12 April 2019
Dear Interested Readers,
What Can We Do About The Poverty Where We Live?
I am reading a new book, Maid: Hard Work, Low Pay, and a Mother’s Will To Survive by Stephanie Land. Over the past two years I have searched for books in my quest to better comprehend the experience of being poor, and better understand how poverty undermines the health and economic well being of us all, not just those who fall below some artificial line drawn by politicians, economists, and social service professionals. I have discovered that what I thought I already understood, I did not fully comprehend. Books like Maid and Hillbilly Elegy are particularly helpful because they add the power of personal experience to the statistics and political discussions of other books.
Barbara Ehrenreich founded the Economic Hardship Reporting Project to promote writing on economic inequality by the people who are living in poverty. Stephanie Land has a remarkable talent that was trapped in a cycle of events that would overwhelm the coping skills of most people. Ehrenreich’s program supported Land in the telling of her story. Ehrenreich wrote the forward to Maid where she said:
Perhaps the most harmful feature of Stephanie’s world is the antagonism beamed out toward her by the more fortunate. This is class prejudice, and is often inflicted especially on manual laborers, who are often judged to be morally and intellectually inferior to those who wear suits or sit at desks.
Ehrenreich’s comment and writers who tell the stories of poverty like Land and J.D. Vance, the author of Hillbilly Elegy, remind me of my surprise and dismay in the mid 80s that Carolyn Chute, a woman who lived in poverty and had been a waitress, a farm worker, a factory worker, and school bus driver, could write a book as powerful as The Beans of Egypt, Maine. It’s hard to be objective about the potential of people who come from a class that is considered by most to be where they are because of some character flaw or intellectual impairment when in fact they live in a world of unreliable resources and with the continuing burdens of scarcity.
Below is a short list of the best books that I have read, and would offer to you if you would like to move beyond thinking about poverty in terms of “welfare” and become more aware of how it undermines the health and well being of its victims in ways that reverberate through the entire community. As the stories and data in the books reveal, the impact of poverty on children is so significant that today’s economic inequality will continue to limit the future of our nation for decades to come. There are other books that I would recommend that provide perspective on poverty and are not on the list, like Arlie Russell Hochschild’s Strangers In Their Own Land: Anger and Mourning on the American Right or Bryan Stevenson’s Just Mercy. These books were not written to be books about poverty or health, but poverty is the foundation of the subjects that they explore, and poor health is one of the outcomes of the problems they address. I would add Doris Kerns Goodwin’s Leadership in Turbulent Times to the list of books not about poverty that add perspective to poverty. She does a remarkable job of describing how personal experiences with poverty motivated Lincoln and LBJ and demonstrates how Teddy Roosevelt went on a quest in New York City to understand and share the experience of the poor in his city. FDR was born into a wealthy family but was a keen observer, even as a child, of the lives of the servants his family employed on their estate. All four were driven by their concern for the poor and the distant goal of true equality in opportunity.
The links above and the links to the books on the list below are to reviews. I have written about most of them in these notes, and if you are interested you can find them using the search function on this website. I have added a short comment about each. I would love for you to send me any books that you have learned from that are not on the list. In retrospect I think I learn the most from those books that offer case studies or are narratives of personal experience.
- Evicted: Poverty and Profit in the American City, by Matthew Desmond: This book won the Pulitzer prize for 2017. The author was doing research at Harvard and now has an institute to study poverty at Princeton. The book is the result of his living in inner city Milwaukee to gather information and first hand experience for his Ph.D. dissertation while he was a graduate student at the University of Wisconsin. Desmond’s own family fell into poverty and was evicted while he was a teenager. The book reads like a tragic novel by Dickens laced with data. The bottom rung of poverty is to be so poor that you are forced into the street. In the book you learn that we spend much more (tens of billions of dollars more) on housing subsidies for the middle and upper classes through tax deductions than we spend on housing for the poor in any form. Renting to the poor is a very profitable business. Housing policy is differentially discriminatory against people of color. Desmond presents his facts and thesis with the skill of a remarkable story teller.
