The Republican plan to eliminate or change substantial portions of the Affordable Care Act is likely to have a disproportionately deleterious impact on women. This is why.

 Women compared to men use more medical services and spend more on health care. Thus, any reduction in government support for health care will affect women more than men.

Women make more visits each year to primary care physicians than do men and are more likely than men to take at least one prescription drug on a daily basis.  According to the Health Care Cost Institute, “In 2015, spending was $5,684 per woman and $4,581 per man. …  From 2012 to 2015, the difference in spending between genders rose from $1,071 per capita to $1,103 per capita.  Per capita spending for women was higher than for men on every type of service, except brand prescriptions.”

Given women’s higher healthcare needs, the ACA protected women by requiring all plans to meet a minimum level of coverage that includes a basic basket of necessary services. The Trump administration has announced that they will reduce the price of premiums so that Americans can have more “choice” to select less expensive insurance.  Less expensive insurance typically covers less, which disproportionately hurts people who have need of more medical services. Lower premiums also may come with higher annual deductibles, meaning that people need to spend a large sum of money out-of-pocket before insurance will pay. Again, this places a particularly heavy burden on people who need more healthcare services.

In particular, women are more likely than men to suffer mental health challenges and women make substantially greater use of mental health services. Beginning in 2020, the GOP plan would eliminate the current requirement that Medicaid cover basic mental-health and addiction services. This roll back of mental health parity requirements will disproportionately hurt women.

 Women are less able than men to afford health care.

According to the Department of Labor, women earn less than men. In 2014, for example, women who worked full time in wage and salary jobs had median usual weekly earnings of $719, which was 83 percent of men’s median weekly earnings ($871).

The Republican plan emphasizes tax credits and health savings accounts, both of which are irrelevant to low-income Americans.

According to the Department of Labor, women are more likely than men to be among the working poor. This is the group that has the most to lose with the Republican plan to decrease subsidies and eventually eliminate the Medicaid expansion.

The Republican approach to Medicaid disproportionately impacts women.

Nationally, women make up 56% of Medicaid recipients (in 2015). In states that did not expand Medicaid under the ACA, women are an even greater proportion of Medicaid recipients. In South Carolina, for example, 67% of Medicaid recipients are women. In Nebraska 66% are women. Thus, phasing out the Medicaid expansion will disproportionally hurt women.

The ethos of suspicion directed at Medicaid recipients will further hurt women. For example, the Republican plan requires states to re-determine Medicaid eligibilities “no less frequently than every six months.” Given that women bear the greater share of responsibility for arranging health care in American households, the need to frequently recertify eligibility will place an increased time burden on women to keep track and show evidence of eligibility.

Near elderly women are at particular risk of losing coverage under the Republican plan.

Women are less likely than men to be insured through their own job (35% vs. 44% respectively) and more likely to be covered as a dependent (24% vs. 16%), a disparity that reflects the fact that women are more likely than men to work at part-time jobs in order to carry out duties as primary caregivers for children, sick and disabled family members, and elderly parents.

At the same time, many American women are married to men who are slightly or significantly older than they. This means that when the husband retires and becomes eligible for Medicare, the wife loses the “dependent” coverage she had while her husband was employed, but she herself will not yet be Medicare eligible.

This age group has particularly high healthcare needs that may become exacerbated while waiting for Medicare eligibility.

Under the A.C.A., plans can charge their oldest customers only three times the prices charged to the youngest ones. The Republican plan allows insurers to charge older customers five times as much as younger ones and gives states the option to set their own ratio.

Planned Parenthood

The Republican plan singles out Planned Parenthood, prohibiting federal funding for Planned Parenthood for one year beginning with the enactment of the law. This will have a disproportionately negative impact on women.

Two and a half million women and men in the United States annually visit Planned Parenthood affiliate health centers for a variety of healthcare services. Most of these people are women who would stand to lose a wide range of primary healthcare services including, but not limited to, contraception.

 Abortion

Under the Republican plan, qualified health plans cannot include abortion coverage except for pregnancies that present life-threatening physical risks (not mental health risks) and pregnancies that resulted from rape or incest.

