Not much has changed in the experience of many since Dr. Martin Luther King, Jr. said,
“Of all the forms of inequality, injustice in health care is the most shocking and inhumane” – Dr. Martin Luther King, Jr
In the days before the fiftieth anniversary of the assassination of Dr. Martin Luther King, Jr. many experts were asked whether things have really changed much in the fifty years since the tragedy. No matter how you answer the question there seems to be universal agreement that we are still a long way from “the dream” King described in his most famous speech. On a hot August afternoon in 1963 standing on the steps of the Lincoln Memorial in front of 250,000 people he described the “is” of that moment and ventured to shared a most personal view of what “ought” to be. He noted that it had been a hundred years since President Lincoln had signed the Emancipation Proclamation on January 1,1863:
But one hundred years later, the Negro still is not free. One hundred years later, the life of the Negro is still sadly crippled by the manacles of segregation and the chains of discrimination. One hundred years later, the Negro lives on a lonely island of poverty in the midst of a vast ocean of material prosperity. One hundred years later, the Negro is still languishing in the corners of American society and finds himself an exile in his own land. So we have come here today to dramatize a shameful condition.
I have been reading Toxic Inequality: How America’s Wealth Gap Destroys Mobility, Deepens the Racial Divide and Threatens Our Future, published in 2017 by Thomas M. Shapiro. Professor Shapiro’s data and narrative documents that the picture today of what “is” reveals that the gap between the “average” African American and the “average” white American is now really greater than it was fifty five years ago when Dr. King gave his speech. Those are disappointing facts when balanced against the “ought” that Dr King presented as his dream. When one considers that in the Roxbury section of Boston, a minority neighborhood, the life expectancy is around 59 years as compared to 91 years in the affluent neighborhood of Back Bay less than two miles away, it is clear that the “is” is still a long way from what “ought” to have been accomplished long ago.
Dr. King rejected the excuses for why one hundred years had passed without the emergence of equity. He had been advised that equality would be “expensive” and that patience and “gradualism” were necessary. He did not accept the analysis:
…we refuse to believe that the bank of justice is bankrupt. We refuse to believe that there are insufficient funds in the great vaults of opportunity of this nation. So we have come to cash this check — a check that will give us upon demand the riches of freedom and the security of justice. We have also come to this hallowed spot to remind America of the fierce urgency of now. This is no time to engage in the luxury of cooling off or to take the tranquilizing drug of gradualism.
He knew the danger inherent in the frustration and the anger of being put off, but he advised those who followed him to continue to take a higher road.
But there is something that I must say to my people who stand on the warm threshold which leads into the palace of justice. In the process of gaining our rightful place we must not be guilty of wrongful deeds. Let us not seek to satisfy our thirst for freedom by drinking from the cup of bitterness and hatred.
We must forever conduct our struggle on the high plane of dignity and discipline. We must not allow our creative protest to degenerate into physical violence.
Dr. King did not advocate for violence, but he also did not advise a passive acceptance of injustice. He used his words and nonviolent protest as tools for change. In the next part of his speech he was explicit about the existence of police brutality. He called out the realities of the ghettos and the lack of physical and social mobility that exist for America’s poor, especially poor minority Americans. He identified the voting irregularities that disenfranchised African Americans and enabled the existence of the injustices that robbed and disadvantaged people through “Jim Crow” legislation designed to perpetuate our American version of apartheid. He was unflinching and brutally descriptive about the injustices that created the “is” of his day.
The climax of the speech on the Mall on that hot August afternoon was “the dream.” I have read that it was not in his prepared speech but was a spontaneous response to Mahalia Jackson’s call to him as he approached the end of the speech. She had heard him talk about “the dream” before so she shouted from the side of the platform, “Tell them about the dream, Martin!” Responding to her plea Dr King gave the gathered throng and all who would hear his words over the years to come a visual image of the “ought” which we still struggle to reach fifty years later.
I say to you today, my friends, so even though we face the difficulties of today and tomorrow, I still have a dream. It is a dream deeply rooted in the American dream.
I have a dream that one day this nation will rise up and live out the true meaning of its creed: “We hold these truths to be self-evident: that all men are created equal.”
I have a dream that one day on the red hills of Georgia the sons of former slaves and the sons of former slave owners will be able to sit down together at the table of brotherhood.
