Category: Healthcare Inequality

Healthcare InequalityInequalitySocial Justice

A review of Capital and Ideology

Thomas Piketty is a French economist famous for documenting the egregious thirty year rise in inequality. When his new book Capital and Ideology came out a few months ago, I started writing up notes — mostly based upon his presentation slides for the book and his course notes for a class based on the book. With each passing day, the inequalities he discussed took on increasingly fatal dimensions. Tens of thousands across the globe, in the U.S., and hundreds in my home state of Georgia have now died thanks to ideologies that uphold inequality.

As the U.S. in particular continues to unravel thanks to its attachment to an “ideology of inequality” I have four takeaways from the book:

  • It’s a decent read if you have the time and patience. You could probably get what you need from the presentation and course slides.
  • Piketty makes the point that if society can’t sell its citizens on going along with a given kind of inequality, then that society is going to collapse. We’re seeing now the early stages of what that collapse looks like.
  • The U.S, Brazil, U.K., and India in particular are trapped in fatal ideologies handed down from the slavery and colonialism.
  • The only bright spot I see for people on the dying end of the inequality is solidarity. We can learn from each other successes — we don’t have to accept this, we have the power to struggle against this. We have the power to say “no more”.

So who is Piketty?

He’s an economist that documents disparity. A succinct example is his famous “elephant graph” of income inequality in the U.S. from his 2014 book Capital in the 21st century.

The top 10% has regained 50% of the wealth.

Since the 1980’s income inequality has exploded in the U.S. and across the world.

Of course, if you’re Black (like I am), or Brown, or Indigenous and living in the U.S., this is nothing new. You probably have years of lived “receipts” from your life and those of friends and loved ones to validate the enormous disparities in wealth, healthcare, and justice. You want academics to “tell you something you didn’t know”, or at least offer some new thoughts on how to re-envision and bring about a more equitable world. Piketty doesn’t have many answers — for those there are hundreds if not thousands of local organizations like The Black Women’s Health Imperative, The Poor People’s Campaign, The Black Mamas Bail Out, Southerners on New Ground consisting of real people making real progress to address the myriad dimensions of inequality that are literally killing us. What Piketty (in the slides) does offer are nice graphs that can help place the struggle in an international and historical perspective. Maybe it’s supplemental information to your lived experience or the brilliant work of Angela Davis or Keeanga-Yamahtta Taylor.

Things probably can’t go on like this for much longer

Every human society must justify its inequalities: unless reasons for
them are found, the whole political and social edifice stands in
danger of collapse.

Thomas Piketty, Capital and Ideology

As of today, some would argue that this society has collapsed. In April, the unemployment rate was believed to be 14% for White Americans, 16.7% for Black people, and 19% for LantinX people. That rate is expected to be much higher in May. This system of inequality has left 15% of its children without adequate food.

As of today, racial inequality in health care means that 70% of the COVID-19 deaths in Detroit are in the under-served African American community, who are just 30% of the city’s population. The COVID Tracking Project’s Racial Data Dashboard is showing how the human rights tragedies in Alabama, Mississippi, South Carolina, and Georgia are unfolding. In the age of coronavirus, the U.S. does not have an answer for the fact that 80% of the African American residents of an assisted living facility in the neighborhood I used to live in are infected with the virus; or why the city of Albany, GA, whose population is 73% Black has had critical medical infrastructure de-funded over the years, suffered the first deaths due to coronavirus in the Georgia, and has been dealing with one of the world’s highest infection rates.

The farcical “reasons for” inequality play out in the rates of infection and death of the undocumented, in Indigenous communities, among the incarcerated, in LatinX communities, unsheltered communities, low income communities, and among Black communities cities like Albany, Detroit, Milwaukee, and New Orleans, and too many other cities. Deaths attributed to racist systems of healthcare access that were too long unquestioned. For this, I think Ibram X. Kendi said it best in an Atlantic article

Why do racial disparities exist?
Why are black people generally being infected and dying at higher rates than other racial groups? This is the question of the hour. And too many Americans are answering this new question in the old, familiar way. They are blaming poverty, but refusing to recognize how racism distinguishes black poverty from white poverty, and makes black poverty more vulnerable to a lethal contagion.

And Americans are blaming black people.
To explain the disparities in the mortality rate, too many politicians
and commentators are noting that black people have more underlying
medical conditions but, crucially, not explaining why. Or they blame the choices made by black people, or poverty, or obesity—but not racism.

Ibram Kendi, from Stop Blaming Black People for Dying of the Coronavirus

Of course, if you’re Black (like I am), or Brown, or Indigenous and living in the U.S., this is nothing new, you have a lifetime of receipts that have shown with clarity America’s commitment to inequality.

unless reasons for them are found, the whole political and social edifice stands in danger of collapse.

