Most unfortunately, the voices and experiences of those who live in poverty are often neither heard nor heeded by society's more powerful. Thus the people living with low SES experience violence that is built into the structure of our society in the form of neglect, denial of certain human rights and inadequate access to quality public and private services, to name a few of the social pathologies that constitute structural violence.
Justin M. List “Illness, Poverty and the Invisible Patient” from the American Medical Association Journal of Ethics
http://virtualmentor.ama-assn.org/2006/11/fred1-0611.htmlI. Which Comes First? For decades, researchers have known that poverty and mental illness are correlated; the lower a person's socioeconomic status, the greater his or her chances are of having some sort of mental disorder. Yet determining if one comes first - if being poor renders a person more susceptible to mental illness, or if mental illness pulls a person into poverty - is decidedly difficult and the relationship between poverty and mental health has long been assumed to be interactive.
Yet a recently published large-scale, seven-year study suggests that poverty, acting through economic stressors such as unemployment and lack of affordable housing, is more likely to precede mental illness than the reverse.
http://www.masspsy.com/leading/0506_ne_cover_study.htmlWe all know that illness and poverty are linked in the United States, but which comes first? Some tell us that poverty is a lifestyle choice (adopted by the “shiftless” and “lazy”). In their world view, poor folks who suffer serious illness are eating the fruits of their (lack of) labor. Since many of the nation’s poor work long, hard hours at low wage jobs, maybe that should read “the fruits of their lack of
high paid labor”. In this world view, every citizen, Tyrone and Manuel as well as Clifton and Brad, can become a bank CEO---- if only he chooses to do so.
On the other side of the debate are those who say that illness—especially mental illness---is the
cause of poverty. This explanation is also problematic, for it can be used to re-enforce the Puritan belief that we get what we deserve based upon where we stand in God’s favor. Since the all powerful creator decides who will be cursed with schizophrenia and who will enjoy a lifetime of perfect health, the nation’s unhealthy poor are God’s rejects, creatures flawed at their conception and destined for a lifetime of hunger and deprivation.
If your tastes are a little bit more Catholic, you may view the presence of the poor as an opportunity---for you to polish up your halo by casting down table scraps to the starving masses that God has put upon the earth to teach folks charity. You can see this tendency among some self described liberals.
I feel for the poor---but I don’t want them living next door to me “The Poor” become a separate race of human being, almost another species. They exist in the same way that Mom, Baseball and Apple Pie exist, as a rarified ideal rather than as people. Charity towards the Poor becomes a luxury---which is often the first thing chopped from state and federal budgets when executives find their profit margins slipping.
Gov. Arnold Schwarzenegger's insistence on cost-cutting measures to weed out what he has described as "waste, fraud and abuse" in California's social service programs has struck a nerve with Democrats, welfare advocates and the frail.
They say the Republican governor is using the poor as a scapegoat for the state's $26.3 billion budget shortfall. They also fear his proposals, if approved by the Legislature, would trigger increased unemployment and homelessness, and force thousands of people from their homes into expensive nursing facilities.
http://www.sfgate.com/cgi-bin/article.cgi?f=/n/a/2009/07/08/financial/f145047D38.DTL&type=business One thing you will notice during this debate----we seldom hear from the folks who have to choose between paying their heating bill and buying food and for whom a mammogram is an impossible dream. For the most part, they are ignored by the press. Many do not have access to the Internet. Their story is told
for them. We read books written by people who have helped the Poor. We hear speeches in which the nation’s ills are blamed on Welfare Queens. If poor folks manage to make their voices heard as musicians, artists, writers, they are soon elevated through the socioeconomic ranks---
We have reality TV about prisons, about corporations, about models, but where is our reality show that records the lives of folks who struggle day after day to survive?
II. Walk a Mile in My Shoes I can think of only one time in the entire history of the United States when people living in poverty have been treated like real Americans.
Chronic unemployment was the central and most persistent feature of the Depression: by 1932, estimates of the total number unemployed ranged from 8 to 17 million workers -- this, at a time when the total U.S. population was just 125 million. A variety of federal efforts were taken to address unemployment in cultural fields.
