ACArally

A decade ago I traveled to the Mississippi Delta, Texas’s Rio Grande Valley, the rust belt of Illinois, the mountains of northern Idaho and the cities of eastern Massachusetts in order to learn how uninsured Americans manage (or don’t manage) their health and healthcare in diverse circumstances. This spring and summer I returned to these communities to seek out the same individuals and families I’d met ten years ago. I wanted to hear how they’ve fared in the wake of the Affordable Care Act.

It is clear to me that June 23, 2015’s Supreme Court ruling in King v. Burwell is good news for millions of middle-class Americans living in states whose leaders chose not to set up insurance marketplaces (“exchanges”). People in those states will not lose their insurance subsidies because the federal rather than the state government facilitates the exchange.

The states impacted by King v. Burwell are, however, mostly the same ones impacted by the 2012 Supreme Court ruling (NFIB v. Sebelius) which allowed states to opt out of the ACAs Medicaid expansion. Lower income people in those states will continue to fall into the coverage gap — the no man’s land for people who earn too little to qualify for subsidized insurance through the exchange but who do not qualify for Medicaid in their home states. In some of those states only extremely poor parents and children are eligible for Medicaid, leaving large numbers of people who are childless or near elderly or poor but not destitute unable to access healthcare.

Texas, one of the states that did not expand Medicaid, has a federally facilitated marketplace. During my return trip to the Rio Grande Valley, I was able to locate 18 of the 26 individuals and families (all adults) I’d met a decade ago. At the time, all were uninsured. Fourteen of the 18 are now insured – a figure that, on the face of it, looks encouraging.

However, of the 14 who are insured, 5 now are covered by Medicare via Disability (as a consequence of becoming sufficiently disabled to qualify for SSI or SSDI). In other words, a third of the newly insured people are covered because their health deteriorated to a the point in which they no longer are able to work. One person is covered by Medicare because she is over 65. Two people have Medicaid but only as a supplement to Medicare; no one qualified for Medicaid as their primary insurance.

All 4 of the uninsured people fall into the coverage gap – when they applied for insurance on the exchange they found that their incomes are too low to qualify for subsidies. The experiences of the Martinez family (a pseudonym) are typical. Maria works full-time in a food service job that provides health insurance for her but requires a bi-weekly payment of $250 to cover her children. Her bi-weekly income is $500, so she had to turn down the coverage. Her husband, Enrique, is a truck driver whose employer does not offer insurance but he earns too little to qualify for a subsidized premium on the exchange. For a short time their youngest child was eligible for Medicaid (CHIP), but then Enrique’s income went up (marginally) and she no longer qualified. In 2013 Enrique spoke with an ACA enrollment specialist who helped him apply for an exemption from the penalty for not having insurance. In 2014 he forgot to re-apply and had to pay $190 in fines ($95 for himself and $95 for their 21 year old child.) In the meantime, he takes medication for high blood pressure when the border with Mexico is safe enough for him to cross over and buy pills there. I make no claim to extraordinary prophetic powers, but my guess is that in another five years he will join the ranks of disabled Texans.

That leaves 5 who are insured via the exchange and 5 now insured through employers – certainly a step up from when I first met them. However, all 10 of these Texans are unhappy with their insurance, for the most part because of high deductibles and co-pays. Rosa, an energetic and articulate middle-aged woman, is reimbursed by her employer for part of the cost of the premium she purchased through the exchange. Because of her low salary she chose a “bronze” plan with a low monthly premium (all that she could afford) but a $4500 annual deductible and $1000 co-pay for hospitalization. With a history of tumors in her breast and kidney, she needs scans that she cannot afford even with insurance. I fear that she too, will join the growing ranks of Americans who are disabled.

Shortly after the Supreme Court’s ruling on the ACA, President Obama spoke from the Rose Garden celebrating our national declaration that health care is a right, not a privilege. Now the challenge is to turn that declaration into reality on the ground – even in states whose leaders would rather thumb their noses at the feds than allow residents of their state to access the care that they need in order to remain healthy.

For more on health insurance read  Health Insurance Roulette: The House Always Wins

For more on the original research in the five states read  Uninsured in America: Life and Death in the Land of Opportunity

 

 

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A bill to create community-­based sentencing alternatives for non-­violent primary caretakers of dependent children (House Bill #1382) was filed a few months ago in Massachusetts. The mover behind this bill was Andrea James, a formerly incarcerated woman and founder of Families for Justice as Healing. According to James, the goal of the bill is “alleviating the harm to children and primary caretaker parents caused by separation due to incarceration of the parents, while reducing recidivism and strengthening family unity and communities.” Citing a report issued by Erika Kates, Ph.D, of the Wellesley Centers for Women, James emphasizes that an estimated two-thirds to three-quarters of incarcerated women in Massachusetts are mothers, over half of whom likely lived with their children prior to arrest.

