine Gorman said,

    Paul Farmer talked about some of these issues at a recent lecture at NYU. I was struck by how he gently challenged the students there to take more seriously the fact that they’d one day be earning their living by providing services/advocating for “the poor.”

    His point was not that it’s wrong to make a living by trying to help poor people. But that it creates a responsibility to make sure you do it right.

  2. msoule said,

    Do you mean in the sense that Farmer was trying to instill the sense that just because they are poor people doesn’t mean that those who care for them ought to be relaxed about their standards of care? I think that this is an essential point and one that gets mixed in with the issue of lowering standards due to lack of resources. There’s a line to be drawn between material limitations and personal limitations. Both certainly exist and both ought to be fought against and rooted out. However, the former are often outside our realm of influence. The latter can be actively searched for and we ought to be on our guard against them.
    I’d be interested to know what else he had to say on the matter.

  3. Christine Gorman said,

    It’s not just standard of care. It’s also about how you allocate financial resources–including, if it comes to it, where you choose to cut.

    You’re witnessing firsthand what’s going on in Chicago. reports that there are more doctors and nurses–those people who provide direct service to the poor–being cut by comparison to adminstrators than for any other public hospital system that has gone through financial woes in recent years. That’s more than just a material limitation; deliberate choices were made.

    (See article at,171NWS8.article)

    NYU says it will make a RealPlayver video of Farmer’s talk available on the web at So keep checking there

  4. msoule said,

    You’re absolutely right. The decisions that were made were made not because there’s not enough money, it’s just not politically productive money and it’s easy to cut services for poor people. And that’s amazing that there were more health staff cut than in any other public hospital’s re-budgeting. Really not surprising but still shocking.
    What can be done to battle this kind of thing?

  5. Christine Gorman said,

    Organize, organize, organize–or at least, that’s my reading of the history of public health. Start with whatever neighborhoods or groups are somewhat more cohesive and build from there.

  6. Mesothelioma said,

    government should help poor people to improve health by providing them cheap health opertunities!

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