Snip
New Deal cultural projects took responsibility for our cultural commonwealth. They took on the task of recording history -- including many parts otherwise deemed too painful or embarrassing to mention.
http://www.wwcd.org/policy/US/newdeal.html#FAPWe all recognize
this photo:
It is as much a part of our national identity as this one:
We look at the skinny, prematurely aged woman, and we see ourselves in the frown lines on her brow. We see our own families in the children who cling to her like a tree in a storm. We do not make excuses----she must have had unprotected sex and had those children when she was too young and that is why the whole family lives in poverty---the way we would if confronted by
this image:
Once upon a time---for a very brief time---we accepted that ours was a society and economy that produced as many tragic life stories as happy ones. We blamed the system, not the people caught up in that system, and we promised to do something about it---
Until poverty was reduced to an “acceptable” level. And then, we forgot most of those vows we had made. Instead. we started talking about Welfare Queens and about how low levels of unemployment were “bad” for the economy. Because face it, this nation’s corporate fascists gets rich off the suffering of the poor. The presence of poverty as a universal fixture in our country is used to drive down the wages of all workers who are told “Shut your mouth, punch the time clock and do are you are told. Or you will end up like one of
them ” . Since no one wanted to become one of
them, we started telling ourselves that they were different. They had nothing in common with us, the so called “hard working Americans”. Poverty had a different skin color, it practiced a different religion, it spoke a different langue----
It was Other.
III. Try to Imagine….That you can see a doctor, because you are poor enough to qualify for care at the county clinic. But, you do not have the ten dollar copay which the clinic’s pharmacy charges per prescription. Therefore, you can not fill the antibiotic prescription which the doctor wrote for you until you get your paycheck next week. By that point, your bladder infection has turned into a kidney infection, so you show up at the local hospital emergency room and are admitted for a life threatening illness. You miss a week of work, putting you and your family further in debt. You are branded a “non compliant” patient, because you did not follow your first doctor’s advice. In other words, it is all your fault.
That your teenaged son is hearing voices that are not really there. They tell him to do things which are dangerous for himself and others. You know that there are medications out there which will turn this stranger back into your dear child----but you do not have two hundred dollars for the initial psychiatric consultation and fifteen dollars a pill for the medication (Abilify) that the doctor will prescribe. The waiting time to see a doctor at the local MHMR, which charges on a sliding scale, is three months, but your son does not have three months. Reluctantly, you follow the advice of your coworkers and turn him over the police for being truant, hoping that the criminal justice system can fill the gaps in our health care system. Congratulations. Your son is now on his way to become a career criminal.
That your birth control pills fail and you get pregnant. Your job does not offer insurance---or maternity leave. If your boss finds out that you are pregnant, you are likely to get fired, which will make it very difficult to support the two kids you are raising as a single mom since your husband moved to another state and has refused to pay child support. You want an abortion, but the closest provider is three hours away. Even though you work for minimum wage, the government will not pay for your procedure---though it will pay for your obstetric care and delivery, no questions asked. Unable to come up with five hundred dollars for the procedure, another hundred dollars for food, hotel and transportation minus the two days wages that you will lose, you miss the deadline for getting the pregnancy terminated. Your boss finds out and you are, indeed, laid off. In your third trimester, you start seeing an obstetrician. Medicaid covers your medical expenses, because the government just
loves your unborn child. But the federal assistance you get for your living children will not even pay the rent and grocery bills.
That you are a self employed farmer who can not get health insurance because of a pre-existing condition, high blood pressure. You wake up one morning with your left leg painful and swollen. Your mother died of a blood clot and you know that this is serious. However, you live in the piney woods of East Texas, and the designated indigent hospital for your area is in Galveston, six hour away. You get in a car and drive six hours to get medical care for your deep venous thrombosis. On the way, you see three hospitals, each of which is equipped to give you heparin and Coumadin, but you pass them by. You were taught to pay your own way, and you know that a bill from one of those private hospitals would cost you your family farm. By the time you reach Galveston, that clot has grown bigger. You step out of your car, and the clot breaks loose and heads straight to your lungs. You suffer a cardiopulmonary arrest just outside the emergency room.