This provision not only reduces access to a needed medical procedure, but it also seems to require some sort of process for determining whether a pregnancy is life-threatening or confirming that a pregnancy is a result of rape or incest. This potentially could force women to prove (to the satisfaction of an insurance company) that she indeed was raped, and it certainly would delay performing the abortion – a delay that in and of itself presents health risks to women.

The Republican plan does allow insurance to pay to treat “any infection, injury, disease or disorder that has been caused or exacerbated by the performance of an abortion.” Since legal abortions performed by a qualified medical provider in a suitable medical setting are extremely safe, this provision seems to be set up for women who have resorted to “backstreet” abortions. While it is unlikely that the plan’s intent is to encourage illicit abortions, this provision seems to acknowledge that an increase in unsafe abortions may be a consequence of the plan.

This analysis was prepared by Susan Sered on March 8, 2017. Healthcare legislation currently is highly volatile with many changes proposed. Stay tuned – I will come back and update this analysis as more information becomes available.

Related articles: Uninsured in Texas, Then and Now     Faces of the Newly Insured      Health Insurance Roulette: The House Always Wins

Life is never boring for the women of Can’t Catch a Break. Over the past months they’ve faced serious health problems; they’ve struggled to care for their children and grandchildren; they’ve suffered at the hands of violent men; and they’ve remained trapped in an institutional circuit that often seems to present more hurdles than actual help. Yet that is not the whole story. Many of the women continue to build and draw upon social networks that provide them with places to stay, help with childcare, emotional support, and medical advice.

See Summer 2016 Update to catch up on the women and to help put the January 2017 update into context!

 

Andrea has not been well. Though trim and fit-looking (she’s an avid fan of exercise tapes), she’s been having trouble breathing and her body has been retaining fluids for almost a year. By December 2016, after a string of hospital stays, she was placed in a nursing home. When we spoke she told me, “I hate to tell you but my heart and lungs are not doing so well, so they brought me here. There’s nothing they can do for me at the other hospital.”

I’ve known Andrea for almost a decade and I still can’t tell whether it’s stoicism, fatalism, optimism and / or complete trust in modern medicine, but she was far more upbeat than I imagine that I would be in her situation. As always, she is comfortable staying in a medical institution — perhaps more comfortable than staying at home. Unable to read (she has had mild cognitive disabilities all her life), she finds navigating daily life on her own to be a challenge. In the hospital or nursing home she is looked after, there are professionals around who can explain things to her, and with her friendly demeanor she can always find a nurse or other staff person to chat with her for a bit. “I’m fine, Susan,” she told me. “I’m holding my own. I can still tell jokes and whatnot.”

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Carly (see “A New Home for Carly“) still has not received her baby back from DCF (child welfare department.) Without the baby, she is no longer eligible for the housing subsidy for her two bedroom apartment. For several months after losing her apartment she was on the streets. As of this writing she is couch surfing with a “friend”. (I put “friend” in quotes because Carly has a long history of being taken advantage of and even robbed and raped by so-called “friends”).

Since the baby was taken away, she has become extremely distressed, tormented by hostile spirits, suspicious of conspiracies to hurt her and to steal her baby, and hospitalized (voluntarily and involuntarily). During one hospitalization, “I was shot full of drugs – of Haldol. That’s why I won’t go back there.”

Through all of this, she remains focused on getting her baby back and attends frequent meetings and appointments with social workers, court-appointed psychologists, lawyers, and doctors. She carries around a large pack with her everywhere she goes. The pack contains “all the papers that prove that the baby is mine and that I took care of her properly. I have her umbilical cord, her footprint from the hospital, and records showing she had her infant check-ups.”

I have spent a great deal of time with Carly and honestly cannot figure out how much of what she does and says has to do with her deeply held belief in the active presence of good and evil spiritual powers in this world; how much may be symptoms of mental illness — even psychosis; and how much may be simple naivete. I can say that from what I’ve seen she took proper care of her baby, but I acknowledge that Carly likely tries to show me that she is stable and competent. I don’t envy the DCF workers, psychiatrists and judges who ultimately will decide whether the child is better off with Carly or in foster care.