- Toxic Inequality: How America’s Wealth Gap Destroys Mobility, Deepens the Racial Divide, and Threatens Our Future, by Tom Shapiro. Dr. Shapiro is a professor at the Heller School at Brandeis University. This little book is a great companion to Eviction for those who would like to better understand generational wealth and poverty. Dr. Shapiro and colleagues followed 187 families in Los Angeles, St. Louis, and Boston for almost twenty years. Half of the families were black and half were white. Shapiro blends stories and data to show the structural disadvantages that make the development of family wealth much more difficult for black families than white families.
- The Broken Ladder: How Inequality Affects The Way We Think, Live, and Die, by Keith Payne. Keith Payne is a professor of psychology at the University of North Carolina. He grew up in poverty in Appalachia in Eastern Kentucky. Elizabeth Kolbert has written an excellent article in The New Yorker showcasing Dr. Payne’s research on the psychological damage of poverty.
- A Framework For Understanding Poverty: 5th Edition, by Ruby Payne (no relation to Keith) Dr. Payne is an educator and successful entrepreneur who some in the academic community of education have disdained. Are they jealous because she has sold more than a million copies of this book which is self published? She has “taught the book” in popular seminars for educators since the mid nineties and there is a companion version for churches that she has authored with her minister. In many ways this is the most useful book I have read in my own quest to understand how to help the people whom I have met in my community who are among the working poor. She gives insights and tools. A friend who is an educator, an immigrant from Africa, and has lived for years on the edge of poverty, recommended the book to me. I met a woman from Indiana this year who is an educator, and asked her if she had any experience with Dr. Payne. What followed was several minutes of positive testimony as a graduate of one of Dr. Payne’s training programs. Dr. Payne offers those of us who are not impoverished insights about our own class concerns and anxieties. Whether you are poor, a solid member of the middle class, or an ultra wealthy jet setter, what you have affects your worldview and your health.
- Behave:The Biology of Humans at Our Best and Worst and Why Zebras Don’t Get Ulcers both by Robert Sapolsky. These are not books that are just about poverty, but in both books Sapolsky, who is a Stanford professor of neurobiology, explains the science behind how poverty, as a continuing stress beginning even before childhood, impacts health and opportunity. Poverty has an impact on its victim from “womb to tomb,” and generates the challenges to health that create the socioeconomic status driven ladder of health that is observable in every society.
- Hillbilly Elegy: A Memoir of a Family and Culture in Crisis by J.D. Vance. This book rocked the world in 2016, and then created some backlash. Was that because of the conservative orientation of the author? To me it felt like an American version of Frank McCourt’s Angela’s Ashes. Some young people overcome enormous barriers and we really do not know for sure how they do it. They are “outliers.” Outliers can always teach us something, but their story can’t be generalized to the whole population with anymore confidence than the patient who defies the expected clinical course of any disease process. Their value lies in the ideas they might give us to develop for less fortunate sufferers of what looks to be the same disorder. Vance has many negative things to say about the way the social safety net worked for him. At one point he muses that the best system would be the equivalent of “a thumb on the scale” for the children of poverty, not for some highly engineered and very proscribed product of policy experts. It’s not Vance’s analysis of how he became a successful graduate of Yale Law School that I found powerful. The power lies in his description of the forces in his environment that he was able to survive. His description makes Ruth Payne’s Understanding Poverty an even more impressive piece of work.
I offer this little syllabus because I have found that these books have greatly helped me to understand the problems that were both easy to overlook, and hard to understand in my own community. I wish that my medical education had included more attention to the issues related to poverty. Seeking understanding is a necessary part of any improvement effort. That’s why in Lean practice we “go to the gemba.” That is why when we want to understand a difficult clinical problem or unusual presentation we go to the literature or ask for a consult. I am not trying to medicalize poverty. But, I am convinced that poverty, the fear of poverty, and the stress that we experience as we try to avoid being in poverty, all contribute to the disease we see in our offices and hospitals. Until we bring ourselves to a greater understanding of poverty, we will make little progress on the issues that challenge our system of care and practice.
