Doctors worry that they are likely to spread disease in epidemics because of inaccessibility or fear of treatment.
By LISA GREENE
Published December 7, 2003
ST. PETERSBURG - Lucy Mitchell got sick last month, so sick that she thinks she had the flu.
But Mitchell didn't go to the doctor. Since she lost her job in September, the 35-year-old St. Petersburg resident has no health insurance.
"I just stay home and try to fight it," she said.
A lot has been written about the health problems of uninsured people such as Mitchell. But their individual struggles to stay healthy aren't what keeps infectious disease specialists up at night.
These doctors see two trends headed for a deadly meeting: The number of the uninsured is rising as concerns about the danger of bioterrorist attacks, such as anthrax, and emerging diseases, such as SARS, are increasing.
The worry: Because the uninsured are less likely to seek prompt care, they would be more likely to spread disease in an epidemic. While the chances of such an epidemic or bioterrorist attack might be remote, doctors say that ultimately, the barriers to getting uninsured people cared for could help infection spread farther and faster than it otherwise would.
"We need to try to fix the American public care system," said Dr. John Sinnott, director of infectious disease for the University of South Florida and Tampa General Hospital. "An obvious place the system breaks down is with infectious disease. If you don't give people access to health care, other people can get infected."
Nationally, there were 43.6-million people who had no health insurance for all of 2002. In Florida, the uninsured grew to 2.9-million in 2001, about a 20 percent increase from 1990.
Those who advocate for the uninsured often point to the health problems they suffer by delaying care: tumors that grow unchecked, untreated diabetes that leads to blindness or amputations. A 2001 Commonwealth Fund survey found that 40 percent of the uninsured had no regular doctor.
What worries infectious disease specialists, however, is the ripple effect, the chances that an uninsured person's illness will affect society as a whole.
"It's not just their bad luck," said Dr. Juan Dumois, chairman of the infectious disease division at All Children's Hospital in St. Petersburg. "It affects all of us."
Dr. Anthony Iton, a member of the board of the National Association of City and County Health Officials, calls the problem "the 800-pound gorilla."
His nightmare scenario goes something like this: Suppose SARS shows up in the United States this winter, a fear being widely discussed by doctors. Then suppose that the first people to contract the disease have no insurance. The victims begin to cough and have a slight fever. But, not knowing that SARS is a threat, they don't see doctors immediately. And, with few benefits and little income, they don't call in sick but go to work, where they spread the disease to others.
Not until they have more severe symptoms do they go to the emergency room. Then, they are put in hospital isolation rooms, and their family members are checked for symptoms. But by then, they already have spread the highly contagious disease to dozens of others, who in turn spread it further.
"The evidence is clear that people without health insurance delay and defer seeking health care," Iton said. "SARS would be no different. ... An uninsured resident is going to think this is a cold and delay seeking care as long as possible until they become very, very ill."
Iton, who runs the health department in Alameda County, Calif., has written a resolution for his association urging the federal government to address the vulnerabilities that the uninsured present for controlling bioterrorism and infectious diseases.
Sinnott pointed to Canada, where the largest outbreak of SARS outside of Asia occurred in Toronto. Almost 250 people became ill and 39 died.
"One of the reasons SARS was readily contained in Canada is because people were afforded easy access to the health care system," Sinnott said.
Not everyone buys this scenario. Because there's no cure or specific treatment for SARS, identifying patients earlier might not make a difference, said Dr. Bruce Flareau, director of medical education for Morton Plant Mease Health Care. Flareau also is director of the Turley Family Health Center in Clearwater, where he sees uninsured patients every day.
"It doesn't make them any less infectious," he said.
But Flareau still worries about infection and access to care.
"In diabetes, the person who suffers is the individual," he said. "With infectious disease, the person who suffers is the community."
Flareau is most concerned about diseases that are preventable because of vaccines. Small outbreaks of measles, pertussis and other once-common diseases keep cropping up because people, often those who aren't insured, don't get vaccinated.
With the increasing immigrant population in Clearwater, Flareau said he is seeing cases in which parents were afraid to get children vaccinated for fear they will be deported.
How big a problem lack of access might be depends upon the disease. The biggest effect likely would be a disease such as SARS or influenza, where the first symptoms are mild and easily confused with the common cold.
But what if there's a bioterrorist attack? Federal officials have talked about the problems of getting care to the uninsured and have told public health and hospital officials to include them in their plans, said Charles Schable, director of the bioterrorism preparedness and response program at the Centers for Disease Control and Prevention.
"Let's say a crop duster flies over St. Petersburg and flies anthrax over the city," Schable said. "The most important thing is to get Cipro in people's mouths. We're not going to ask for people's insurance cards."
Federal officials have planned for distributing Cipro, an antibiotic used to treat anthrax, in community centers and at nongovernment sites, Schable said, because they realize illegal immigrants and others distrustful of the government would be reluctant to seek medical help at government sites, even in an emergency.
Those plans are good, Iton said. But a visible attack isn't what he worries about. If terrorists don't announce an attack, the uninsured could delay the detection of illness.
"The earlier we can detect something is occurring, the better chance we have of saving lives," Iton said. "Any delay in people presenting to the medical community with their symptoms is time we've lost and can't reacquire."
So how to solve the problem? Advocates for the uninsured have a quick answer for the threat.
"This is another reason for making sure everyone has insurance coverage," said Dr. Georges Benjamin, executive director of the American Public Health Association.
A disease outbreak whose spread was scientifically linked to uninsured people might motivate politicians to advocate universal care, Dumois said. Still, universal care is a political issue all its own, and its passage would require a major campaign.
Another possibility is suspending Medicaid eligibility rules during an outbreak, so uninsured people easily could get coverage. Iton pointed to New York, which provided disaster-relief Medicaid after Sept. 11, 2001, largely because so many people were out of work and had lost coverage.
But providing coverage after the epidemic arrives, Sinnott said, is "locking the door after the horse is gone."
In the meantime, caring for the uninsured falls largely to hospital emergency rooms and community clinics, such as the Judeo-Christian Health Clinic in Tampa and the Turley Family Health Center.
Elizabeth Ortiz, 20, is a patient at Turley. She recently brought her 1-year-old son, Ismael, in for a checkup. Through an interpreter, Ortiz said she doesn't put off going to a doctor if she gets sick, because she knows she can receive care at Turley.
But Dr. Brandi Phillips, who treated Ismael, said too many of her patients find Turley after long periods without seeing a doctor.
"Some of them have gone years without care," she said. "I recently saw a gentleman who hadn't gotten health care in three years, even with a 50-pound weight loss."
Even so, those clinics treat only a portion of the area's uninsured, Flareau said.
"It's kind of like shoveling against the tide," he said.
- Times researcher Kitty Bennett contributed to this report.
