“All right, Ms. Wells, we come out and check on everybody,” Cox said in a tone that makes you want to put your head on her shoulder. “You had pneumonia, right?”
Cox didn’t know oak trees, but she knew how to figure out the real causes of chronic health problems. For example: when to ask people whether they could not afford their insulin, or for some reason were not taking their insulin, or were not keeping their insulin cold, or couldn’t keep their insulin cold because they didn’t have a refrigerator, or couldn’t keep their insulin cold because they did have a refrigerator but didn’t have electricity to keep it running. Not having health insurance was a huge problem in Mississippi, but it wasn’t the only one.
“So you good with doing your medicines?”
Wells made a guilty face.
“You oxygen dependent?” She was. “You know, you’re not typically overweight for us southern folk…”
Laughter. “Oh, I’m overweight,” Vonda said softly.
Wells had worked at a Jackson hospital as a certified nursing assistant for five years before she started getting sick with asthma-related illnesses. No one wanted a nurse carrying around an oxygen tank, she said, so now she was trying to work a handful of hours a week at the Four C’s, a Christian community center.
“I stayed in Illinois for twenty-five years,” she said. “I didn’t really have asthma symptoms till I came down here…”
“You been in this house?” Cox said. The house was obviously old, the rug thick, the air damp. “There’s something in the house that’s triggering it. I bet you need to get tested.” Cox made a note. “And I’m putting a little checkmark down here that you got the basic light, gas, and water … Your major problem is the asthma.”
“And congestive heart failure.”
“And congestive heart failure.” Cox paused and tilted her head. “Have you been taught how to manage your congestive heart failure? Because you should have a scale.” She looked around the house gamely as if she believed a scale might pop out from behind the TV.
“I need a scale?”
Cox explained why people retain fluid. She then asked whether Wells had checked her blood pressure and told her that on her chart her blood pressure had been at 212 over 100, which is stroke level. Wells didn’t know that, and she looked briefly bashful, but Cox had a way of soothing embarrassment away. She asked Wells how many sodas she was drinking, and explained that juice has a lot of sodium in it, too. “Knowledge is power. Okay?” Cox said gently. “’Cause you’re forty and you’re oxygen dependent. We don’t want you goin’ on a date with an oxygen tank!” Wells laughed again.
Cox said she would try to find a company who would come and test the house for toxins, and made an appointment for Wells to come back to a medical clinic. Wells got up to walk her to the door, the oxygen tube dragging the length of the house. Cox paused at one of the photographs on the wall.
“You got a beautiful family!” Cox said. She zeroed in on a slim, healthy-looking, smiling woman. “Now, is that Mama?”
“That’s Grandma,” said Ms. Wells. “She was ninety-five when she passed. I moved down here to help her out.”
I saw something dark pass over Cox’s face, which might have been the same as what went through my mind: What had happened to America? Why had the previous generation lived to ninety-five, and the current one could barely breathe?
All of the sick people I met shared a story of personal economic decline. There was Regina Huggins, a white woman in her forties who had been in the hospital twenty times in eight months, had no health insurance, and couldn’t afford a primary physician. She had worked for the Presto factory in Jackson for many years, until it closed, and after she was laid off, at the Piggly Wiggly. Neither the factory nor the grocery store offered health insurance, and after a lifetime of low-paying work she had nothing to show for it but three hundred thousand dollars in medical bills. There was Mamie Marshall, a licensed beautician who had worked for Packard Electric, a subsidiary of General Motors, and also as a bus driver for the Jackson public schools, and in her last working years as a nanny. She was dying of bone cancer. “I worked,” she said. But none of these employers—not one of America’s greatest companies, nor one of her country’s public school systems—had left her with the means to care for her health.
*
IT TOOK THE IRANIANS no less than a revolution and twenty difficult years to reform their own health care and economic disparities. Throughout the 1960s and 1970s, the Shah of Iran encouraged Iranians to become Westernized urban consumers, ignoring the concerns and plight of poor villagers living in the countryside. These policies, among many others, led to the Shah’s overthrow in 1979 and the rise of the Ayatollah Khomeini, who came to power in part because of his furious defense of the lives of the poor. Around that time, in the spirit of the revolution, a group of Iranian doctors proposed a new rural health care system. Such initiatives were what made the Islamist and Islamic movements from Hezbollah to the Muslim Brotherhood to Turkey’s AK Party so lasting; they provided basic human services.
The Iranians built “health houses” in thousands of villages, to be used by fifteen hundred people within no more than one hour’s walking distance of the house, which was a thousand-square-foot building equipped with examination rooms and sleeping quarters. They staffed the houses with community health workers, or behvarzan, one man and one woman, and gave them basic medical training. The behvarzan were trained in nutrition, they could take blood pressure, they could keep tabs on who was pregnant and needed prenatal care, they could advise on family planning, provide immunization, and assess environmental conditions such as water quality and housing safety.
It was these “health houses” that Dr. Shirley, and his Iranian partner, the academic Dr. Mohammad Shahbazi, wanted to imitate. The behvarzan came from the villages they would serve. Rural Iranians wouldn’t trust people they didn’t know, something that struck Dr. Shirley as similar to poor black patients unlikely to trust white people from the city. The behvarzan got to know many of their patients from birth. Even during the most brutal years of the Iran-Iraq War, the Iranians implemented their plan, and today, seventeen thousand health houses have served twenty million Iranians. The idea of building seventeen thousand health houses seems daunting, but to Dr. Shirley, the system’s great appeal was its simplicity.
When Dr. Shirley went on his tour of Iran in 2009, he noticed that some of the men did not look happy about the Americans’ arrival. While inside a teahouse, one Iranian man said to Dr. Shirley’s translator:
“What are the Americans doing here? Did they come back to ruin our country again?”