My own strong support for this proposed legislation grows out of the research I have conducted for the past decade among Massachusetts women who have been incarcerated. The majority of these women were primary caretakers of dependent children at the time that they were incarcerated, and the consequences of incarceration were and remain overwhelmingly negative for the children, their mothers, and often for the entire extended family.

When mothers are sent to prison, their children become collateral captives, following their mothers into the institutional circuit and often ending up in foster care or living with an extended family member who may be less able to parent than the incarcerated mother.

Continue reading

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My friend Isabella has been beside herself with worry over her son and her housing situation. Ever since the first time we met (seven years ago!) in a half-way house for women, she has told me that she wants Americans who are fortunate enough to live in secure and stable housing to know what people who are dependent upon the institutional circuit of shelters, clinics, welfare, jails and DYS must go through just to (barely) hang on. I urged her to writer down her experiences. What follows is a Facebook conversation between us about what she’s been going through these past few months.


Isabella: Like many others, my husband and teen-age son and I have been living in what they call “scatter shelters.” What that means is that there aren’t enough good solutions for homeless families so they put us in apartments scattered around the city. Because we are a family, we were given one bedroom in a four bedroom apartment shared by four families. Some of the families have several kids, so it was very crowded. We all shared the living, kitchen and bathroom. One of our housemates at that apartment was an alcoholic and hit our son in the head with a bottle of Grey Goose. After that the manager moved us into another shared apartment in even worse conditions than the first one.

We are not criminals or children, but at the scatter shelter we all have a 9:00 curfew, 11:00 on weekends (though we can get a weekend pass.)

One weekend our son was staying with his grandmother and he called us up to say she had kicked him out. But it was after curfew (he had permission to be out but we had not arranged to be out) so we had to call the shelter supervisor to get permission to go and get him. By the time we reached her and got permission the last T [public transportation] had run so we had to take a taxi, which cost us $120 – a very big part of our monthly income.

 

Susan: Are you able to set up the apartment to feel like home?

 

Isabella: Because of all the moves and living in one room most of our stuff is in storage, including a television and really nice living room set that my father bought us before we lost our housing. But storage is expensive and we owe $3000 to the storage company. The company will not accept a partial payment and told us that they would auction off our stuff if we can’t come up with all of the money right away. But both of us are disabled and we live on Social Security so we couldn’t come up with the money.

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I’ve been anxious and depressed through all of this, but what’s happened in the past two weeks has pushed me over the edge and I’m crying as I write this.

 

Susan: What’s been going on?

 

Isabella: Our son had gotten into some trouble for which he was put on probation. Unfortunately, he violated the terms of his probation and so he was taken into DYS (Department of Youth Services) custody for an indefinite time of anywhere between two weeks until up until his eighteenth birthday. So I’m SUPER STRESSED OUT, losing my mind actually, because we have NO IDEA where we’re gonna go. They’re saying that since our son is in the custody of DYS that he cannot be considered a part of our “case file” so we can’t stay in the family shelter. But he can’t be released by DYS to us if we don’t have a stable environment to live in. But we’re going to lose our place in the shelter because he is not living with us RIGHT AT THIS MOMENT and without him as part of our case file we are $26 over the monthly limit to qualify for a homeless shelter.

I called the housing office and was told that our son DOESN’T qualify as homeless, because and I quote the almighty DIRECTOR of DHCD, “He already has a place to stay [in DYS custody]; so he’s not homeless…” They said, “When he gets out and is homeless have him call us to verify he’s on the streets and we’ll reevaluate your eligibility.”

So basically we’re stuck in a Catch 22: Damned if we do, damned if we don’t!!! He CANNOT be released if we do not have a place for him to stay…BUT, we cannot keep a place to stay if he remains in lockup!!! I can’t win! I’m losing my fucking mind!!!!!! I’m so sorry for the vulgarity but I am flabbergasted.

I’m SO SUPER STRESSED I have no idea where we’re going and the thought of being homeless with our son frightens me like nothing has ever frightened me before.


