I have lived on the Gulf Coast for all but 5 of my 50 years. I grew up in Baton Rouge, Louisiana and now live in Mobile Alabama. I was educated in the public schools during the height of the de-segregation battles and my experiences were colored by those battles in a number of ways. I ran track in high school and was in the racial minority on that team (as well as among the slowest). I have worked at South Alabama to increase minority representation in the medical school as well as the residency class. Although aware of race, I try to not let racial awareness influence my decisions in any way (and hopefully am successful most of the time).

I began thinking about race because of the events of the past week. The first was my trip to Uriah. I was asked to go and represent the Alabama Rural Health Association and speak to a group of black ministers (their word, not mine) on “ObamaCare.” As we drove to the church (go north past Little River, go over the bridge into the next county (no sign, turns out to be Monroe), take a left after the first two towns (churches, really) onto the dirt road) I couldn’t help but reflect on how difficult it was to make ends meet in this part of America. Although only 1 hour away from my home, it seemed like another country.

The ministers were acutely interested in what I had to say. I pulled up information regarding the benefits soon to be made available as a result of the passage of the Affordable Care Act and expressed my concern that state leaders may not avail themselves of these opportunities unless prodded. The ministers are very concerned about their congregants as well as their own health (which it turns out could use some help as well). The most interesting question I got was whether the reaction to “ObamaCare” was as much a function of President Obama’s race as it was his policies. Given that every President since Harry Truman has tried and failed I am more impressed by his abilities than disappointed by the reaction of some.

My second observation is a consequence of my visit to the PCPCC Stakeholders meeting in DC. Aside from the obvious contrast in settings, I remain concerned as I attend these meetings and see large corporations (Whirlpool, Boeing), government agencies (the VA, Tricare, Medicare) and large provider groups report success as they transform the process of care and see little of it in Mobile. I had a very interesting conversation about this with Allan Goroll, MD regarding reform and the South. He pointed out that the Community Health Center Movement which is vital to providing care to 20 million (soon to be 40 million) Americans got its start in Mound Bayou Mississippi and suggested that given enough interest and willing workers more surprising things have happened.

Third was an article in the New England Journal of Medicine about health care reform and Medicaid. In this article, the author reports that Medicaid has undergone a fundamental change. He reports that historically the program was seen as a poorly designed safety net, only to be used by the very poor. The not so very poor either had to find reduced healthcare or go without. As written into the Patient Affordabilty Act, Medicaid will act as a true safety net, functioning as a provider for those between jobs which provide insurance as well as a provider for those who are unable to get insurance through their jobs. In this way, Americans will be provided a coverage umbrella which will facilitate delivery of preventive and chronic disease care throughout the life span eliminating a rush to care which now occurs at age 65 (when the time for the most effective prevention has passed).

In an article by Greta de Jong entitled Staying in Place: Black Migration, the Civil Rights Movement, and the War on Poverty in the Rural South (subscription required) the politics of the South in the 1960s are cast in a different light. The farm worker was not needed, so one interpretation of the racial politics of that time identifies the lack of attempt to develop the resources for the community was a hope that the poor, uneducated black worker would move away if starved and barred from services such as health care. The story seen in this light is one of workers fighting to access services guaranteed by a federal government while local politicians fought against these efforts.

I remain concerned that the southern states  may once again try to block the federal government as they try to deliver services to the citizens (in this case health care). The New England journal article identifies seamless health care as important to our wellbeing as a society, regardless of how access is acquired. My conversation with Dr Goroll reminded me that it was as a result of Southern community activists that we have a delivery infrastructure that can be used to deliver this care once implementation occurs. The black ministers reminded me of the importance of place, community, and being on the side of right. Let the games begin.

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