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In a Time of Scarce Resources …

“In a Time of Scarce Resources” is a talk I gave at the Hiram College Summer Seminar on global injustice in the spring of 2006 about health and health care inequalities in the United States and their direct relationship to justice. In it I also summarize the history of the black inner-city ghetto from my book Urban Injustice: How Ghettos Happen.

I'd like to begin with a quote from Hebrew Bible scholar Walter Brueggemann:

"Something happens to a society when its wealth is reckoned in commodities, and it is stashed away for some to have and some not to have.  Some can pay and some can't.

"Something happens to a society when its 'know how' becomes sophisticated and mystifying and technical, and it is possessed by some and not possessed by others.  Some know and some don't.

"Something happens to a society when a sense of solidarity among persons yields to a kind of individuality, when a sense of belonging with each other is diminished and a sense of being apart from each other takes its place.  Some belong and some don't.

"Whatever it is that happens is happening to us.  And there is the new, powerful emergence of those who can pay and those who know and those who belong.  Very often the paying ones and the knowing ones and the belonging ones are the same ones--or at least they talk only with one another and trust one another.  They are content to be left to their own resources, which are ample.  And so the others--the ones who can't pay and don't know and don't belong--are left to their own resource­lessness."

--Walter Brueggemann

For the past twenty-some years I've worked in the inner-city of Washington with those who can't pay, and don't know and don't belong, and I’d like to share some of that with you this afternoon.  As an introduction, let me tell you about three sets of experiences.

First, over the last several years I've been assigning my students Howard Zinn's classic text, A People's History of the United States, and so I've had to read it over a number of times myself.  It's is not your usual high school history textbook but rather the story of the United States from the points of view of some of the people who lost out: Native Americans, indentured servants, tenant farmers, women, African Americans, radicals, unionists, and so on.  Zinn doesn't claim his history as the history of the US, only a history.  In fact, he says it's intrinsically impossible to write the history of anything because history comprises an infinite set of events.  All historians select from that infinite variety.  There's always a point of view.  Unfortunately, our usual histories are mostly written from fundamentally the same point of view (the wars and who won them, elections and who won them, power and who wielded it, etc) and so it's easy to come away thinking that this oft-repeated history is the history of our country.

Out of everything that happens in my classes, it's usually Zinn's book that creates the most transformation, and it's changed me, too.  I no longer see the United States in the same way.  It's not that I didn't know at some level about the extermination of Native peoples or the horrors of slavery or the savagery of the war in Vietnam.  It's more that I previously saw them as some sort of aberration of American character, allowing me to maintain my rosy American exceptionalism.  From that point of view, the political turn of the last six years has felt like a violent wrenching, a tearing of our American fabric rather than a deepening of our sinfulness.

But Zinn's cold, clear-eyed perspective on our history reminds me that we've been supporting brutal, anti-democratic dictators for years, waging deadly aggressive wars on smaller countries for decades, torturing people for centuries, and favoring the rich over the poor forever.  That's not, of course, all that we are.  But that's part of what we are.

The second set of experiences has been my practice of medicine and my work at Joseph's House over the past two decades.  When I first arrived in 1983, I was quite overwhelmed by the brokenness of many of the people who came into my office.  Communication difficulties, missed appointments, important medications not taken, to say nothing of addictions, abuse, joblessness, single-parenthood, and violence sent me veering toward that point of view that blamed my patients for their poverty.  If they couldn't get themselves in to for a specialist consultation we'd arranged or in for a well-child check … well, no wonder they were poor.

Fortunately, I hung in there and slowly my patients educated me.  It was a gradual process but one event stands as a marker.  Margine was a young woman who'd been a patient of mine for several years.  One day she visited my office with Robert, her son, almost two years old. 

Robert had a minor viral illness and was understandably a little crabby.  As I interviewed Margine, Robert slipped off her lap and wandered over to the toys in the corner of the room.  Soon, many of the toys lay scattered about as Robert rummaged unsuccessfully for something he might like.  Suddenly Margine noticed, sprang up, and grabbed her son's arm, yanking him away from the toys, scolding, "Stop messin' with the doctor's toys.  You always be gettin' into trouble."  I tried to suggest gently that the toys were there to be messed with, but Margine locked her son onto her lap.