 

While many of the poor, chronically ill and criminalized women I know turn their anger and blame on particular “bitches” who work in social and correctional services, Isabella has made clear to me from the first time we talked that, “It’s a system that is designed for us to fail.” Emergency assistance programs make frequent changes in eligibility criteria for receiving services, causing feelings of uncertainty and vulnerability in those who are dependent upon welfare as well as obligating recipients to spend great amounts of time and energy re-certifying their eligibility for the support and services that, in most other industrialized countries, are considered a basic right.

Even when you qualify for assistance, it turns out that Social Security Insurance (SSI) and Temporary Assistance to Needy Family (welfare) remittances are not sufficient to live on. As a result, recipients also are drawn into homeless shelters or other housing programs. Homeless shelters, while better than the street in most instances, are structured around rules that seem designed for people to break them. For a mother, residence in a homeless shelter is a surefire way to draw in child welfare services. Child welfare services are more likely than not to send women to drug testing programs which in turn easily leads them into the correctional system. Conditions of probation and parole — such as requiring constant urine tests — make it impossible to hold down a job. And children like Isabella’s son who were drawn into child welfare services are more likely than other children to end up in juvenile detention facilities, jails and prisons – all but guaranteeing that they will remain stuck in the same institutional circuit that failed them from the start.

You can read more about Isabella and the institutional circuit in Can’t Catch a Break.

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I recently read this powerful piece by Jean Trounstine. Jean has graciously agreed to let me repost it here, so that I can share it with my readers. It originally appeared at jeantrounstine.com


 

Every semester my students from Voices Behind Bars, a class I teach at Middlesex Community College in Massachusetts, go to prison. They used to visit state institutions but now that the Massachusetts state prisons do not offer tours (perhaps because it is a hassle to have outsiders trooping through them and criticizing what they see) the students take a tour of Billerica House of Correction, where they experience confinement to some degree and listen for an hour to an incarcerated man talk about his life and what it is like to be behind bars.

Originally, the Middlesex House of Correction was built in 1929 and housed 300 men. Now it has more than 1100, after a $37 million dollar expansion which prison officials say was to accommodate the closing of the Cambridge Jail —not without objections from activists and community members who opposed more prison building (actually costing $43 million per The Lowell Sun.)

I’ve always thought it’s not ideal to have my students learn about prison by going to a place where people are only kept for 2 1/2 years, the county sentence at a house of correction. Certainly a far cry from a life sentence. I told myself students couldn’t really learn as much about the strains of prison without seeing the harsher conditions that exist in state institutions. That is, until this last visit.

Most of the tour went as usual. We went through the older part of the facility where cells can get up to 110 degrees in the summer. We saw the visiting room where men talk to their loved ones through glass. The officer who showed the students around Billerica explained that prisoners must walk on the green stripes in the hallways; there were the usual men cleaning with mops and pushing large barrels down walkways; the smell was of too much cleaning fluid. We passed through the health unit where men were waiting to see practitioners and others were isolated in cells. It was prison as usual.

We no longer are allowed to see the Hole or what prison officials call the Segregation Unit, since men are there disciplined to solitary confinement which my students know Supreme Court Justice Anthony Kennedy recently said can drive men mad. Therefore, the highlight of the tour is always taking them into what is called a “pod.” A pod is the relatively new term in prison construction where prisoners can live in a contained unit. These pods are somewhat stale and robot-like but they allow the COs the ability to see what is going on.

We entered the pod where men do drug treatment and have earned some privileges. It has the reputation of being a better place to reside than the old part of the institution which is pretty grim and can house two men in a cell. To the left is one old institutional unit at Blillerica, looking a little prettier than it really is with whitewashed grey walls, all somehow devoid of color in reality:

On the pod we entered, those incarcerated run some of the addiction groups themselves, we were told. On the tier above the day room where prisoners sit, eat, and play cards at the tables, are rows of cells where men live. The same cells are on the first floor all around the room.  Each cell has a tiny vertical slit—a window—and when we come into their space, the men inevitably stare out the window at us. At times, they’ve pounded on their doors; at other times, they’ve all been at tables eating lunch, trying to ignore the fact that there are outsiders nearby.

This time, when the twenty of us entered, there were only a few men in their brownish beige uniforms sitting at tables. Another two were talking to the guards who policed the room, two perched at a computerized station at one end. The students all took turns entering a cell to see what it is like, a rather disturbing experience on many levels for most of them. One student, we’ll call her Sofia, suddenly turned toward me as Spanish was heard above us. She pointed up at a window where a man smiled widely and pressed his face against the slit.

“That’s my brother,” Sofia said, her eyes filling with tears.

I looked up and he waved at me, his sister’s teacher. Sofia looked away.

