Something I have been struggling with since beginning to work in healthcare is the ability of individual organizations to treat an entire community. Especially now having worked in academic, private and non-profit settings, it always seems that certain segments of the population drop to the wayside. For example, working on an adolescent substance abuse research study in a university setting, our team worked with an already marginalized population of youth with substance abuse issues. However, we were constrained with whom we could reach. While we did stalk, make home visits and drive hours to accommodate participation, it didn’t always work. If the person could not find a ride to that Panera Bread or Starbucks or whatever agreed upon location for a scheduled interview, we simply did not gather information on that person. Thus, the adolescents who had the hardest time were not included; those who spent all day trying to find a roof to sleep under that night, those without a support system of any kind, those who dropped out of school and didn’t have a source of income, or those who were so deep in their addiction that an hour long interview was a crazy thing to ask of them. It is these, the most vulnerable and the most in need, who get often are excluded from research. I find this exclusion to be true in other areas of the healthcare, including those that treat patients directly.

As I learn more and more about aging populations, advanced chronic illnesses and treating the chronically ill, I have come to understand some common threads among these populations. For those near the end of their life, they are typically in their 70s-80s, somewhat equal gender breakdown, usually suffering from one of four major illnesses (CHF, COPD, cancer, debility – although diabetes is arguable another major contributor), and reliant on caregivers, just to name a few. Considering age, illness and the dependence factor, these patients are clearly a vulnerable population. The fact that any organization can care for these patients is a feat in itself. It is not cheap. In addition, caring for these patients requires coordination among multiple clinical disciplines (e.g. nurses, physicians, social workers), successful partnerships with other healthcare facilities (e.g. nursing homes, assisted living facilities) and constant communication with the entire family and caregivers of the patient. But, even within this righteous work, there are segments that are left out. For instance, persons suffering from severe mental illness may have extreme difficulty managing medications or adhering to a care plan. They may be more difficult to locate, tougher to communicate with or more unpredictable that other patients. These are the patients who get left behind, because the resources needed to care for this doubly vulnerable population are so much more than one organization can afford.

I am left thinking that when healthcare exists in silos, whether it be by disease or age or region, there seems to always be a part of that silo that is disregarded and left to fend for themselves. I am constantly wondering, who are those segments in Detroit who are being forgotten about? Where can we find the resources to serve this entire community of people? Not just those with insurance, or who live in x, y or z neighborhoods, or who are the most vocal. Is there a way to address this problem as a city as a whole, or will it have to exist project-by-project, with the risk of cutting out the most vulnerable sections of already disregarded populations? As we continue to move forward in all endeavors, not just healthcare, it is imperative to ask ourselves who is being marginalized and why.