Some minutes later as I was examining the child, I tried to get a look into his ears.  Predictably enough, Robert jerked his head back and started crying.  Margine's response was to shake him again, whack him on the bottom and scold, "You sit still for the doctor!  You always be bad like this!" 

I found myself furious with Margine.  There were other indications that she might be abusing her son--our receptionists had seen her strike the boy in the waiting room--and her behavior in front of me certainly supported our suspicions.  But a little reflection soon convinced me that--while my anger might have been appropriate--directing it at Margine wasn't. 

For Margine was at the time still fourteen.  I'd been her doctor since she was eleven, and I knew about her own history as an abused child.  Margine's mother Margaret was also a patient of mine; she'd been a heroin addict during Margine's entire childhood and had simply not been available as a parent, so Margine was passed around from relative to relative, living in constant chaos.  Margine had become sexually active by the time she was eleven, and all our attempts to provide her with counseling or birth control were futile.  She even hinted from time to time that she wouldn't mind having a child so she could have someone to love her, so she could be important in the community.

But now Margine and Robert were locked in.  They lived in a neighborhood of unspeakable violence where everyone has a family member or close friend who's been killed.  Violence is so endemic that many inner-city children simply don't expect to live into adulthood.  In our cities we segregate all the poor so that in their neighborhoods only poor people live.  There are few jobs and none of them pay an unskilled worker enough to live on.  The school system was--is chaos; more than half of the kids in our neighborhood drop out of school before graduating, and the ones who do "make it" are two years behind national norms. 

We could go down the list of things that most of us believe everyone deserves--a decent education, a neighborhood relatively free of violence, a job on which one could support a family, housing that one could afford--and we would discover that none of these has been available to Margine. 

So whose "fault" was this abuse of Robert?  Who could I blame?

Now, in fact, most of my patients weren't like Margine at all.  Most of them were doing the best they could within a system that was stacked against them.  But the ones who stick out in my memory are those who wouldn't (or couldn't) connect with my program.  In time, I understood that much of this behavior came from their history of abuse and abandonment.  With even more time, I stopped blaming the men and women who came into my examining room for their limited ability to cooperate with me.  But it still upset me.  It still frustrated me, made me angry, sometimes made it very difficult for me to give compassionate care to the person in front of me.

But after a while, even that changed.  After a while I began to realize how hard almost every one of my patients was struggling to do the right thing.  Abusive of her children?  Maybe, but also abused herself and sometimes desperately unhappy with her behavior.  A part of the violent drug culture?  Perhaps, but also tender toward his newborn baby.  My eyes were opened even further after we'd moved into Joseph's House and began to know the men there more intimately.  Here were men almost all of whom had been to prison, many of whom had lived a violent life before coming to the house, and who now had AIDS.  Yet in an environment of love, acceptance, and nurture, they were no different from any of the rest of us, broken but struggling to be the person they dreamed of. 

It took me years before my heart was changed and my eyes could see that every one of them was doing the best he could with what he had.  Some of the people I've worked with are very broken people.  In many cases, that brokenness will never be healed.  And to blame them for that is to miss a much deeper truth! They'll continue to frustrate us, but it's also possible for us to grow so that their wounds break our hearts rather than harden them.   

My third experience--to complete this rather extended introduction--was reading Paul Farmer's book, Pathologies of Power.  Farmer, as most of you know, is a Harvard medical school professor and infectious disease specialist who spends most of his time caring for patients at his AIDS clinic in Haiti and other places around the world. 