The recent murder of Breonna Taylor tragically brings to mind the assassination of Fred Hampton, and the murder of Ahmaud Arbery follows the familiar pattern of state sanctioned lynching.

If you are old enough to remember the late 1960’s or early 1970’s, you know what societal collapse in the U.S. looks like, and this is it — you’re on the edge of dread waiting for the eventual spark that leads to the 2020 version of Watts, or Detroit or Ferguson.

The same patterns of inequality happen across the globe

It won’t come as a surprise that the kinds of ideology that enable these patterns of inequity happen across the globe.

Surprise, Brown and Black people see their interests protected by the Left
White supremacy and inequality cleave society in France
The racial, class, and caste divides are global
The disparities in the U.S. that you knew.
The divides mirrored in Britain

That the same race based inequalities play out in Brazil, France, and the U.K. on the one hand is not encouraging. That Black Britons are also more at risk of COVID death like their U.S. counterparts is tragically believable. That the persistent divides in caste in India mirror the U.S. inequalities is tragic. Piketty’s analysis of caste inequality is probably not nuanced enough to give a complete picture, but maybe Nitin Bharti’s dissertation is one of many starting points You don’t wish these hardships on anyone.

I struggle to come to answer the “Now, what is to be done?” question.

The paths forward

As I’ve thought through the book — or rather just the ways in which inequality and ideology intersect — a few things stood out.

Talk to your children.

In long breakfast conversations, my partner, Gayatri Sethi, and I talked to the 15 and 13 year old how Capitalism and it’s ideologies play out in the mess we’re in. My partner gave the unedited version of her sparring with various nobel laureates as a University of Chicago economics undergrad, only now having the words to express the depth of the racism inherit in their view of the world. She explained the meaning of the Tswana saying “a person is a person among people”, that humanity cannot be reduced to a profit motive, that you can only exist fully in a society when you acknowledge the humanity of others. We talked through Piketty’s The Economics of Inequality with the 15 year old — he understood it and wrote a successful book report!

Maybe building a generation that knows that things are wrong, and they don’t have to be this way, and what alternatives are is a good start.

Seek solidarity

My daughter at a solidarity protest

There are so many people around the globe, and down the block making moves to change things. Angela Davis mentioned the amazing work of Brazillian activist and councilwoman Marielle Franco, that continues despite her assassination. The protest movement in Hong Kong was largely responsible for the successful grass-roots response to the coronavirus, thus providing a path for effective action in the face of a pandemic. The same same activists are protesting today. The Indian state of Kerala has demonstrated how to effectively confront coronavirus with limited resources. With inequality so perversely compromising the lives of so many, there is actually a wealth of human ingenuity and experience that can lead us out of this mess.

Organize

In the U.S. an election is also looming. Again, it is worth noting the Hong Kong movement created the infrastructure that zeroed out COVID-19 in spite of an anemic government response. It’s worth remembering that movements like the Montgomery Bus Boycott, the Sit Ins, and the heroic Voter Registration Efforts of the the 1960s created changes that democratized the United States without the support of and in spite of the U.S. political parties. Freedom Riders did not need Democrats, Republicans, Socialists, Libertarians, or Marxists to validate the legitimacy of their collective action. We don’t need politicians to approve our struggle for freedom or to save us from tyranny. The inequality graphs point to significant coalitions of every day people that could be organized around tangible change across divides of race, class, caste, and privilege.

I guess to close, I see room for optimism, hope and justice, because I know that human beings have shown an astounding inventiveness in transcending that which divides them in order to build that which saves them.

AtlantaGeorgiaHealthcare Inequality

Restarting Georgia’s economy from coronavirus the right way

There are serious concerns about the decision of Georgia’s Governor Brian Kemp to reopen businesses as of Friday, April 24th.

Georgia’s governor wants to open businesses. Where’s the science?

Here are some among the many concerns:

  • What are the protections for workers at barbershops, gyms, nail salons? Will PPE be mandatory, will they be provided by the state?
  • Will workers and customers at such establishments be able to get free testing?
  • Will the state expand medicare to pay for healthcare costs incurred by people who catch the virus?
  • Will the state provide secure mechanisms for contact tracing?
  • Will the state provide expanded minimum wage guarantees to employees putting themselves at risk?
  • Will the state provide for a moratorium on evictions and actions against those businesses who choose not to reopen?
  • Will mayors choose morals above profits to protect their citizenry?

By now, there have been a lot of analyses of appropriate ways to reopen economies. For example, Austria is investigating a rollback in it’s lockdown but provides more social support and has reported 1/3 the deaths as the state of Georgia. Masks are required in public spaces. Georgia has also not shown the sustained downward trajectory of cases. Most alarmingly, Georgia, as many other areas, has tremendous inequality in healthcare access according to recent figures from the Georgia Department of Health, more than 50% of the deaths occur amongst African Americans. Black people account for just over 30% of the residents of the state.

