Limited-Resource Medicine, Part III: Where the Conditions Are

The conditions the diploma trains for are in most of the world. They are also here.

This is the third and final essay in the limited-resource medicine sequence. Parts I and II argued that "tropical medicine" is a misnamed category and that the medicine it actually teaches is limited-resource medicine. This essay is about where in the United States the conditions exist and what naming them honestly would require.

The conditions are concentrated in identifiable places. The data on the disparities they produce is published and unambiguous. The policy mechanisms that maintain the conditions are nameable. The reason the country has not built a medical category around them is not that the medicine is absent. The reason is that the country has not been willing to name what it would have to confront if it did.

The Geography

Limited-resource medicine is the actual practice of medicine in the following places in the United States.

It is practiced on the Pine Ridge Indian Reservation in South Dakota, where Lakota life expectancy is approximately twenty years lower than the national average and where the Indian Health Service facility responsible for the population's medical care has been chronically understaffed and underfunded for the entirety of its existence. It is practiced on the Navajo Nation, across Arizona, New Mexico, and Utah, where similar IHS dynamics intersect with vast geographic distances, limited specialty access, and disease patterns shaped by uranium mining contamination, food insecurity, and the structural legacies of forced relocation. It is practiced at the Winnebago Comprehensive Health System in northeast Nebraska, where the tribal health center I work in serves the Winnebago and Omaha tribes under similar resource constraints.

It is practiced in the Mississippi Delta, where the majority-Black agricultural communities of the historical cotton belt have some of the highest poverty rates, lowest life expectancies, and most attenuated medical infrastructures in the country. It is practiced in the Alabama Black Belt, in the rural counties of South Carolina, in parts of Louisiana, in eastern Texas. These are not regions where "global health" is the salient framing. They are regions where the same operating conditions exist that the global health curriculum was built to address.

It is practiced in Appalachia. The mountains of eastern Kentucky, southern West Virginia, southwest Virginia, eastern Tennessee, and western North Carolina contain medical environments with limited specialist access, high rates of chronic disease shaped by mining occupational exposure and intergenerational poverty, and a rural hospital landscape that has been contracting for two decades. The patient who has driven two hours to reach the clinic and whose follow-up will require another two-hour drive is the patient the limited-resource framework was built for.

It is practiced in urban communities of color across the country. South Side Chicago. North Philadelphia. Parts of Detroit, Baltimore, Memphis, the Bronx. These are not regions of geographic isolation. They are regions of structural disinvestment. The hospitals that closed there closed because the population could not pay enough to keep them open. The clinics that remained are limited-resource clinics. The medicine they practice is the medicine the diploma trains for.

It is practiced at federally qualified health centers across the country, serving immigrant, undocumented, and low-income populations. OneWorld Community Health Center in south Omaha is one such facility. There are roughly fourteen hundred FQHCs in the United States serving roughly thirty million patients a year. The medicine practiced at those sites is, in operating terms, what the diploma was built to train.

This is not a marginal patient population. This is tens of millions of Americans. The medicine that is being practiced for them is limited-resource medicine. The country has not been willing to call it that.

The Data

The disparities the conditions produce are documented in the federal data the country has been producing about itself for decades.

American Indian and Alaska Native maternal mortality is roughly twice the national average. Black maternal mortality is roughly three times white maternal mortality. The country with one of the highest per-capita health expenditures in the world has a maternal mortality rate higher than every other wealthy country and, in some demographic subgroups, comparable to middle-income countries with persistent internal inequality.

Type 2 diabetes prevalence in some tribal communities exceeds twenty percent of the adult population, among the highest rates documented anywhere in the world. Cardiovascular mortality is approximately thirty percent higher in Black Americans than in white Americans, with persistent gaps across age and geography. Infant mortality in some American communities approaches rates seen in middle-income countries. Life expectancy in some United States census tracts is more than twenty years lower than in adjacent tracts, a gradient steeper than the gradient between many wealthy and low-income countries.

Tuberculosis prevalence in the United States is overall low, but among foreign-born residents the rate is more than ten times the rate among the US-born. Hepatitis B prevalence is similarly elevated in immigrant populations from endemic regions, often without prior screening. HIV prevalence in some demographic subgroups in the American South approaches rates seen in sub-Saharan Africa.

These are not exotic findings. These are the documented epidemiology of structural disadvantage in a wealthy country. They are produced by the same forces that produce comparable epidemiology elsewhere — concentrated poverty, attenuated infrastructure, historical and ongoing exclusion from the resources that support health. The framework that the tropical medicine literature has built across more than a century is the framework these populations require. The framework has been there. The country has been pretending the populations have not.

