If you are a close reader of these notes, you’ve probably figured out that my career was as a physician first and then secondarily as a healthcare administrator who was fascinated by the many facets of healthcare management and policy. Put into the language of David Brooks’ new book, The Second Mountain: The Quest for a Moral Life, that career with those two tasks was my first mountain. I am now climbing my second mountain. Second mountains are about callings and passion, and my passion has become exploring the needs of the underserved and getting my hands dirty trying to make a difference where I live for the people that I encounter who are struggling just to get by in the “live free or die state.” Put in terms of the healthcare jargon of our times, I have been captured by the desire to do something “on the ground” about the issues that constitute the social determinants of health. I care about the underserved and disadvantaged in urban centers like the Greater Boston area, but I have a new appreciation for the issues of poor in the rural and small town environment.
When I think about the rural and urban poor, I am reminded that Dr. Robert Ebert was very concerned about the same groups more than fifty years ago. In October 1967 he delivered the Kate McMahon Lecture at Simmons College where he said: Â
In my opinion the social problems [in healthcare in 1967] are of greater magnitude than those which are strictly medical. Not only is there a place for the physician in the approach to these problems but he must be involved if they are to be solved…There are two groups who have suffered from the changing pattern of medical practice: the rural population and the urban population occupying the central city. Both groups present special problems, and both require new approaches to solutions. Most of you are familiar with the problem of the rural community….The health problems of the urban poor are intimately linked with their socio-economic problems, and they cannot be solved by imitating the care given in the suburbs.
It was only recently that I realized that when discussing the issues of care in the rural environment, Dr. Ebert was talking about access to care for both the poor and for those who had resources. When talking about the issues in the city he was only talking about the problems of getting care to the poor. Perhaps rural and small town poverty was not the pressing issue that Dr. Ebert saw with the urban poor. Over the intervening 52 years poverty has become a much more observable and significant problem in the “fly over” communities of America. The last 50 years have been tough on farm communities and the economies of small town America.
In the Second Mountain Brooks underlines the importance of community by making it part of the committed “Second Mountain” life. He says:
People on the second mountain have made strong commitments to one or all of these four things:
A vocation
A spouse and family
A philosophy or faith
A community
When you get into trying to understand the needs of your community, you discover very quickly that within the community there are many people who are struggling. You also quickly realize that state and federal programs to aid the poor are very “porous” and difficult for clients to access. The structures of the programs are feel as if the primary objective is to prevent people who “don’t need help” from getting it. The complex rules and requirements for monitoring are the cause of much of the stress in the lives of the poor. We should be concerned that the poor often suffer indignities from issues that arise from the programs that we have designed to help them. I have heard it said that no federal program has ever lifted anyone out of poverty; only the direct actions of another individual, like a mentor, a caring physician, a committed social worker, a minister, or some other source of personally focused concern can really help lift someone out of poverty.Â
Those inclined to be concerned about government expenditures on poverty programs suggest that since they are “ineffective” we are wasting taxpayer money on them, and should therefore reduce or eliminate them. I have come to the conclusion that programs to combat poverty are both ineffective, but absolutely necessary. I believe that we can and should improve our efforts to find ways to make public assistance more effective and couple the programs with the supportive efforts of caring individuals and groups within the community.  The design and administration of the programs could be improved to make them more effective if we were concerned more about helping everyone who needed help, and less concerned about making sure that no one who “didn’t need help” and was scamming the system was excluded. We will always gain benefit from the interest and involvement of concerned individuals who can partner with programs to make a difference in the lives of individuals.
Authors like Matthew Desmond who wrote Eviction: Poverty and Profit In the American City and Professor Thomas Shapiro of Brandies who wrote Toxic Inequality: How America’s Wealth Gap Destroys Mobility, Deepens the Racial Divide, and Threatens Our Future, discuss the ineffectiveness of our federal programs for the poor as a function of the fact that they are challenged in every federal budget. Let me explain.