I asked the young woman if she had known he would be here, and yes, Sofia said, she knew he was in this  facility but no, she had no idea she might see him. She seemed torn, wanting to look, wanting to hide. She said under her breath as others continued their entrance into cells, as far as she knew, he had no hope of ever not doing drugs. She’d lost touch, she said. She couldn’t imagine he might be doing OK.

But the young man’s face lit with joy when he saw her, and before we left that unit, it was almost as if a light went off for her too. Prison became about loneliness, about being apart, about the kind of pain that happens when families break up. It was no longer just about this space or this room or that hallway. Sofia’s brother, as close as he was, was nowhere near his sister. And would not be for a long time, perhaps never. She understood that and so did I.

When we exited Billerica that day, Sofia told the other students about her brother behind bars. Now, after walking through Billerica, and after being with Sofia, they understood why prison was not just a physical place, but a deep wound.

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My friend Tonya, a woman in her late thirties who has lived in poverty for decades, called me today. “I feel like a sponge,” she said. “Everyone’s problems trickle down onto me and I absorb them all.”

Tonya was referring to the term “trickle-down economics.” While she didn’t have the exact definition of trickle-down economic theory in mind (trickle-down economics is the idea that tax breaks and other economic benefits provided to businesses and upper income levels “trickle down” to benefit all members of society), she clearly understood that trickle-down economic policies have not worked for her over the decades in which the gap between rich and poor has widened dramatically.

Trickle-down prosperity is at best “voodoo economics” and at worst a cruel trick played on the majority of the American people. But trickle-down poverty is all-too-true at the level of families and households. Eighty percent of Americans do not have sufficient savings to weather a two month loss of income. For these millions of people, an illness or job loss affecting one member of a household trickles down and out to networks of friends and family shouldering the responsibility to help pay for basic housing and subsistence food.

Poverty also trickles down from generation to generation. Children who experience poverty are more likely than other children to grow up to be poor. Tonya is already keenly aware of this fact. As a young mother, she could not afford housing. She and her daughter lived in shelters, parks, friends’ living rooms, and – for a time – in the stairwells of local universities. Tonya eventually lost custody of her daughter on the grounds of not providing a safe environment for her. Her daughter did not thrive in the years she lived with relatives, a foster family and in institutional settings. Now in her early twenties, she does not have a high school diploma, struggles with reading and writing, and has never held a job. She does, however, have a baby. And just like when she herself was a young child, she is dependent upon other people offering her a place to stay.

Everyone –extended family and social workers alike – expects that Tonya will take the grandbaby. But Tonya, who finally has a stable place to live, is raising a young son of her own and barely scraping by on a few hundred dollars a month of welfare payments. (Full disclosure: I have known her son since the day he was born and can vouch for Tonya’s dedicated parenting and for her son’s unbelievable cuteness!) For a variety of reasons – lack of education, health challenges, bias against out-spoken Black women – she has not been able to keep a steady job. Most recently she was hired to work at a local supermarket for wages that she describes as “high school kid wages” but was fired after a few weeks when she had to call in sick with a throat infection, despite showing her boss a note from her doctor attesting to her infectious health status.

For the past six months Tonya has been stretching her welfare check to help support her daughter, grandchild and a brother who has mental health problems as well as a criminal record that essentially makes him unemployable. She is terrified that the expenses of taking on another person will take away resources that her son needs. There are days when she does not have the money for bus fare so she cannot take her son to school – a sort of trickle-down educational deficit issue that gravely worries her. She also is behind in her rent and in danger of losing her housing, which would likely mean that her son would be taken from her.

I asked her, “Can’t anyone help you out? Can your mother help? Your son’s father?” “No one has any money,” she replied. “We’re all in the same boat. And I’m the one who’s been keeping it going for everyone but there are days when my head is bobbing up and down to get air. I’m near the snapping point; my hair is falling out and I am having nightmares every night. I don’t know why I can’t get ahead. I can’t even catch up. I see people who have the life I want – a job and a house. There’s something wrong with me that I can’t have those things.”

“Tonya,” I told her. “There’s nothing wrong with you that a good dose of fair and rational economic policies wouldn’t cure.”

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You can read more about Tonya here: Sex, race and prison’s violent double standard: Incarcerating men hurts women, too

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I’m excited to share that I will be making three appearances in the Boston area soon! I will speak about the day-to-day lives of Boston-area women who struggle with violence, poverty, illness and the challenges of an unforgiving world at these venues:

On Wednesday, March 25 at 7:00PM, I will be at Porter Square Books at 25 White Street in Cambridge, a “fiercely independent” bookstore that encourages and promotes face-to-face conversations between local authors and readers.