That you are the neighbor of the farmer who died of a blood clot after driving six hours for treatment. When your own leg swells up, you decide to go straight to the nearest ER, even though you do not have insurance (pre-existing condition: asthma). You are expecting a bill of a few thousand dollars. Turns out that your emergency room care alone is over ten thousand dollars. The bill for your hospital stay is so high that you have to take out a mortgage on your house and farm, which you own outright. Because of complications from your blood thinners, you are in and out of the hospital for several months, during which time you can not make the money to pay the mortgage. There goes the family farm.
That your father suffered from diabetes, high blood pressure and high cholesterol, which were never diagnosed because he worked in a job that did not supply health insurance. He developed premature coronary artery disease and died at the age of 30 from “indigestion”. Your mom went back to work, at a minimum wage pink collar job. You and your siblings ate a lot of bread and grease, because they were filling and not too expensive. You lived in a really bad neighborhood, because the rents were cheap, so you could not go outside to play and your school cut its physical education program in order to devote more time to training students how to pass standardized tests. College was out of the question. You had to go to work to help support your family. By the time you are in your mid twenties, you are over weight, with high blood pressure, cholesterol and diabetes, but you do not know it, because your job does not supply health insurance. On your thirtieth birthday, you suffer a severe attack of “indigestion”---and, remembering what happened to your dad, you call 911. By the time you reach the hospital, you have already infarcted a huge piece of your left ventricle and you develop congestive heart failure that forces you to quit work. After a couple of years, you qualify for disability and Medicare. By this time, you can barely walk across the room. You will now be able to see doctors and get treatment, which will keep you alive in this invalid condition for many more years.
That your mother died from a stroke when she was in her thirties. No one has ever told you why. Your aunt, with whom you live, has lupus and can not keep a job. Your grandmother died of colon cancer related to her undiagnosed ulcerative colitis. Recently, your neck began to swell up and you have noticed that your heart beats too quickly and you are losing weight. You sign up at the local indigent health clinic and are told that your problems are not emergencies and therefore you will have to wait three months for an appointment. While waiting, you go into thyroid storm and suffer a stroke from your extremely high blood pressure. The emergency room is able to save your life, but you suffer permanent paralysis on your left side and will have to be in a nursing home.
That you retired from your job, which provided insurance, when you were sixty. Since your husband worked for the government and had great insurance that covered the two of you, you were not worried---until he died suddenly of a heart attack. Now, for the first time in your life, you have no health insurance. You cross your fingers and hope that nothing will happen before you turn 65 and can qualify for Medicare. When you notice a breast lump, you decide that it is probably a cyst---you had a benign cyst removed many years ago, when you were still insured. The lump keeps getting larger. Then, your armpit begins to hurt. There are lumps there, too. Still, you wait and hope—until one day, you can not get your breath. And your chest hurts. Thinking this is a heart attack, you rush to the closest emergency room, where you are told that your breast cancer has metastasized to the pericardium, the lining around the heart. You get emergency surgery to free your heart from the constrictive band and your breathing improves. The hospital is able to facilitate your Medicaid application (they do not now want to get stuck with your bill), and
now you can see an oncologist for your late stage cancer
That you are always tired. You get eight or nine hours of sleep a night, but you still wake up feeling exhausted. Your blood pressure is through the roof even though you take four different medications---which you are lucky to get for $10 each rather than $100, since you qualify for treatment in a community health center. You wish that you could find a better paying job, one with insurance, but your head hurts all the time and you are too exhausted at the end of the work day to take after hours classes. Your partner tells you that you snore, and someone mentions that could have sleep apnea. You ask your doctor during your next visit and you are told that your clinic does not cover the costs of sleep apnea diagnosis or treatment “because there is not enough money in the budget”. You are given the option of paying for the test yourself----but you would need to put up $800 in order to be tested for something you might not even have. So you put it off---and eventually your high blood pressure causes your kidney’s to fail. Congratulations. You qualify for Medicare, to pay for your dialysis. And you can finally get that sleep study. Too bad you had to lose your kidney’s first.