Middle and upper class Americans get huge federal subsidies that are multiples of the money that is given to the poor and underserved. Most middle and upper class benefits come to us through the tax structure. From a budget perspective tax deductions for personal deductions, business expenses, home mortgages, employer expenses for healthcare benefits, and retirement benefits result in decreases of hundreds of billions of dollars in federal revenue. They are part of our culture, and these expected deductions are never questioned. We did not make any substantial changes in the tax code between 1986 and 2017, and when the law changed the take of the middle and upper classes was even more. Federal programs like housing vouchers, subsidies for childcare, SNAP (food stamps), WIC, job training, Medicaid, and other programs for the poor are debated with every budget as “expenses” that are vulnerable to budget cuts to pay for the deductions given to “taxpayers.” Since expenses are managed every year through the federal budget, they are easy targets for the political process even though they have less impact on the nation’s bottom line than the tax deductions given the wealthy. A program that provides support one year may be gone soon after the next election when party control of a critical Congressional committee changes. It is ironic that the earned income tax credit for the poor is widely considered to be the most effective federal antipoverty program. Obviously to get the benefit from the earned income tax credit you must be able to work and earn some income. If you are in poverty because of a disability, or can not work for some other reason, this great program is of no benefit to you.
Books like Hillbilly Elegy: A Memoir of a Family and Culture in Crisis by J.D. Vance, Maid: Hard Work, Low Pay, and a Mother’s Will to Survive by Stephanie Land, The Broken Ladder: How Inequality Affects the Way We Think, Live, and Die by Keith Payne, and The Glass Castle: A Memoir by Jeannette Walls are all memoirs and analysis of how it feels to live without means written by people who struggled and succeeded in their attempts to escape from poverty. I would suggest that each author would consider their experience to be the exception, and not the usual experience. None of the authors hold themselves up as an example of how to get out of poverty. Their focus is on giving those who have never experienced poverty a sense of what they experienced. Each book describes the experience of poverty as being a struggle that is much like dealing with a chronic disease. There are frequent experiences of frustration with the system, experiences with the misconceptions of those not in poverty, frequent encounters with burned out program managers, and the exhaustion of trying to get to multiple minimum wage sources of income. They tell a story of always running uphill against the wind. The stories that they tell are in stark contrast to the mythical life of Ronald Reagan’s “welfare queens” and the overflow implication that most people on public assistance are involved in a fraudulent activity, or are just plain lazy.
Dr. Jerry Morris, the British physician/epidemiologist, who is famous for demonstrating that sedentary London bus drivers had more cardiovascular events than the ticket takers who were running up and down the steps of double decker buses, was also one of the leaders in the study of the social determinants of health in Britain. Don Berwick quoted him in a recent speech about the social determinants of health.
A minimum income includes not just what is necessary for food and shelter, but what is required to live a life of dignity and to take one’s place in society.
To my ear that quote resonates with a quote that I took last week from David Brooks’ Second Mountain.
“The other more important part of the consciousness is the soul. Now, I don’t ask you to believe in God or not believe in God. I’m a writer, not a missionary. That is not my department. But I do ask you to believe that you have a soul. There is some piece of your consciousness that has no shape, size, weight, or color. This is the piece of you that is of infinite value and dignity. The dignity of this piece doesn’t increase or decrease with age; it doesn’t get bigger or smaller depending on your size and strength. Rich and successful people don’t have more or less of it than poorer or less successful people.
…Because each person has a soul, each person is owed a degree of respect and goodwill from others. Because each person has a soul, we are rightly indignant when that dignity is insulted, ignored, or obliterated.
I was recently rereading Convictions: How I Learned What Matters Most by the theologian Marcus Borg. The book was an end of life analysis published in 2014 just before Borg died of pulmonary fibrosis. In his description of progressive American Christianity in contrast to evangelical conservative American Christianity Borg writes:
The political issues of conservative Christianity are primarily about maintaining personal standards of behavior and belief. Many are about abortion, sex and gender: homosexuality, gay marriage, the role of women in the church and family and society, and for some even opposition to contraception. Other political issues concern the cultural affirmation of Christianity: praying in public schools, displaying the Ten Commandments in public places, putting “Christ” back into Christmas, teaching “creationism” as well as evolution in public schools.
For progressive American Christians, these are not the important issues of our time…Rather, the primary political issues are about justice and peace.