On Wednesday, April 8 at 12:00 noon I will speak about the problems of fragmented health care and social services for criminalized women at the University of Massachusetts, Amherst, Arnold House, Room 120.

 

On Sunday, April 26 from 11:30AM to 12:30PM, I will be at Church of Our Saviour at 21 Marathon Street in Arlington, an Episcopal church seeking insight into the complexities of being helpful to marginalized people.

All events are free and open to the public. Please come and let your friends know!

Candidate Charlie Baker; photo by Matt West

After running on a campaign of new and smart ways to reduce government spending, Massachusetts Governor Charlie Baker (R) has proposed budget cuts for fiscal year 2016 that are neither new nor smart — going after the low-hanging fruit of government funded Medicaid (MassHealth) for the Commonwealth’s poorest, sickest and most vulnerable residents. Most of the proposed savings to MassHealth in Gov. Baker’s plan are merely a matter of bookkeeping – shifting costs from fiscal year 2016 to fiscal 2017. But the Administration also aims to reduce spending by requiring over one million residents enrolled in MassHealth to prove that they are still eligible. Though the Administration has not provided an estimate of how many ineligible people are enrolled, Baker’s budget team estimates that this move will save the Commonwealth $210 million.

The immediate plan is for the Commonwealth to contact 1.2 million people who were automatically re-enrolled in MassHealth when the Health Connector (‘Exchange’) website experienced technical failures in 2013. Each of these people will receive two letters asking them to reconfirm their eligibility. After 60 days those who do not respond will lose coverage. That may not sound unreasonable, but as a sociologist who works with low income women, I suspect this plan presents disproportionate hardships for residents who do not have permanent addresses or who struggle with understanding government forms and with gathering the required documentation; that is, the people who most need consistent healthcare coverage. Individuals who lose eligibility will be allowed to re-certify in the future, but the immediate effect will be disrupted care and an uptick in expensive emergency department usage.

The scanty information released by Governor Baker’s office indicates three categories of potentially ineligible people who would be eliminated from the MassHealth rolls. The most straightforward are people who still are on MassHealth plans but have moved out of state and receive coverage elsewhere. These people, however, would not seem to account for much spending given that they have other insurance where they actually live so are unlikely to use MassHealth benefits. The second category is people who have had a change in income sufficient to place them over the eligibility threshold. Given the absence of a meaningful economic recovery for low wage workers in Massachusetts, this category likely consists of individuals and families whose current earnings push them marginally over the eligibility line. Switching these people from MassHealth to the heavily subsidized insurance policies that they are eligible for through the Health Connector is unlikely to make much of a difference in the budget.

A third category – people who are purposely cheating or “working the system” — has not been explicitly singled out in statements from the Governor’s office. But given 2010 gubernatorial candidate Charlie Baker’s fake electronic benefit cards that said: “Deval Patrick’s Massachusetts EBT Welfare Card. Swipe me for booze, cash, cigarettes, and/or lottery tickets at taxpayers’ expense,” weeding out Medicaid cheaters certainly lurks behind the call for re-certification. Again, we have no information regarding numbers, but we do know that hunts for fraudulent welfare claims consistently turn up very little cheating and thus very little cost-saving. Last year, for example, Maine Gov. Paul LePage (R) released data intending to prove widespread welfare abuse but in fact showed that 99% of all welfare benefit transactions were legitimate and legal.

The re-certification process in and of itself will be costly. If we calculate (modestly) 15 minutes for a government worker to process a straightforward re-certification, the 1.2 million re-certifications will take approximately 300,000 hours. And if we assume (modestly) a salary of $15 / hour for the workers who process re-certifications, the bureaucratic cost will come to 4.5 million dollars – a substantial chunk of what the Administration is looking to cut from the MassHealth budget and money that surely could be spent in a manner more conducive to protecting the health of Massachusetts’ residents.

These numbers are just an estimate, and I assume the Governor’s staff has more accurate numbers. But even if I’m off by 50%, we’re still looking at a cost cutting plan that is likely to cost the Commonwealth a great deal both in terms of salaries and in terms of health.

For more on the larger picture of  health care coverage click:  Health Insurance Roulette: The House Always Wins

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The Jewish holiday of Purim starts this evening and continues throughout the day tomorrow. Something of a cross between Halloween and Carnival (though more toned down than either), Purim is one day in the year in which Jewish children and adults are encouraged to wear costumes. While I’m sure there will be a few fabulously funny and innovative outfits at my synagogue tonight, I know – even before seeing them – that most of the little girls will be dressed as princesses or brides while quite a few of the adult men will be dressed as women. Coming on the heels of Mardi Gras, Purim has me thinking about why so many cultures feature costuming practices that draw attention to gender.