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Daisy remains limited in her ability to care for herself, but both of her children have stepped up and are able to help her out. Her son has arranged for a supermarket to deliver food to her at regular intervals. She is not up to cooking (she is allowed to use the kitchen in her rooming house), but can prepare simple breakfasts and frozen meals for her lunch and dinner. She continues to enjoy the program for disabled adults that she attends three days each week, and considers the other people there to be her friends. And, “I do my laundry every single weekend.” She sees her daughter at regular intervals and her son and his wife took her along on a road trip to Ohio to visit her in-laws for Thanksgiving.

She does feel lonely much of the time (on the days she does not go to her program she rarely talks to anyone), and spends more time than she’d like cooped up in her room watching television.

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Francesca (see “The Bitch at the Welfare Office“) is still living in a working-class suburb with her son and younger granddaughter. She is busy raising the child and has landed a part-time job at a local supermarket. She does not earn enough to be independent, and continues to rely on her son and boyfriend (she has been in several serious relationships during the past year) for financial support. Unfortunately, that support comes with strings attached. In the case of her son, the strings are expectations that she take on the lion’s share of child care. In the case of her boyfriend, the strings are a matter of exerting control over her time and activities. But overall she is happy with her current life and posts encouraging comments on Facebook at least once a day.

One of Francesca’s greatest assets is her ability to nurture social ties. Over the years she has maintained a strong relationship with the mother of her older grandchild. That relationship is paying off now as the two women help one another with child care. All in all, Francesca has managed to create a safe, cozy and loving family and home for her granddaughter.

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Ginger (seeThe New Price of Freedom“) is back in touch with me on a regular basis! In the summer and early fall she was living on the streets. When I ran into her she told me she was smoking a lot of crack and staying with her “trans mother” (an older woman who had helped her come out as trans when Ginger was in her teens.) A mutual friend told me that he saw her fish around in the garbage and take out a cup and then sit down on the sidewalk with the cup in front of her to panhandle.

A few weeks later she called me from a “safety” phone that she had been given by an agency that helps homeless people. She had moved in with her Aunt after “a homeless man from the Boston Common hit me in the head.” She had a concussion and spent three days in the hospital. When we got together for coffee she told me that she actually had been beaten up three times by the same homeless man who called her “ugly names” because she is trans. When she went to the police they told her they wouldn’t do anything because they told people to stay out of the Common at night. She also had her ID stolen. When she went to meet with a housing advocate he told her that she needs to get her ID first. For Ginger, this is a pretty overwhelming task, involving visits to various offices and paying fees that she cannot afford to pay.

Throughout late fall and early winter she has stayed off crack, resumed her beloved weekly bingo games, and returned to the excellent doctor who has helped her with anti-depressants and hormones over the years.

In November she moved in with an old boyfriend who lives in a rooming house (SRO) but, “We got into a domestic dispute. He hit me over the head with a lamp.” I asked her if she called the police. She said she couldn’t “because I’m a known trespasser [in his building] and they’d arrest me.” For now, she is staying with his brother and trying to move forward on getting her own housing.

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Isabella (see “Failure by Design: Isabella’s Experiences with Social Services“) continues to grieve for her late husband. Over the past months she’s lived in several different apartments, each of which turned out to be problematic. She has come close to getting a job but in the end things have fallen through. She continues to help out friends and acquaintances who need to get into detox or who need help managing their methadone regimes or other drug-related health problems.

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Joy continues to cycle through psychiatric wards throughout the Commonwealth of Massachusetts. In September I visited her in a locked psychiatric ward where she’d been taken after attempting suicide. She told me that she had overdosed. “I just tried to end it. But someone found me and here I am. I woke up in the hospital with tubes everywhere. They told me I almost died. … I had not used drugs for a long time. I got high that one night to kill myself.” The person who found her called 911, and then stole her phone.

