One city, two worlds.

The scenario is becoming achingly familiar to me: a woman in her fifties with no health insurance suffers a stroke. With luck, it is a small stroke--a "warning sign." But the patients I'm likely to see as a rehabilitation physician are usually not that lucky. The stroke is invariably large, causing significant disability. And the other familiar part of this scene? While treating her, I discover, unbeknownst to the patient, that her blood sugar and blood pressure are out of control. Undoubtedly, the undiagnosed hypertension and diabetes contributed to the stroke. So what's the back story? Perhaps she works a job that doesn't provide insurance, or she can't afford the premiums. She has mouths to feed, rent to pay, and bills. She's raising her children in a violent neighborhood where the public schools are inferior, receiving a little over half of the tax dollars per student that the wealthier suburban schools do. She takes three buses to get to work. Her neighborhood has no grocery stores with healthy food, only fast food and liquor stores. Preventive health care is not an option. The acute care hospital where the uninsured person is admitted immediately starts the process of applying for public aid. The process takes about three months--the initial months most critical for stroke rehabilitation--and in the meantime, finding an acute inpatient rehabilitation facility willing to accept a patient who is "public aid pending" is extremely difficult. Once the public aid is in place, medical options will be a little easier to find--but only a little. Fewer doctors accept public aid. An elective procedure--like a knee replacement for crippling arthritis--is almost unattainable for many public aid patients. After working on Chicago's upscale Gold Coast for twenty-two years, I recently moved my clinical practice to the Lawndale community, one of Chicago's poorest. I joined Schwab Rehabilitation Hospital, part of the Sinai Health System. Though they are only five miles apart, the neighborhoods and the health care systems couldn't be more different. Since I first learned about George Engel's biopsychosocial model of medicine in medical school twenty-five years ago and throughout my following years practicing physiatry, I've been increasingly convinced that such a heuristic best captures the scope of the problems (and potential solutions) in health care. A core principle for rehabilitation physicians is that disability is a product of both the patient and the environment. An expanded notion of this principle is now being captured in the "biopsychoecological model," which adds an environmental perspective to the social domain. I think about my young stroke patient from Lawndale in this context. She may be impaired from her stroke, but her mobility difficulties are exacerbated by lack of a wheelchair-accessible home, curb cuts, and safe public transportation systems. The environment is absolutely critical to her health and well-being, as are her medications, an appropriate diet, personal assistant services, and health care professionals who accept public aid. While these issues are not unique to Lawndale and can arise on the Gold Coast as well, the pervasiveness, scope, and severity of these issues are exponentially worse for those in the former community. So here I am--thinking more about these basic needs than whether the Lokomat or robotic therapy is the best treatment for my patient's hemiparesis. I'm lucky because my current hospital system is one of the few that provides rehabilitation services for patients who are "public aid pending," but what about her medications, medical supplies, and needed equipment? What about transportation to and from appointments? And how to get her timely, adequate personal assistant services? This latter is particularly critical as her daughter--the first of her family to attend college--is considering dropping out of school to take care of her mom. The only other viable alternative--a urinesoaked, short-staffed nursing home--is simply too heartbreaking to consider. …