To begin with, it’s useful to make some sort of distinction between clothing and costuming, though these categories certainly overlap. When I dress up in a tailored blazer to go to court I feel that I’m putting on a costume although that blazer was purchased at Macys – not at a costume store, and similar blazers are fairly standard items in the wardrobes of professional women today. Yet I do see something of a difference between clothing that is mostly functional (we wear it to keep warm, protect our skin from the sun, keep our bodies clean or dry, avoid being arrested for indecent exposure, or warding off unwanted interpersonal contact) and costumes that we intentionally don for their symbolic value with the conscious intention of drawing attention, reactions and interpretations.

Like all symbols, costumes are multivocal or multivalent, suggesting multiple meanings to the dresser, the wearer, and the viewers.

As a Jewish American mother, for many years I served double duty as a dresser for Purim and for Halloween. At first I consistently dressed my babies and toddlers in gender neutral “cute” outfits. At an age in which they were too young to notice or care I pushed back against gender stereotypes but embraced age stereotypes (cuteness) by dressing them as un-sexed teddy bears, bunny rabbits, and that ultimate cross-cultural costume: the Purim pumpkin.

As soon as they were old enough to care, my children demanded gendered costumes. My daughter, like all of her friends, dressed as a princess, a fairy or the Biblical Queen Esther (happily for my wallet, these are basically interchangeable costumes) for nearly a decade. Her costumes challenged age norms (she dressed as a young woman, not a little girl) but magnified gender with make-up, jewelry and long skirts that made running and climbing impossible.

My sons went through a brief cowboy, policeman and soldier stage (they later told me that they didn’t care about the costumes but they wanted the guns that we normally did not permit in our pacifist household.) But for most of their childhood and early teen years they wanted to dress as a hyper-masculine super-hero.

Not just any super-hero. My eldest son in particular would begin planning his Purim costume a good four months in advance. Over that time he’d consider, play around with and even stress over whether he would be Superman or Spiderman. Perhaps the tenth time he woke me up at night to talk about the heavy decision weighing on his heart I realized what was going on in his mind: He cared so much about his costume because the decision of being Superman or Spiderman really was about being Superman or Spiderman – a decision of existential importance. Would he be able to climb the outsides of buildings or would he be able to fly? My son helped me see a deeper cultural truth: Costumes are transformative. For that reason many religious traditions use costuming and masks for ritualized existential transformations in which the costume wearer becomes – embodies or is possessed by — the god or the spirit.

Once boys reach their later teens and adulthood and (assumedly) become too sophisticated to think that they truly will be transformed by their costumes, many turn to dressing up as women. Blonde wigs, high heels and mini-skirts are sure-fire recipes for getting a laugh at Purim, Halloween and Carnival masquerades. (Of course, cross-dressing limited to the privacy of one’s own bedroom is likely to be interpreted as pathological or at least bizarre.) At these same events it is rare to see adult women wearing “men” costumes. A woman can masquerade as a particular male profession or identity (fireman, Elvis) but dressing in “men’s” clothes simply means wearing normative clothing in a culture in which male is normative and female is “special” or “other”. Masculinity lacks much of the ‘artifactuality of the feminine’. In fact, a woman wearing generic men’s garments (slacks, button down shirt) at a Purim or Halloween party would likely be asked why she isn’t wearing a costume! This is what Peter Tokofsky calls the ‘asymmetry of cross-dressing’.

Costumes conceal identities and free us to do things we wouldn’t normally do (for example, flirt, get drunk) AND free other people to do things TO the costumed one (I think here of the behavior of “straight” men at a drag show). Embracing that sort of freedom, many cultures practice what anthropologists call rituals of reversal; that is, rites in which, for a prescribed amount of time, social roles and norms are turned topsy-turvy. Classic anthropological wisdom goes like this: In repressive and strictly hierarchical cultures tensions build up. Rites of reversal are an opportunity for everyone to blow off steam for a few hours or days at the end of which most people will feel relieved to go back to the ‘natural’ social order. In her work on Mardi Gras, Carolyn Ware argues that “when men dress up as women they reaffirm masculinity by ridiculing the feminine and therefore ratify the social order.” Chaos is fun for a little while, but few of us want to live out our whole lives in a drunken Mardi Gras parade.