That your parents were always fighting when you were young. Mostly, they argued about money. Sometimes your dad would beat your mom, after he had been drinking. Your mother drank, too, but in private, after everyone else was asleep. There was never enough money to pay the bills. At least a couple of times each year the lights or phones or water would be turned off. You could never afford the clothes and toys that other kids had. Your teeth are crooked but you can not get braces. You can not play outdoors, because that would cause your asthma to flare up---and there is no money for treatments. One night, your mother calls the cops after a particularly bad beating, and the next day at school you get teased because the neighbors saw the police haul your father away. You hate your mother for being so weak. You hate your dad for being so cruel. You vow that you will not grow up like them. When a boy tells you that he loves you, you sleep with him, though you are only fifteen, because you are so desperate to hear someone those words to you. You get pregnant. You are happy, because now you will have someone---a child---who will love you forever. You have now become a statistic---unmarried women and their children are the face of poverty in this country.
IV. The Invisible Poor The above vignettes are all based upon true events (though some of the details have been changed to disguise identities). I selected these stories out of many others that I have witnessed in order to make a point. Sometimes illness leads to disability which causes poverty. Sometimes illness leads to huge medical bills that cause poverty. Some hereditary illnesses can cause multi-generational poverty---and poverty, in turn, worsens the multi-generational illness. Mental illness can cause poverty. Poverty can contribute to a host of conditions from depression to drug abuse to delayed diagnosis and treatment of curable diseases. People who live in poverty may not care enough about themselves or their own future to use even available health resources. Poor folks may care about themselves, but find that it is impossible to get the kinds of treatment that other Americans, those lucky enough to work for the government or large employers, enjoy. When you are poor, the safety net often does not kick in until you are permanently disabled---which means permanently poor, too.
So, how will the latest Health Care Reform help the people I describe above? The woman with the kidney infection still will not have enough money for copayments. Since the bill sets no limits on deductibles and other barriers to care, many people will find themselves forced to buy insurance they can not afford to use.
The woman with the schizophrenic son may find that her insurance has a ridiculously low annual limit for psychiatric care. The bill allows the federal government to decide what limits are acceptable, and it does nothing to keep the insurance industry from conspiring to set prices and benefits the same which eliminates consumer choice. Remember, the insurance industry currently is exempted from anti-trust rules.
The woman with the unplanned pregnancy still will not be able to get an abortion. The first man with the blood clot will now have insurance, but it may only cover treatment at a hospital a couple of hours away, so there is a chance he will still code in the parking lot. His neighbor, who will also have insurance, may find that the closest emergency room in not on his plan, and so he may find himself stuck with a big bill, even though he is insured.
The next two people are the success stories of HCR. The woman with Grave’s Disease will be diagnosed promptly and start treatment. Let’s just hope that living in working class poverty does not make it impossible for her to pay her deductible and copayments. The retired widow with breast cancer will probably get life saving treatment---but she may have to drive quite a distance in order get to participating provider hospitals and doctors.
The man with sleep apnea may or may not get timely treatment. His new insurance plan is likely to throw up a bunch of obstacles to keep him from getting that sleep study---like a five to ten thousand dollar deductible---- and there is no guarantee that they will cover CPAP or other treatments even if he is diagnosed. Being tired and sleepy all the time, he may not have the energy to fight his insurer for the care he needs.
The unwed mother still faces a lifetime of poverty, since making birth control easier to afford will not change the underlying problems that lead her to become pregnant.
Though the Democrats may have started out with good intentions, I am afraid that they will end up just like Schwarzenegger in California, making decisions which are politically expedient in the short run while ignoring the real opportunities which we have to improve the lives of
all Americans. They will do this, because they believe---and have persuaded a bunch of Americans to believe---that folks living in poverty do not count. They are not heard. They are not seen. They are invisible.
V. Just the Facts Sadly, we may have seen the best that our elected leaders can offer us in the way of health care reform. In our current political climate, where it takes hundreds of millions of dollars to get elected president, only money talks. If we want to have a seat at the bargaining table, we need to make sure that the one with the most popular support, not the one with the biggest coffer, gets elected.