A long chain of miserable events had led her to the point of wanting to end her life. Both of her parents have been unwell and may not be able to care for her daughter for much longer. She did not have a place to live and had been staying with a man who constantly criticized her and told her that she can’t do anything right. And she’d spent the previous month in prison. “A drunk woman started fighting with me [in the street.] I slapped her to get her to let go of my hair, and the police arrested me. I was still on probation from [an old] charge of soliciting a police officer [for sex] so they locked me up. I asked them to take me to a hospital and the police refused. When I saw the judge after a month he said to me, “You’ve been in my courtroom at least twenty times. I see that you have paid all but $260 of your restitution and fees [on old charges]. That’s enough. I’m releasing you on time served and remitting the remaining payments. Your probation is terminated.” Joy plead guilty (she told me she didn’t know why) “and that was that. I was released.” Unfortunately, on that same day a former boyfriend who had beaten her up (badly) was in court on the domestic violence charge. Because she had to come to court for her own hearing she was not able to go and testify at his hearing, and he was released. She asked to be able to go and testify but “I was told that wouldn’t be possible because I had to appear at my own hearing.” After he was released, Joy said, he told people that he would track her down wherever she went. She is terrified of him.

While we chatted at the hospital I noticed that her eyes were puffy and her speech slightly slurred. She said she was given Librium to help detox from alcohol – she had begun drinking over the summer and had become addicted. She’d also been put on Haldol and a few other psychiatric medicines.

Her hospital caseworker joined us and we talked about where Joy would go after the hospital releases (at some point in the next few days.) The caseworker had been tasked with setting up Joy’s outpatient therapy, not with finding her a residential program. Joy made her own call to a rehab program she’d been in previously and was told that they couldn’t take her unless she detoxes there first. “But I’ve already detoxed here! They told me to get high and then come to detox and then I could get into the program.” The caseworker confirmed that this is indeed the case, and told Joy that, “You need to do what you need to do to get into a program.”

We asked the caseworker about getting Joy into a group home under the auspices of the Department of Mental Health (DMH). The caseworker explained that group homes only accept people coming from state mental hospitals and Joy is not sick enough to need to go to the state mental hospital. I pointed out that Joy has repeatedly tried to kill herself. She replied, “Joy is high functioning and does not fit the criteria for a state hospital. What you need to do, Joy, is go to a homeless shelter. They will work with you to help you save money so that you can get an apartment. You need to get a job and then the shelter will reserve a bed for you. You need to go to your outpatient appointments and see the doctor. It’s a lot of work but you have to do it. It’s up to you to do the work.” Incredulous, I pointed out to the caseworker that Joy cannot get a job or an apartment. She has three felony convictions, has been homeless since age 18, and has already been in just about every shelter and program in the state.

We then asked what will happen if no placement is found for her when she is discharged. “You will be given two weeks supply of your medication and we’ll set up an appointment for you with an outpatient psychiatrist.” Joy pointed out that it takes longer than two weeks to get an appointment.

The caseworker was not being mean-spirited. Rather, she was a very young woman with no concept of the realities of life faced by someone like Joy. My sense is that she truly believes that if Joy tries hard she’ll make things work.

By November Joy was in another locked ward in another hospital – her third of the fall. When we spoke on the phone her speech was slurred from the medication they gave her. “They are discharging me today – couldn’t find a program or placement. They’ll pay for a taxi.” She told me that she would be going back to [the emotionally abusive] man she’d been living with when she’d tried to kill herself in September. She knew this wasn’t a good solution, “but I have nowhere else to go.”

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Kahtia (See “Prostitution, Decriminalization and the Problem of Consent“)

Throughout the first part of the fall Kahtia was doing well – volunteering everyday at a soup kitchen and attending multiple AA and NA meetings each week. With pride in her voice, she told me how many people the soup kitchen feeds each day and how much the staff appreciates her dedicated work. Most important, the family court judge told her that if she continues doing what she has been doing she will get her daughters back from DCF custody in a few months.

Her daughters were not doing as well. They had been taken away from their third foster home because the foster mother hit one of them. Now in foster home number four, one of the girls had become very introverted. The new foster mother took them for haircuts, which she is not supposed to do without Kahtia’s permission. “She gave them yuppy hair cuts. I mean, they look cute but it’s not what I would have done.” Kahtia expressed concern that the girls will become accustomed to living in a wealthier household and will resent her when they come back home to her.