I started a petition to ask for more accountability. If you’re a resident of the state, please ask questions via the governor’s constituent services site. If you live in Atlanta or Decatur, or Albany, you can express support for your elected officials to enact morally responsible policies. GoFundMe campaigns or other mutual aid might be effective in keeping your favorite local business afloat while safe practices are enacted.

Please stay safe.

Black Women's HealthHealthcare Inequality

Centering the health of Black women

It has been three months since my mother died. Through the deep feeling of loss, I am learning that the process of grieving is a continuous reflection: a meditation to pull meaning, hope, joy, wisdom out of memories that are still sharp and vivid.

More than anything, I am left with a profound sense of gratitude. That she shared, loved, and praised so generously. That she rejoiced in giving, embodying her birth name Joyce. I feel gratitude that she lived a full and glorious 88 years, educating scores of children as a middle school teacher, enjoining her many friends to “Keep hope alive and keep your spirits up”, encouraging her neighbors, church members, and relatives with gestures large and small of love and acceptance. I feel immense gratitude that she left to this world friends, nieces, cousins, children who still continue to support each other and strive to carry on the essence of her soul. She never forgot a birthday — celebrating each with elegantly crafted cards adorned with exquisite calligraphy and thoughtful words. Her retirement was spent as a prayer to life: gardening, traveling, and loving three grandchildren. For these gifts, I am thankful.

She indeed gifted us many lessons. The way in which she died — to be specific her last few weeks in the hospital — is one among many; a kind of charge, a parting story to be unfolded by us the living to survey, understand, and learn from in order to improve and uplift the lives of the next generations. This particular lesson is on how health is provided and not provided to women of color; it is about how a system fails to understand and value the lives of Black women; it is about how to destruct and then rebuild a racialized hierarchy of who lives and who dies.

This life life lesson from Joyce is to figure out how to center the health and well being of Black women.

Let me explain. My mother had to be taken to the emergency room after dealing with stomach pain that had gone on for weeks. Like many Black women of that age, she had feared going to doctors — news is often bad, and for Black women born in the 1930’s the remembrance of Tuskegee experiments, segregated hospitals, visits to doctors who could not be bothered to appreciated and respect Black women’s bodies play into the oft-quoted “anywhere but the doctor” sentiment. There is a podcast How the bad blood started, that sets this in historical context.

When my mother arrived at the hospital, I don’t doubt that the immediate emergency surgery — removing a section of her intestine — was performed well. American excels at emergency and trauma response and has probably mastered what to do with Black bodies in physical trauma. You see this approach to care in the policies that govern many communities of color.

The tripartite system of the IHS, tribally operated clinics, and urban Indian clinics represent a unique ecology within which American Indians seek help for physical, mental, alcohol, and drug problems. This is particularly relevant when discussing health care challenges for American Indian elderly since the emphasis of the IHS system is on acute rather than chronic health problems

From Understanding Racial and Ethnic Differences in Health in Late Life: A Research Agenda. National Research Council (US) at https://www.ncbi.nlm.nih.gov/books/NBK24693/

In the days that followed — as my mother tried to recover from the stomach surgery — I began to notice a pattern. The Black nurses seemed to spend more time, ask more questions. One of the Black nurses braided her hair, spent the time to turn her gently, administer the massages to keep her muscles moving, southed her mouth with water to keep the dryness in check. They took the time to perceive and understand their patient, to build the bonds of knowing and trust that would facilitate care. They took the time to recognize her humanity and enter into the process of healing. The White nurses seemed indifferent at best. I noted in my journal trying to disbelieve my eyes.

The surgeons — they were all white — offered curt responses to our questions. When my brother and I asked why duplicate tests had been run, why we were not consulted about a procedure, we were met with defensiveness. You can’t imagine the the restraint required of a data scientist not to resort to physical violence when they dismissed and told not to ask questions, when their mother’s health is at question.

Along with one of the Black nurses, we — her children — figured out that she had likely had a stroke; that sometime on the Tuesday of her second week in the hospital she had lost a lot of the functioning on her left side. As she began to fade, we only got partial answers from the doctors. What was a minor stroke one day, was significant the next. She developed a throat infection, she began to fade. Again, it was the Black caregivers at a hospice center that insured that her final hours at home were calm, prayerful.

Three months after my mother’s passing, we are still consulting with Medicare and the insurer on procedures that may or may not have been necessary or duplicative.

Everyone will acknowledge that the U.S. medical system is in crisis. It assumes that cases will be resolved through litigation — so stories of mothers falling through the cracks of overworked providers are common. Billboards of malpractice attorneys feature prominently in Atlanta — they are on buses, on the radio, and their ads will track you on the internet. Yes, I get that, but there are other factors at work.