He writes of consulting in the Russian prison system, which is experiencing an epidemic of multiple-drug-resistant tuberculosis.  The vast majority of these patients are treated inappropriately with standard first-line drugs because the prison system--reeling from the Russian economic collapse--can't afford the appropriate (and much more expensive) second-line drugs, which are necessary with multiple-drug-resistant TB.  According to Farmer, the international health community--citing cost-effectiveness concerns--continues to recommend protocols calling for the cheaper yet ineffective first-line drugs and refuses to provide the Russians the needed medications … or even to document that they should have them.  Thousands are dying. 

Farmer asks the question: Is this not an abuse of human rights?  The international community--especially the northern developed countries--obviously has the resources to treat this epidemic appropriately, yet we choose not to.  How, he asks, is this different from condoning torture or other human rights abuses?

From within our current free-market capitalist economics, of course, there's an obvious response to this question.  There's only so much money in the budgets of the international organizations, and they need to spend that money in the most cost-effective way and yada-yada-yada.  But Farmer points out that by continuing to recommend the standard first-line drugs, the international health community is complicit in the human rights abuse.  The alternative--even if they couldn’t afford to provide the medications from their own budgets--would be to acknowledge their incapacity and at least blow the whistle on the political, economic, and social system that consigns these thousands to utterly preventable deaths … and may very well lead to a wider epidemic in the (mostly poor) communities from which these prisoners come.

Farmer insists that we face the reality that the world's economic, social, political, and military order confers affluence upon a minority of us, poverty on most, and destitution upon a good billion.  This poverty and destitution aren't relative terms but absolute conditions that, for instance, kill 25,000 children a day around the world, consign millions to death by AIDS, and make the median age at death in sub-Saharan Africa five years old.  The fact that the affluent do not do more to prevent these deaths makes a certain macabre sense within the free-market capitalist theology.  But what does it ultimately do to the human spirit when millions of people suffer and die every year from utterly preventable deaths, while we live in a surfeit that could easily relieve the worst of the suffering?

Okay, so that's the introduction to my talk!

My task, as I see it, is to provide some background to the domestic side of global health care injustice, and I'd like to do that by focusing on the urban, African-American ghetto.  (I focus there because that's my experience and my passion, not because that's the only, or even the major part of, US poverty.  Only about a quarter of the nation's poor are, in fact, black and only half of those live in inner-city ghettos.)  Unlike other developed countries, the United States doesn't keep usual demographic data by socio-economic class, so we don't know as much about poverty and health as we should, and we often use minority status as a stand-in marker for poverty.  In thinking about those statistics, however, we should remember that they also include the affluent members of those minorities so the reality of what it's like for poor blacks or Native Americans or Latinos is considerably worse.  But just a couple of almost random statistics:  

  • The black infant mortality rate is 2½ times higher than the non-Hispanic white infant mortality rate and the gap seems to be widening.
  • African-American women are more than twice as likely to die of cervical cancer as white women.
  • Rates of death from heart disease are 29 percent higher among African-American adults than among white adults, and death rates from stroke are 40 percent higher.
  • The incidence of AIDS among black women is 18 times higher than among white women; for men it's 9 times higher among African Americans.

Most of us are so used to such statistics that we hardly hear them, much less know how to respond.  If I'm honest, my tendency when somebody recounts those stats is often to think about the black, urban ghetto and its overwhelming issues, throw up my hands, and go on to the next subject.

But I'd like to slow us down this afternoon and take us back to the formation of that ghetto.  Working in the inner city, I had come to understand that once born into the ghetto it's difficult to get out.  But then I began asking myself: Where'd this ghetto come from in the first place?  Why is it a black ghetto?

As I asked that question, I recognized my unspoken assumption: that there was something in African-American behavior that was ultimately responsible for the formation of the ghetto.  After doing some basic historical reading, however, I discovered how wrong my racist assumptions had been.  There is, in fact, a unique history to the African-American ghetto, which few in the white community know.  All poor people struggle against great odds, but the odds against which poor African Americans have been thrown are something else again. 

Let me share a little of that with you.