I have a dream that one day even the state of Mississippi, a state sweltering with the heat of injustice, sweltering with the heat of oppression, will be transformed into an oasis of freedom and justice.
I have a dream that my four little children will one day live in a nation where they will not be judged by the color of their skin but by the content of their character.
I have a dream today.
I have a dream that one day, down in Alabama, with its vicious racists, with its governor having his lips dripping with the words of interposition and nullification; one day right there in Alabama, little black boys and black girls will be able to join hands with little white boys and white girls as sisters and brothers.
I have a dream today.
I have a dream that one day every valley shall be exalted, every hill and mountain shall be made low, the rough places will be made plain, and the crooked places will be made straight, and the glory of the Lord shall be revealed, and all flesh shall see it together.
This is our hope.
It was spontaneous poetry. It is the expression of the true American Dream. It is the appropriate successor to expand the resolve at the end of Abraham Lincoln’s Gettysburg Address:
It is rather for us to be here dedicated to the great task remaining before us-that from these honored dead we take increased devotion to that cause for which they gave the last full measure of devotion-that we here highly resolve that these dead shall not have died in vain-that this nation, under God, shall have a new birth of freedom-and that government of the people, by the people, for the people shall not perish from the earth.
Dr. King’s message, like Lincoln’s a century before, was a call to all of us to actualize the potential of America as a place where the individual experiences of a diverse people are realized by recognizing our basic equality in ways that enable us to be a harmonious community. To hold such a view is dangerous. It cost both Lincoln and King their lives. The fearful alternatives to justice for all that he warned us of have never been closer than they are in this moment.
We should not waste either Dr. King’s sacrifice by failing to notice that his message and concerns were timeless and universal. By the time of his death he knew that injustice and inhumane disregard for human rights were infectious diseases that threaten us all. The courage and hope that defined him are our only hope if what “ought” to be is our collective dream. The “is” of the moment is not permanent. It will move toward what “ought” to be only if we will it. We learn from history that if “is” does not move toward “ought,” it can become a nightmare of “ought not” rather than the realization of a dream.
Congressman John Lewis and others, like some of the experts at the Brookings Institute, have speculated about what Dr. King would be saying or doing if he was still with us today. I did not disagree with any of the ten opinions of the Brookings experts, but I was sorry that they had not included an opinion from one of their healthcare experts. I will try to do the job.
Over the last year of Dr. King’s life he was clearly embracing the issues of inequality across all races at home and around the world. Given his focus on racial injustice and poverty, I am sure that he would be a strong advocate for a focus on the social determinants of health. There are several famous quotes to give us a sense of his concerns that intersect with poverty and the social determinants of health beyond the quote about inequality in healthcare being “shockingly inhumane” that support my contention.
If I couple Dr. King’s statements about poverty with the reality that at the time of his assassination he was planning the Poor People’s March on Washington, I would have to conclude that if he were alive today Dr. King would be a leader in the fight to eradicate the inequities in education, jobs, housing, food availability, and criminal justice that we loosely group as social determinants of health. He would be appalled by our failure to responsibly address the epidemics of gun violence and opioid misuse which threaten all of us and are best conceptualized as epidemic public health problems.
If Dr. King were alive I must believe:
- That he would consider the ACA an important but insufficient small first step toward equity in access.
- That he would be disturbed by our inability to come to consensus about how to humanely resolve our controversies over immigration policy.
- That he would be concerned with the suffering and lack of access to care of many of the undocumented people in our society.
- That he would be active in trying to expand the social safety net as a small step toward the elimination of poverty as a threat to health.
- That he would be an enthusiastic supporter of the objectives of the Triple Aim.
- That he would understand the importance of eliminating overuse and misuse of medical resources.
- That he would applaud Don Berwick’s articulation of the Moral Era of Healthcare, “Era 3.”
I think that he would be disturbed by the reality that in America in 2018 life expectancy is a function of zip code rather than genetic code and that he would advise electing legislators who would be concerned enough to develop a workable strategy to eliminate the injustices that create the reality of what “is” and usher in a reality that is closer to the equity that “ought” to be.
Dr. King stands in history as the strongest and most compelling voice for the expansion to all people of the high minded principles that the founding fathers conceptualized for themselves and those whom they considered to be their peers. We have always been a work in progress. We will always need someone that reminds us of where we should be going.