Costumes can elevate (as in the case of the Superman costume) but they also can degrade. A number of years ago an anthropologist colleague in Israel observed the Purim costumes of ultra-orthodox Jews whose religious beliefs demand extensive gender segregation and limit leadership roles to men. In the ultra-orthodox neighborhood of Mea Shearim she noticed a pattern of men dressing as women and women and girls dressing as inanimate objects. In this scene, unlike in the Superman scenario, costumes moved people down an existential level.

For some of these ultra-orthodox girls the cumbersome de-humanizing Purim costumes were good practice for wedding costumes that, for some groups, include a long opaque veil wrapped around the bride’s head hiding her face from the audience, covering her eyes and making her dependent on others to lead her around. I see much the same process of existential transformation in the extreme coverage of women’s bodies and faces demanded by ISIS and other extremist and ultraconservative religious groups:  Full body and face coverings erase markers of individuality, turning the wearer of the costume into a symbol to be “read” by others (for modesty, piety and moral status) every moment of every day in every setting and situation.

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As awareness is growing of the financial and human costs associated with mass incarceration, we’re hearing talk from politicians on both sides of the aisle (and, believe it or not, even from the Koch Brothers) about the need for “alternatives to incarceration” (ATIs).

The term “alternatives to incarceration” takes for granted that we are talking about ways to handle criminals who otherwise would need to be incarcerated — that incarceration is a reasonable baseline against which to measure “alternatives.” In light of the over-representation of Americans of color and low-income Americans in jails and prisons, however, it’s necessary to be careful about any sort of presumption of correlation between criminality and incarceration. In fact, about a third of people locked up in the US are awaiting trial; that is, they have not been convicted of a crime. Another third are locked up because they violated the terms of probation or parole; that is; the “criminal” act was not sufficiently egregious to require imprisonment but a subsequent action – often simply not showing up for a meeting with a parole or probation officer, or failing to keep up restitution payments or money owed in court fees – was the reason for incarceration. And 97% of federal and state criminal prosecutions are resolved by plea bargain – often accepted by defendants out of fear that if they don’t accept the deal they will be locked up even longer — rather than by trial.

Given these numbers, it’s easier to make a case for abolition than for “alternatives to incarceration.” But that is not the direction in which public discourse seems to be moving. To the contrary, the increasingly popular sentiment goes something like this: A whole lot of people sitting in jails and prisons are mentally ill; they are drug users who need treatment more than they need punishment. Echoing this sentiment, Los Angeles County – the US county with the largest number of incarcerated people – recently approved a $1.9 billion proposal to tear down Men’s Central Jail and construct a 4,885-bed “Consolidated Correctional Treatment Facility”. And while “treatment” certainly sounds beneficial, the content of that treatment has yet to be spelled out.

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Over the past five years I followed a cohort of Massachusetts women who cycle in and out of prison as well as a variety of treatment programs. All of the women, at some point in their lives, have been diagnosed with a psychiatric disorder (most commonly substance abuse, bipolar disorder, PTSD). Overall, these twenty-six women spent far more time in treatment than in correctional settings. Yet, at the end of five years only three women had settled into reasonably secure housing, stable employment and long-term desistance from substance abuse.

Typically, treatment programs include some combination of pharmaceutical, twelve-step and psychotherapeutic components. Most of the women I have come to know are prescribed mind-boggling assortments of psychotropic medication, some of which make them, as Elizabeth (a white woman in her early forties, Elizabeth was homeless for a decade) used to say, into “a space shot” who shuffles around in a daze that puts her at elevated risk for being robbed or assaulted. Whether anti-anxiety, anti-depression or anti-psychotic drugs, these medications are not intended to cure the underlying problems such as sexual assault and homelessness that lead to anxiety, depression and substance abuse. Rather, psychotropic medications are prescribed in order to manage the individual’s response those problems.

While not all treatment programs prescribe psychotropic medication, virtually all incorporate – explicitly or implicitly — twelve step ideology and practices. Treatment facilities tend to be plastered with twelve step slogans such as “Let Go and Let God” and “Cultivate an attitude of gratitude,” and formal AA/NA meetings typically are part of the treatment regime. With emphasis on admitting one’s powerlessness (Step 1) and making moral inventories of one’s faults (Step 4), these programs do not seem to offer the women I have come to know a meaningful script for re-organizing their lives. When I visited Joy, who has been homeless for nearly fifteen years and nearly died as a consequence of a brutal sexual assault, several weeks into her stay in a treatment facility she enthusiastically explained to me that, “I’m learning that my problems are in my head.” Unfortunately, her problems also were in the real world: Less than a year later she was back on the streets where she was sexually accosted by a police officer who then arrested her for solicitation.