Right after the Civil War, African Americans started migrating out of the South, dispersing mostly to small towns and rural areas in the North, where they were apparently initially welcomed.  Shortly after the end of Reconstruction, however, (about 1890) the mood in those Northern locales began turning ugly.  Often using alleged incidents of black-on-white violence, entire black communities were razed … across the North.  African-American were run out of town.  Police harassed blacks who appeared to be more than passing through.  In other cases, black families moving in were simply shunned until they moved out.  Or other means were found to deliberately exclude them.  This has been a hidden history, only recently researched, but it's probable that over half of all northern towns and smaller cities became what they called sundown towns,[1] owing to the signs sometimes posted at the corporate limits: "Nigger, Don't Let the Sun Go Down on You in whatever-the-town-was."  With the advent of suburbs in the beginning of the twentieth century, almost all of them, including now those in the South, were sundown, the restrictions often written right into the deeds.  In many places, these sundown practices continued well into the 1960s, and in some places until very recently.  There's an ugly reason behind our continuing segregation, and it has nothing to do with African Americans not wanting to live in integrated communities.

With World War I, the decline of southern cotton and the industrialization of northern cities brought almost two million African Americans in the Great Migration from the rural South into Northern cities.  Like other immigrant groups, they clustered around the factories where they worked.  Unlike other immigrants, when they became affluent enough to move into more middle-class neighborhoods, increasingly rigid, often violence-enforced segregation prohibited them from moving out of their enclaves.  White homeowners formed "neighborhood improvement associations," signing legally binding "restrictive covenants" with each other, legally prohibiting them from ever selling to African Americans.  And ongoing violence against blacks kept the borders between white and black communities increasingly fixed and impermeable.  By 1930 the outlines of today's ghettos were firmly established.

During the Great Depression, Roosevelt took bold moves to reduce poverty.  Three of his more important programs, however--federally mandated unemployment insurance, old-age pensions through Social Security, and federally insured loans for the construction or purchase of new homes--were largely closed to African Americans.  The Federal Housing Authority systematically redlined black areas, refusing to guarantee mortgages there.  Before they would insure new mortgages in even a white area, the FHA sometimes required the community to create those restrictive covenants forbidding sale to blacks. 

Exclusion from these FHA guarantees may seem like a relatively trivial matter, but it was, in fact, especially pernicious.  Not only did it keep the money from new home construction out of the black community, but home ownership is also the way most Americans build assets.  It's the usual path to the middle class.  Without the FHA mortgage guarantee, one had to put thirty or forty percent down, making purchase for most impossible.  These New Deal programs were by far the largest "affirmative action" programs the government has ever undertaken, but they were largely for whites.  It's no accident that today a black family's assets average less than 10% of a white family's.

A second Great Migration to northern cities occurred with World War II, but since the borders of the ghettos were fixed, the newcomers had to cram themselves into already crowded areas.  Even with the overcrowding, however, these ghettos were quite different from the ones we think of today.  They were "vertically integrated" societies that "worked."  Lower-class, working-class, middle-class, even upper-class African Americans lived in relative proximity.  Education was highly valued, and levels of social organization were high with churches, businesses, fraternal associations, political organizations and less formal groups providing the usual social glue.  These were functioning societies, poorer on the average than their white counterparts, but otherwise little different.  The levels of single-parenthood, joblessness, drugs, and violence we today associate with the inner-city ghetto were simply unknown.

But within the next twenty years, between the late 1940s and the mid-1960s, this would change drastically, again due to a convergence of forces over which the residents of the black ghetto had no control. 

  • Urban renewal and the federal interstate highway program preferentially selected African-American, inner-city neighborhoods for destruction. 
  • The federal government built subsidized, public housing to assist the poorest who were displaced by these programs, but that only made things worse by concentrating all the poor people together into newly built "projects" where only poor people lived. 
  • Huge, federally funded highway programs and middle-class tax breaks subsidized the movement to the suburbs, leaving behind those ... who couldn't move out. 
  • Even the end of legal segregation allowed middle- and upper-class African Americans to move out of the urban ghettos, leaving, again, the poorest. 
  • With devastating results, thousands of good, well-paying, semi-skilled, inner-city jobs disappeared as urban industries collapsed or moved away due to increasing computerization and lower, non-unionized wages elsewhere.   
  • Small businesses then followed the money, so the inner-city black neighborhoods were soon wastelands of poor, under-skilled, unemployed people living in ghettos that had lost many of the ties that bind people together.