Justice includes “procedural” justice, meaning the fair and equal application of the law, as in the criminal justice system. But justice also has a larger meaning: it is about fairness within a society as a whole and a concern for “the common good”–about putting society together in such a way that it serves the interests of all rather than primarily the interests of those who have done well. Medical care and a good education should be available to all and not only to those who can afford them. People should be paid a “living wage” so that anybody who works full-time can afford food and shelter. People who can not work should be taken care of. Justice as the “common good” emphasizes what it means to be a community, a society, a nation, and not just a collection of individuals. Â
Each of the memoirs of poverty that I have cited above indirectly or directly describes the “soul sucking” realities of the experience of poverty. I was very touched by several vignettes that Stephanie Land describes from her initial experience as a homeless mother when her boyfriend threw her out because she did not want to abort her baby. She goes on to describe the life of a mother scrambling to get housing subsidies, food stamps, and WIC benefits while working multiple minimum wage jobs, mostly as a maid, or sometimes doing seasonal landscaping and yard work, all while trying to attend community college. There are several of her stories that tear your heart out.
One story focuses on the shame associated with using SNAP and WIC subsidies. You might look at the picture that is at the top of this post to set the stage for the little drama that I will describe. The story begins when Stephanie, our overworked single mother, has to cancel a job to keep her appointment with the social worker who administers her WIC benefits. At the appointment she learns that after the first of the month WIC will no longer cover whole milk. She will no longer be able to get organic whole milk for her three year old daughter, and she is concerned that the fat and calories that have been removed is replaced in skim milk with additives including excessive sugar. She believes that this is not optimal for the health of her daughter.
Technically she was right, although the differential increase in sugar is small. Some authorities are concerned that there is less nutrition for a child in skim versus whole milk. Based on her concern she goes to the grocery store to get her organic whole milk before the first of the month. When she gets into the checkout line, she gets plenty of “looks” because of her appearance. She is quite accustomed to receiving “looks” from those who are behind her in line when she uses her SNAP card or WIC coupons to buy food. Those looks and comments accelerate from an “older couple” when the cashier loudly announces that her WIC allowance no longer covers whole milk.
She is immediately embarrassed as she realizes that they are looking at her ragged work clothes and use of a WIC card, and are making judgments about her character, but she is determined to get the milk that she is entitled to have because it is not yet the date when the benefit changes. She asks to have the cashier call the manager while the older couple behind her becomes more obvious in their disdainful behavior. It turns out the store has decided to implement the change in policy ahead of time for their convenience. She persists and finally gets her milk. I will let her tell the rest of the story:
As I pushed my cart away, my hands still shaking, the old man nodded toward my groceries and said, “You’re welcome!”
I became infuriated. You’re welcome for what? I wanted to yell back at him. That he’d waited so impatiently, huffing and grumbling to his wife? It couldn’t have been that. It was that I was obviously poor and shopping in the middle of the day, pointedly not at work. He did not know that I had to take an afternoon off for the WIC appointment, missing $40 in wages, where they had to weigh both Mia and me. We left with a booklet of coupons that supplemented about the same as those lost wages, but not the disgruntled client who I’d had to reschedule, who might, if I ever needed to reschedule again, go with a different cleaner, because my work was that disposable. But what he saw was that those coupons were paid for by government money, the money that he had personally contributed to with the taxes he’d paid. To him, he might as well have personally bought the fancy milk I insisted on, but I was obviously poor so I didn’t deserve it.
I do believe the issues of poverty and the social determinants of health are related to our individual and collective “souls,” and, as Dr. Morris has implied about the UK, our collective goal for everyone in our communities should be something like he suggests:
A minimum income includes not just what is necessary for food and shelter, but what is required to live a life of dignity and to take one’s place in society.
Everyone is entitled to nothing less. If we are not going to effectively enable poor people to escape poverty, the least we can do is give them the respect that every soul deserves. We discount our own gifts, and we multiply what we “did on our own.” The data is convincing that your status in life has more to do with the accident of your birth than almost any other factor, including your own willingness to work. The overwhelming majority of the poor that I meet want to work more than forty hours a week if they can. Many of the privileged people that I have known are oblivious to the true origins of their advantage.  I firmly believe that we would all be better off if everyone in this country could count on the fact that their personal resources included the fact that they were born into a country that always cared about their well being and potential, and had made it a national objective to level the socioeconomic ladder of health to give us all the chance to live a life of dignity and find our place in a great and generous society.