If we can get our heads around the complexities and many manifestations of a bucket of related diseases like the various forms of cancer or metabolic syndrome, or if we can change the trajectory of a disease from certain death to chronic disease management, as we have done with HIV/AIDS, why have we had so much trouble making headway on improving the health of those living in poverty? Perhaps Sapolsky comes closest to answering this question. He suggests in both of his books that we assign substantial agency and personal responsibility for the troubles to the victims of poverty. That attitude is also reflected in the quote from Barbara Ehrenreich about how we feel about those doing menial labor. In that regard we seem to revert to a medieval mindset or attitudes that go further back that blame disease on sin and sloth. If we had stayed with that approach for HIV/AIDS, it is likely that we would not be able to celebrate the successes that have been won.
This last week David Brooks considered some of these same issues as he contrasted the success of improving poverty in Canada to our continuing frustrations in a column entitled “Winning the War on Poverty: The Canadians are doing it; we’re not.” He reports that between 2015 and 2017 Canadians reduced their prevalence of poverty by twenty percent. Canada now has 850,000 fewer people living in poverty. The obvious question is, “How did they do that?” Brooks tries to tease us a little by forcing us to first look in the mirror before getting the answer to Canada’s success. The “current status” picture that he gives is a good description of the approach to poverty that is used in my adopted hometown and state.
Before I describe this methodology, let’s pause to think about what it’s often like in American poor areas. Everything is fragmented. There are usually a bevy of public and private programs doing their own thing. In a town there may be four food pantries, which don’t really know one another well. The people working in these programs have their heads down, because it’s exhausting enough just to do their own work.
A common model is one-donor-funding-one-program. Different programs compete for funds. They justify their existence using randomized controlled experiments, in which researchers try to pinpoint one input that led to one positive output. The foundation heads, city officials and social entrepreneurs go to a bunch of conferences, but these conferences don’t have much to do with one another.
In other words, the Americans who talk about community don’t have a community of their own. Every day, they give away the power they could have if they did mutually reinforcing work together to change whole systems.
After forcing us to look at our failures despite earnest and broad based efforts for decades, he reveals the Canadian secret.
About 15 years ago, …They realized that poverty was not going to be reduced by some innovation — some cool, new program nobody thought of before. It was going to be addressed through better systems that were mutually supporting and able to enact change on a population level.
Local grassroots coalitions combined the insights and intelligence of the poor with resources from the government in combination and coordination with private individuals, business, and nonprofits and together these work groups began to study the needs of their community with the goal of having fewer poor people rather than just offering more services to the poor. We must give resources to people who are acutely in need, but we have a systems problem that keeps them in need. The goal must be moving people out of poverty. That is the goal that Ruth Payne is working toward. Tom Shapiro and Matthew Desmond are describing the barriers we erect that prevent progress toward that goal. J.D.Vance complained about the efforts, ostensibly in his behalf, that were a burden for him. The other important aspect of this objective is that it has a disease model counterpart. We may have eradicated polio and smallpox. Millions of people live with the dream of conquering cancer, and millions more are employed in the effort, but we pat ourselves on the back with our efforts to provide what amounts to palliative care to those suffering from the disease of poverty. Not since Lyndon Johnson have we done what the Canadians have done and asked ourselves how do we conquer poverty, eradicate it like it was a disease. Brooks goes on to say that the Canadians have a third objective,
Third, they broaden their vision. What does a vibrant community look like in which everybody’s basic needs are met?
Brooks continues the story by saying that after about a year of reflection at the local level each community came up with a plan. There is no one plan that fits all. There are principles and objectives that apply to every community, but the path to the goals vary by community because each town’s poverty problems are unique to that community.