What had once been thriving neighborhoods were now gone.  Instead those who had been unable to leave, who were least educated, the least skilled, the most ill, and the most likely to have other problems were packed together in artificially created neighborhoods where little of the previous social organization remained.  Chronic joblessness leads to hopelessness and abandonment of the labor market.  Women have little incentive to marry if men aren't able to support a family.  The drug industry finds a fertile source of employees when there are no other jobs.  Good role models for the children disappear.  Education seems less and less important.  Schools die, and students spend years learning little.  In most ghetto areas, over half drop out before graduation from high school.  Adolescent behavior runs unchecked because adults are no longer in the social networks that allow control of adolescents.  It doesn't take long for a so-called "culture of poverty" to grow.  And thousands of Margines are born.

Beginning in the mid-1970s, another storm gathered against the African-American communities.  We began imprisoning increasing numbers of people, especially young African-American men.  The "war on drugs," mandatory minimum sentencing, so-called "truth-in-sentencing laws" limiting or eliminating parole, three-strikes-and-you're-out provisions, and increases in sentence length have meant that between 1970 and 2000 the US prison population septupled, giving the US the highest rate of incarceration in the entire world, roughly seven times that of Western Europe.

As bad as that's been for whites, it's been a disaster for blacks who have been treated far more harshly.  Black men are incarcerated at rates seven to ten times higher than white men.  Black drug users, for instance, have about twenty times the risk of going to jail as do white drug users (same crime, different consequences).  Almost ten percent of all young black men are in prison.  And if you look at that majority of poor African-American men who dropped out of high school, by the time they reach their twenties, on any given day fully a third are in jail or prison.

Think of that statistic: a third of young black high school drop-outs in prison!  Our incarceration policies have devastated these already ravaged communities, pummeling their economies, destroying families, shattering hope.  Can you imagine the Manhattan Project that would be instituted if a third of any other community were incarcerated!  The injustice would be obvious to us all.

One significant reason for this black-white disparity has been the almost absolute power now given to prosecuting attorneys in most cases within the criminal justice system.  Mandatory minimum sentencing laws have virtually eliminated the power of judges to modify sentences based upon individual circumstances.  But, for any given transgression, the prosecutor has absolute discretion to charge you with any of a range of felony charges … or with a misdemeanor … or not charge you at all.  The prosecutor can bring you to federal court (where sentences are usually longer) or to state court.  And it's the charge and the venue that ultimately determine how long you'll spend in jail.  So the prosecuting attorneys--usually white, at least middle class, and with a bias toward prosecution--become not only the prosecutor but also the judge and jury of young people whom they rarely understand.  Underfunded public defenders have virtually no time to spend with an individual client, so a full 90% of cases are resolved by plea bargains: after threatening you with a charge that will mean 30-40 years in jail, the prosecutor offers a plea bargain for, say, two or three years in jail.  And if you're a poor black man who knows what your chances are in open court, you'll accept the plea bargain, even if you're innocent.

The deep injustices of the arrest, trial, and sentencing disparities between whites and blacks has taken on an even more sinister cast with studies now suggesting that virtually the entire racial difference in AIDS incidence can be explained by the differential rates of incarceration between blacks and whites.  Right, it appears that the incarceration of black men itself leads to that incredible nine-fold difference in AIDS rates between white and black men and the stunning 18-fold difference between white and black women.  We're clearly in the realm of the human rights abuses Paul Farmer speaks of.

The black ghetto was constructed by social forces almost entirely outside of the control of the community that lived there.  It's tempting for the casual observer to look at the behavior of the residents and conclude that the enormous health disparities within the poor black community (and other poor communities) are largely the result of individual behavior--addictions, abuse, violence, diet, and so on.  The reality, however, is that it's injustice that's largely responsible for the health disparities in the poor black community.