In this Longreads piece, Danielle Jackson talks about the mortality crisis facing Black mothers. Lest you think this is just about poverty and access to adequate health — it certainly is a factor — please remember how Serena Williams nearly lost her life in childbirth. Don’t take my word or those of my mother’s — physicians do not see Black women, they are not trained to see Black women.

It goes much, much further. Georgia’s governor proposed this year to cut funding for research aimed at improving maternal health for Black women. A study came out after my mother’s funeral which highlighted how algorithms used in hospitals to allocate care showed bias against Black patients. We are apparently just not worth saving. Further, if you are a Black scientist interested in doing research on how to improve the health of Black people, it will be harder for you to obtain research funding and obtain tenure.

The figures from the U.S. Centers for Disease Control tell bittersweet stories.

Thankfully, the racial disparities in mortality have decreased — from a five year gap in life expectancy between Black and White women in 1999 to a 3 year gap in 2013. But despite that drop, the gap seems to have been been constant over the first part of the 2010s. Further, disparities in the number of deaths around childbirth and Alzheimer’s disease have increased.

The day after my mother’s passing I learned that my oldest son and his companion were expecting a child. It brought joy to our family in a dark time, but there yet we have to go forward in the knowledge that his partner, and their child are at higher risk giving birth in the U.S. than in the Caribbean. They live in Illinois, where the Black infant mortality rate is 12.8 — higher than that of the Virgin Islands, Barbados, Granada, Saint Lucia, Antigua, and the Bahamas. In London, the infant mortality rate among mothers of Caribbean descent is 8% — although this is twice that of the general population it still gives children born to Black mothers better odds than Chicago or Atlanta. In other words, in nearby places with Black populations of 90% or greater, infants are faring better. There is nothing inherent about Black children that predisposes them to die like this.

As I contemplate the seriousness of these trends, I recall my grandmother who was lost to Alzheimer’s. As we sat planning the funeral, we received a visit from one of Mom’s college friends who was going through the early stages of the disease. She had been brought to our home by a friend who had explained that they were trying to participate in a clinical trial to address the low participation of Black women in experimental Alzheimer’s therapies.

But there is something more in these figures as I think about it. Does the United States preserve this hierarchy of healthcare because it would undo axioms of existence? As the Center for American Progress stated in this 2018 report

That is, the social and economic forces of institutional racism set African American and non-Hispanic white women on distinct life tracks, with long-term consequences for their health and the health of their future children. The experience of systematic racial bias—not race itself—compromises health.

Exploring African Americans’ High Maternal and Infant Death Rates,  Cristina Novoa and Jamila Taylor

The racist hierarchy of how health in the United States is done is apparent in so many ways.

Even with ACA, people of color — for Indigenous, African American, and Latinx citizens most acutely — continue to be mis-treated under the U.S. healthcare system. From Key Facts on Health and Health Care by Race and Ethnicity | The Henry J. Kaiser Family Foundation

Among the Indigenous peoples of the United States, 30% have no access to health insurance, among African Americans, the uninsured rate is 12%. What are the lessons to be learned from the relative resilience of LatinX citizens? Are the racial categories of the 19th and 20th century, constructed out of a context white supremacy appropriate for the challenges that are faced in the 21st century? What are the objective ways in which these disparities can be effectively addressed?

There are people that are wrestling with these questions. Healers like Brittany Kellman are trying to create health centers that actively engage with the unique health situation of Black women. But the barriers of access, physician engagement, perception, and systemic pressures are huge.

Ultimately, radical change in healthcare options depend upon the willingness of government and systems to address disparity. The access to health and being should not be left to the luck of the draw — where you live, who your parents were.

In my desire to be an optimist, ideas and thoughts on addressing the problem:

Mural near my grandmother’s childhood home
  • If you’re African American, talk to your friends and loved ones about health. Discuss what’s worked, what hasn’t. The challenges you’ve faced. Document your interactions with the healthcare system. Knowledge is power, sharing is love.
  • Find the healers, providers, institutions in your community that care and are invested in improving the health of Black people generally and Black women in particular.
  • Encourage your mothers, aunts, daughters, partners to get care from the providers that care. Work with each other to take ownership of care, health and healing.
  • If you’re a healthcare professional, it’s time to demand a rethinking of how nurses and doctors are trained to interact with their patients. You cannot save our lives if you cannot appreciate our humanity.
  • Regardless of your political affiliation, you can work to ensure that everyone in the U.S. has access to healthcare that keeps them alive and well. Ask yourself if the county you live in ever worried about the cost of endless wars or drone terrorism.

No, I have not solved this gem of a puzzle that Joyce bequeathed. It is one of the many meditations of grief.