The Bottom of the Health Care Rationing Iceberg

A stink filled the room as my patient eased coal-black toes out of his shoes. After spending winter nights in a tattered sleeping bag behind a local grocery store, he had developed frostbite and then gangrene.

In the hospital, we gave him intravenous antibiotics and debrided the dead tissue from his toes. Soon he felt better. He was enjoying regular meals and the kind at- tention of his nurses. Each day, a new crayon portrait of his life on the street went up on the walls, scary scenes depicted in bright colors and childlike simplicity.

When the hospitalist said he was getting ready to discharge him, the patient’s nurse shook her head and crossed her arms. “How is he supposed to heal if he goes right back out to the streets?” she asked.

She wasn’t wrong. More than one in four discharged homeless patients is readmitted within 30 days, according to a recent study by a team from the Boston Health Care for the Homeless Program.

The hospitalist noted that the patient would have been dis- charged much earlier if he hadn’t been homeless. “But is hospitalization really the cure for home- lessness?”he asked, as he ran a finger down a list of emergency department patients waiting for a hospital bed. “Don’t we owe them something, too?”

There it is, I thought: the bottom of the health care rationing iceberg.

To read more, including about the contrast between our careful efforts to allocate mechanical ventilators amid the COVID-19 pandemic and the haphazard way we leave the homeless and others out of health care resource allocation on ordinary days, check out my new essay up at The New England Journal of Medicine.

World AIDS Day 2016

As World AIDS Day approaches on Thursday, there is so much to be thankful for, and so much work yet undone.

People with HIV on effective treatment live as long as those without HIV, and almost never transmit HIV to their seronegative partners. Pre-exposure prophylaxis (PrEP) is safe and it works, and through it and other means of prevention we are slowing the epidemic, bit by bit. This fall a new vaccine aiming to build on the RV144 success story began testing in South Africa.

Despite those massive successes, 2 million more people are newly infected with HIV every year. Less than half of the world's HIV-positive population can access HIV therapy. In the United States, only 30 percent of people with HIV achieve the goal of full virological suppression on medications. A substantial fraction of people living with HIV don't know they are infected, and stigma is still a problem for people with HIV.

HIV is the defining health threat of our day. We have made real progress, but we cannot be complacent. It was a honor to discuss these issues and more for NHPR's Exchange radio show.