The point of what I'm saying is that health disparities are primarily a subset of social, political, and economic injustice.  While specific health interventions--universal health insurance, AIDS education, aggressive prenatal monitoring, and so on--will certainly help, at least in the United States the fundamental cause of health disparities is social injustice itself.  I've been talking about the inner city, but one would find analogous issues in any poor community, whether in Appalachia, on a Native American reservation, or in immigrant populations.

Unfortunately, that reality makes it considerably more difficult for health care professionals to respond: the problems seem so overwhelming and intractable, and we don't have the expertise to approach them anyway.  What good does it do to point out that health care disparities are the result of social injustice if we can't do much about it anyway?

I'd like to suggest, however, that education and advocacy may be especially important tools at precisely this moment.  For a wide variety of political reasons that I won't get into this afternoon, most people in the United States believe that the time of extreme social injustice is over, and it's time for the poor to get on with their lives.  People, in fact, don't know about the injustice and by not educating them, we become complicit in the ignorance … and the ongoing injustice.

I was startled several years ago reading a scientific paper by Paul Farmer in a straightforward medical journal.  What was unusual about this paper was that in the discussion of whatever scientific topic he was writing about he included several explicit paragraphs about the impact of social injustice upon AIDS in his community.  This wasn't an opinion article about injustice.  It was the usual scientific paper about a certain medical issue, but it acknowledged the otherwise unspoken reality.  It was advocacy right there in a medical journal!  What would it be like if most of our scientific papers on health and health care began to name and acknowledge the role of injustice?  What would it be like if our education of medical students regularly pointed out the injustice at the bottom of the phenomena we were studying or seeing in the clinic?

What would happen if people from the health care community regularly wrote letters to the editor or to our legislators pointing out the injustice involved in whatever issue is current?  Or occasional opinion pieces?  And so on.

Part of the frustration that many of us feel is that our country seems to be heading the other way.  Tax cuts, budget cuts, punitive welfare requirements, exclusion of immigrants, and disdain for the poor seem to be the order of the day, not justice.  Even pure science is attacked as leftist propaganda.  Who's going to care?  Who's going to put up with our efforts to educate them?  It can seem like spitting into the wind.

I'd like to suggest, however, that history is rarely continuous.  There are usually almost mysterious breaks in history, often precipitated by social and political disruption (like we're now seeing in the United States) that allow for the really new. 

In the Judeo-Christian religious tradition from which I come, injustice is simply the most important spiritual issue, and the judgment on societies that don't take care of their poor is quite straightforward: God's protection will be withdrawn.  In the current climate where religious concern seems to be focused exclusively on homosexuality or abortion, it's easy to forget that justice is the primary concern of both Hebrew Bible and New Testament. 

But one doesn't need to be a believer to understand that a nation that neglects its poor weakens the fabric of the entire society and initiates its own undoing.  Indeed, historian and political critic Kevin Phillips, examining the three major Western empires before ours, finds that each empire was ultimately characterized by an increasing economic inequality that was directly related to the fall of that empire.  It's not difficult to see that something quite similar is happening to us.  Injustice is sucking at our very marrow.

Anyone who looks with a cold eye at our current political and social scene, I think, has to recognize that we're headed for trouble.  An increasingly militaristic leadership and a foreign policy unilateralism, a growing political polarization and ideological rigidity, a looming foreign debt crisis, the replacement of science by ideology at the highest levels, the collapse of basic infrastructure, the increasing economic inequality within the country and the abandonment of the poor … these are not signs of stability.  

In such a time, it's doubly important for us to be naming the truth of our circumstances so that whatever new order replaces the current instability can have the truth of justice available to it.  Ultimately, if we hope to survive, this society will have to right the wrongs it’s heaped upon the poor, especially the black poor.  The first step in that long road is that others know the truth of the injustice.  So, it’s up to us, who already know, to tell them.

[1] Loewen, James, Sundown Towns