What Naming It Would Change

A medical system that named limited-resource medicine as a clinical category, and named the populations that require it as the populations of the United States rather than of somewhere else, would have to do several things differently.

It would have to fund the Indian Health Service at parity with its statutory obligations. The IHS per-capita funding has been a fraction of Medicare per-capita funding for decades. The gap is documented. The closing of the gap has been recommended by every commission, advisory panel, and federal review that has examined it. The gap remains. A medical system that named the conditions would not be able to maintain it.

It would have to fund federally qualified health centers at levels stable enough to support the medicine being practiced there. The Community Health Center Fund has been on a cycle of continuing resolutions and short-term extensions for years. FQHCs are operating limited-resource medicine in the United States and the funding mechanism for them is itself limited-resource.

It would have to expand Medicaid in the states that have not done so. The non-expansion states are concentrated in the South and contain a substantial fraction of the population practicing limited-resource medicine in the United States. The non-expansion is a policy choice. The mortality data showing the cost of that choice is published.

It would have to teach limited-resource medicine in medical schools as core, not elective. The current curricular treatment of global health as elective is sustainable only because the relevant medicine is positioned as something done somewhere else. Once it is positioned as the actual practice of medicine for tens of millions of Americans, the elective positioning collapses. The curriculum has to move into the required years.

It would have to fund residency training at FQHC, tribal, rural, and urban-disinvested sites at levels appropriate to the training value those sites deliver. The community health center residency model, of which the program I help direct is one example, was built on the recognition that primary care in limited-resource conditions is the actual practice of medicine for a substantial fraction of American patients. The model is underexpanded relative to the need.

It would have to disaggregate health data by race, ethnicity, place, and structural condition rather than averaging the disparities away into national means that obscure them. The CDC has done much of this when pressed. The reporting that should be standard is granular. The averaging that has been standard is a political choice that allows the medical system to avoid confronting what its own data shows.

It would have to recognize structural competency — the ability to recognize and engage the structural determinants of patient health — as an evaluated clinical competency in the same way that diagnostic reasoning is an evaluated clinical competency. The vocabulary exists. The evaluation infrastructure does not.

These are large changes. None of them is impossible. All of them have been argued for, in different vocabularies, for decades.

The patients have been here. The medicine has been here. What has not been here is the country's willingness to call it by its name.

This is the medicine my colleagues in family medicine are destined to practice — and the medicine where the discipline's distinctive training is fully deployed. In urban areas, pediatricians, internists, med-peds, and OB-GYNs are abundant; the work that full-spectrum family medicine is built for gets done by adjacent specialists, and the family physician's training advantage is muted. In rural, tribal, and FQHC settings, that specialty redundancy does not exist. The family physician is the obstetrician, the pediatrician, the internist, the proceduralist, and the primary contact — often the only physician within a geography measured in hours. The discipline's distinctive value is operative there and attenuated everywhere else.

Family medicine is structurally the specialty of limited-resource medicine. Its future depends on whether the discipline names that role or lets it dissolve into generic primary care.

Naming it is the precondition for investing in it. Right now the country underfunds the residency programs that train physicians for these settings, underfunds the FQHCs and tribal health systems that employ them, underrepresents the work in the curricular hierarchy of medical education, and underprices the labor of the physicians who choose it. The misnaming has made the underinvestment look like a series of independent oversights rather than what it is — a system that has not been built to value the specialty that cares for the most vulnerable patients on the planet.

The framework is in another country's curriculum. The patients are in this country. The naming is overdue.

About the author

Peter Schindler, MD, PhD is an Assistant Professor of Medicine and Associate Program Director of the Community Health Center Family Medicine Residency Program at the University of Nebraska Medical Center. He practices at Winnebago Comprehensive Health System, OneWorld Community Health Center, and Nebraska Medicine. He completed a Primary Care Research Fellowship at McGill University and holds a BSN from the University of Wisconsin-Oshkosh, an MS and PhD in nursing from Emory University's Laney Graduate School, a Diploma in Tropical Medicine from the Liverpool School of Tropical Medicine, and an MD from the Medical College of Wisconsin-Green Bay. He is board certified by the American Board of Family Medicine. The Interprofessional publishes new essays every week at the intersection of medicine, nursing, and the clinical knowledge that lives between them.

Disclaimer. The views in The Interprofessional are Peter Schindler's own and do not represent the official positions of the University of Nebraska Medical Center, Winnebago Comprehensive Health System, OneWorld Community Health Center, Nebraska Medicine, or any other affiliated institution.