There are changes that are common. Improved day care, better transportation, and workforce training problems are broadly needed resources. Nationwide, Canada has access to healthcare as a right. They have what Brooks says is “essentially guaranteed income for the young and the old.” Brooks’ description makes the process sound like a nationwide Lean project when he adds:
The process of learning and planning and adapting never ends. The Tamarack Institute, which pioneered a lot of this work, serves as a learning community hub for all the different regional networks.
The final pearl that Brooks offers is a metaphor from the Paul Born, the head of the Tamarack Institute.
…the crucial thing these communitywide collective impact structures do is change attitudes. In the beginning it’s as if everybody is swimming in polluted water. People are sluggish, fearful, isolated, looking out only for themselves. But when people start working together across sectors around a common agenda, it’s like cleaning the water…New power has been created, a new sense of agency. Consistent with the teaching of continuous improvement science is the belief that social change requires a methodology, and that won’t work without a community wide commitment to the objective.
For about a year now, tI have been part of a group of people in my community who have been feeling our way toward something that is beyond just offering aid to those in distress. When I read Brooks’ column I felt like he had been reading our mail. We sense that there is not a lack of interest or concern in our community, but we know we have just been putting bandaids on a growing problem. In next Tuesday’s post I will provide a snapshot of where we are on what I am sure will be a multiyear journey with no guarantee of ever arriving at the destination.
If you look around the country you can see that in many communities the providers of healthcare are leading efforts to improve the health of the community by partnering in the process of addressing community development and poverty. Gundersen Health in LaCrosse, Wisconsin is an example. I am proud to say that Guthrie Health in the “Twin Tiers” of Pennsylvania and New York is another health system that is asking itself what it can do to improve its community. I am sure that there are others. I think that despite all of the issues that divide us there is a growing sense of “fellow feeling” in our communities and it makes me feel so good when I see or hear of healthcare professionals serving as leaders in improving their communities and fulfilling the expectation that we can be deep reservoirs of positivity and influence in the communities where we live and work.
The Sun Came Out. The Red Sox Won A Game. Is Spring Here? Will It Last?
The picture in today’s header was taken during my Tuesday afternoon walk at about the time that Mookie Betts struck out with Pedroia and Bradley patiently waiting for him to drive them home to tie the score. I was listening to the game while I took my walk. To add to the moment the temp was 29 degrees. The wind was blowing so the sense of chill made it feel like the mid teens, and we had another inch of snow in about the same time it takes me to walk three miles. The lake was still frozen, despite a few days of rain with temps in the low fifties while I was away in California. I had hoped to return to no ice and no snow, but it was not to be. As I continued to trudge home through snow in the aftermath of Mookie’s ill timed whiff, I vowed not to listen to or watch another Red Sox game until they won one.
Wednesday was a little warmer. It got to the mid thirties and the Sox had the day off to lick their wounds. Yesterday was one of those gloriously clear days with no wind and a bright sun that made it feel like a beach day even though the temp did not crack fifty. I wondered, “Can this last? Will there be a spillover effect on the Sox?” True to my vow I did not watch last night’s game. I get updates of the score on my iWatch. As the evening wore on, and as I typed this missile, it was not looking good for the hometown team. They were headed to a sweep by one of the worst teams in the league, and then it happened. My watched pinged and I read the message that proclaimed that the Sox had won in the bottom of the ninth on a walk off hit by Devers. Now I am hoping for a two game winning streak.
Spring, hope, and baseball are such a beautiful triple fantasy made all the better by the fact that only hope is for certain. I am now eagerly anticipating “ice out.” I am hoping that the Red Sox will come out of their unexplained and uncharacteristic slide and give me the relief I need to get through all the certain trials and tribulations associated with mud season and the flies that will certainly follow.
We have Patriots Day and the Marathon to anticipate for Monday. The weatherman is suggesting that once again it may be run in a monsoon. That’s probably better than a snow storm.
Be well, take good care of yourself, let me hear from you often, and don’t let anything keep you from doing the good that you can do every day,
Gene
