For almost a decade I worked as a nurse home visitor in Philadelphia with a well-regarded program that pairs nurses with first-time moms. In the morning I would put on my backpack full of child-development accoutrements, grab my baby scale and jump on the 23 bus.
In the Center City/downtown area where I lived, life expectancy was 78 to 80 years. When I got off the 23 bus less than 15 minutes later in lower North Philadelphia, it was less than 70 years.
If you didn't mind exposure to snow, sleet, rain, beating sun and the occasional family pet slobbering a little bit on your paperwork, the job itself was a gem among nursing jobs. We got to spend time, substantial time, with patients (we called them clients), and got to witness first-time parents work what seemed like miracles.
Partnering with young moms meant I had the enormous privilege of witnessing many first breaths, first steps. I also got to attend more than my fair share of high school graduation ceremonies, rites of passage that my clients fought hard to reach.
T.S. was one 16-year-old who as she said "was not going to become a statistic." She went into labor early and her baby was extremely premature, born 15 weeks early. Although it would be months before the baby could eat by mouth, T.S., who I'm identifying by her initials because she was a minor, immediately began pumping her breast milk and saving it in the hospital's NICU freezer.
She stayed with the baby every minute they allowed her to during her immediate postpartum period, and when she returned to school six weeks after the baby was born, she continued to pump during the school day, visiting the nurse's office between classes.
When school dismissed at 3:15, she rode the bus to the Center City hospital where her baby was in the NICU and stayed until after 10 each night. If I stopped by on my way home, I'd often find her almost asleep, holding her baby in her arms while poring over a textbook propped on a tray table.
At six months, her baby was strong and healthy enough to leave the hospital. T.S. continued her junior year.
Three weeks before she was to graduate from high school, I got a call from T.S. She was crying.
"My house has lead in it and now my baby has lead poisoning." I waited for her to continue. "I did everything I could do to make my baby healthy and now our house poisoned my baby!"
She had been conscientious about taking the baby for checkups, and a simple blood test had caught the rising lead level before it could do permanent damage to her growing child. But the lead in the house's pipes and paint made the house unsafe. Her family had to temporarily double up with extended family until they could get a new apartment. T.S. spent her graduation night sleeping with her baby on her cousin's couch.
She was right; her house had poisoned her baby. In North Philadelphia, much of the housing stock is older and still contains lead paint. Programs to address the problem and help with lead abatement are under constant budgetary attack.
As health care providers, we can work hard to provide good care and even advocate for expanded access to health care, but that there are a myriad of other greater factors that contribute to people dying early. Those factors aren't within any individual's control; they that can only be addressed by the larger society. But as a culture it seems like we've decided that we're okay with not addressing environmental factors, which means we're okay with T.S's baby having a life expectancy that is almost a decade less than a baby born the next neighborhood over.
These geographic health disparities aren't just happening in Philadelphia. Late last month, the Robert Wood Johnson Foundation released a set of maps that reveal the startling differences in life expectancies among people in major American cities, including New Orleans, Kansas City, Mo., and Washington, D.C.
The RWJF website calls the maps "conversation starters," and from a policy standpoint that makes great sense. But as a health care provider working long term in areas we call "at risk" (a not very kind euphemism for "under-resourced,") I do wish the fact that we let so much of our population die so young were a conversation stopper instead.
I wish that if I started showing the RWJF maps around the average middle-class cocktail party that all talking would cease, the partygoers silenced in horror by the inequity. But instead of silence, I'm pretty sure the greatest result would be knowing nods and helpless shrugs and rescinded invitations from future middle-class cocktail parties.
Do our six stops on the subway or 15 minutes on the bus protect us too much? I would hope that hearing a hard-working mom cry "my house poisoned my baby" would move us from talking to doing.