Most treatment programs in Massachusetts also include some sort of psychotherapy, and nearly all of the women I know have been treated by multiple therapists over the years, sometimes beginning in adolescence or even childhood. With its focus on the individual psyche, psychotherapy addresses personal flaws such as poor impulse control, allowing oneself to be a victim, and struggles to “get over” past traumas. But as Elizabeth explains, “I don’t need to talk about my problems. I need a place to live so that I won’t be scared all of the time.” This does not mean that therapy is useless; it does mean that “talk is cheap” without the material conditions that permit women like Elizabeth and Joy to build a secure life.

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There is little evidence pointing to long-term success for any particular drug treatment modality. Studies showing positive outcomes typically fail to track program participants for long enough time to establish meaningful rates of success, look only at participants who completed the program, fail to control for confounding variables, or look at very small numbers of participants from the start. The absence of evidence for the success of treatment programs is especially glaring when the treatment is coerced or carried out in a coercive situation. It may be tempting to believe that even if treatment doesn’t help everyone, at least it doesn’t hurt. Yet, as we’ve learned from the past — from efforts to “cure” homosexuality to the tranquilizers (“mother’s little helper“) of the 1960s,  when a patient’s ideas or behaviors challenge social hierarchies of race, gender, sexual orientation or class, treatment that is ostensibly for the patient’s own good may be used to bring the “deviant” individual back into line. As those of us old enough to remember Jack Nicholson’s performance in One Flew Over the Cuckoo’s Nest can attest, therapeutic interventions aimed at “getting inside” the patient’s head can carry heavy costs indeed.

The murky line between punishment and treatment has not been lost on some of the corporations involved in the prison industry. Correctional Healthcare Companies, for example, has expanded beyond providing medical services to prisons and now offers services for the “full spectrum” of “offenders” lives: “pre-custody, in custody, and post-custody,” a timeline that perhaps says more than the company intended about American understandings of criminality.

Read more: Incarceration by Any Other Name: A Return to the Cuckoo’s Nest?

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A Guest Post by Amy Agigian, Founding Director of the Center for Women’s Health and Human Rights at Suffolk University

AmyAgigianGreetings from Boston, where we are currently experiencing Snowmageddon 2015. We’ve had four storms, accumulating over seven feet of snow, in less than three weeks, making this the snowiest month in Boston’s long recorded history.

But what does our unparalleled snowfall have to do with women’s health and human rights? First, the health effects of extreme temperatures hit those with fewest resources–money, housing, safety, good health–hardest. It makes sense if you think about it: if you’re already sick, or living in a violent home or neighborhood, added difficulty getting around is much more serious than for healthy people who are safe at home. If you are homeless or have precarious housing, finding shelter and keeping track of your possessions is that much harder in the brutal cold. The lower your income, the more you will likely depend on massively-disrupted public transportation. And obviously, if you have little money, you can least afford to miss days of work when businesses shut down during blizzards. People caring for children and other dependents also struggle with the dearth of passable sidewalks, breakdowns in public transportation, inability to rely on the timely arrival of caregivers, and simply being stuck in the house day after day.

In addition to these immediate burdens, this historic weather has longer-term implications. Counterintuitively, Boston’s “extreme weather events” are likely part and parcel of global climate change. Global warming leads to more severe snow and rain storms, as well as heat waves, droughts and wildfires. Instead of this month being a freak outlier, we are likely to suffer more, and worse, extreme weather events as climate change intensifies.

All over the world, women bear the worst brunt of a degraded environment. As  UNFPA explains, women are disproportionately affected by global environmental hazards. Women are the majority of those who stretch the family budget when income is disrupted, take care of family members when they can’t afford or access formal healthcare, and walk farther to gather and carry water or firewood. All over the world, women’s resources and health are taxed by such burdens. These hardships exacerbate violations of human rights including the rights to health, an adequate standard of living, and gender equality.

It follows, then, that women must be central to finding both short and long-term solutions to these problems. Women bring critical perspectives, insights, and priorities to discussions of extreme weather. Women’s health and human rights should be put at the center of all policy discussions and funding decisions, at every stage of planning and implementation of solutions. Snowmageddon 2015 has brought much of New England to a grinding halt. Centering women’s health and human rights can help it from becoming the new normal.

Click here to read about the Center for Women’s Health and Human Rights.