By every measure, America is hanging onto its first world status by a thread. And even that is arguable. We have been in slow decline toward third world status for the last 30 years. And nothing speaks to this reality more than this country’s poverty rates. It is sad that poverty is measured in percentages and indices that are debatable at best. As in many news stories, an effort is made to personalize — to render concrete — these elusive numbers. The happiness of the person who found free fruit but could not afford it at Walmart, cited at the end of the article, is a touching story. These are the stories of real poor folks, who have seen me as patients, in rural northern California. Folks like the married couple, both of whom were on active army duty in both Iraq and Afghanistan. They left their kids with their parents while they served. They wanted to continue serving, but were informed they could not because of “military cutbacks.” They asked for job direction from VA counselors who were no help, and finally both found minimum wage jobs. Their new wages combined total less than 1/4 of their military salaries, but they still make too much to qualify for insurance. They own some land — from the family – where they are living with their children in their parents’ houses. They are wondering how they are going to pay for their children’s medical care. Like the young man who has impacted wisdom teeth and back pain from a serious accident at a saw mill. Something ran amok and tons of wood fell on his back. He cannot pay for either dental care or an operation on his back. His family has chipped in for medical marijuana. He has no idea of how to do anything except stay home, in pain, depressed, and stoned. Or there’s the older woman on oxygen who cannot lift her tank and has a bag of pills she cannot lift either. She needs me to hold her hand while she limps with great pain into my office. She has a broken hip but until she is old enough for Medicare — a year or so — mostly her friends shop for her and bring her everything she needs. What she really needs is an operation on her hip but has no idea how to pay for it. I tell her to ask her doctor for some kind of a device to assist ambulation. She says a cane is not enough and nobody will pay for a walker; certainly not for a wheelchair. Some people think Obamacare might help but have no idea what to do until then. I have seen unemployed young people who are glad they are still on their parents’ health insurance. The kinds of things I am seeing are the kind of things that missionaries see in third world counties. I know some physicians who have been discouraged from that kind of work, simply because people need basic food and shelter before they can be cured or managed. From what the people above tell me, they do not seem to have these things, either. Hanging on by a thread to our first world status? No. The thread has broken and we are third world. Now.