Later in the fall Kahtia called to tell me that, “I am going through the worst thing in my life. DCF entered a charge of sexual and physical abuse against my husband [the girls’ father]. They haven’t told me any details and they’ve canceled home visits for the girls.” The story, as best as she can figure it out, is this: Quite a while ago, before she lost the girls, they told her that “Daddy touched me”. She took them to the hospital where they were examined but there were no physical signs of rape and no follow-up inquiry. Several months into their foster care time they said the same thing – that “Daddy touched me” (apparently referring to the same incident.) The girls spoke with their therapists but nothing more was said and nothing else happened. Then, almost a year later, in their third foster home, they mentioned it again. “They sent them to a  trauma specialist – I don’t even know what that is – and now the whole thing is under investigation. I don’t know why they talked about this now. Did something new happen in foster care that triggered them to say this? I don’t know what is going on. I don’t know if my husband really did hit or sexually abuse the girls. I feel guilty for not protecting them. Or if the whole thing is made up by DCF? I don’t know. I’m devastated, Susan, especially, you know, because I was a victim of incest and of rape.” She told me in tears, “All I ever wanted was a family, a husband and my children, a house with a white picket fence and a dog in the back and a cat on the window sill.”

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Melanie‘s doctors seem to have stopped looking into her medical problems and are concentrating solely on her PTSD. She has been placed on Disability (SSDI), which does not please her. But she is allowed to work part-time and has arranged to return to the shelter where she had been working, albeit as a “relief” staff rather than a shift supervisor.

Her big news is that — after several tries — she passed her test for her learner’s permit. She feels that she is able to drive, but because of her learning disabilities she’d “bombed” the written test. This time she was allowed to take the test with pencil and paper (instead of on the computer), and the person who administered the test was nice, which allowed Melanie to relax and focus on filling in the right answers. “I feel that everything is coming together!”

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Tonya (see “Knowledge is Power“) is still living in the same apartment. She is dedicated to raising her son and helping out with her grandchildren. Much of her time and resources are eaten up by  family members who come to her for a place to stay and assistance of various sorts.

Her son is now in school and there is no role for her there as a volunteer. “I need something to do but don’t know what to do.”

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Vanessa, now a grandmother, is staying at a homeless shelter. She has not had stable housing for several years. She looks forward to holidays when she can come stay with her mother for a few days. Other than those visits, she seems to be holding steady — no major disasters but no progress in terms of housing or employment.

 

To read previous updates click on:  Summer 2016  New Years 2016   Summer 2015   Christmas 2014 / 2015    Fall 2014 

 

 

In previous posts, I shared stories of Americans who had been uninsured when I first met them a decade ago and who, in the wake of the ACA, now are insured. These stories were inspiring, encouraging and – in a few cases – disappointing in that health insurance alone cannot make up for a lifetime of sub-par living conditions, harmful working conditions, and the cumulative ill effects of inadequate health care.

As the president-elect and Republican congressional leaders are reiterating promises to repeal the Affordable Care Act, it’s crucial to remember what it’s like for Americans to try to scrape by without dependable access to health care. The experiences of people living in states that elected NOT to expand Medicaid eligibility under the ACA serve as a wake-up call for what things were like during the bad-old-days. In this article published in Health Affairs I share the story of Texas parents valiantly struggling to care for a child with disabilities, even while their own health deteriorates due to lack of medical attention.

I ended that article with a section I called “Playing Prophet.”

For the time being, at least, it seems unlikely that the Texas health care landscape will change. The barrage of anti-Obamacare radio, television, and billboard ads I heard and saw when I visited Texas during my research represent a well-financed campaign that, unfortunately, has convinced even those people who would benefit the most from the ACA.

Luis and Daniela’s situation probably won’t change much, either. Luis will get older, still working long shifts driving trucks and loading and unloading them. Daniela will age, too, still lifting Alexa. Alexa will never be able to care for herself. And her brother, now a teenager, will age out of CHIP and either become one of the lucky few in the Rio Grande Valley who finds a job that offers insurance or hope and pray that he remains healthy enough not to need much medical care. It’s likely that the next time I visit them, either Luis or Daniela, or possibly both of them, will have become too disabled to continue working and finally will have health care coverage through Disability—which will come at the price of a substantial drop in family income as well as a blow to their self-esteem as providers. It’s hardly an ideal solution for their family or for Americans overall.

Post-election, this prophecy actually feels overly optimistic. In light of Republican promises to privatize Medicare — as well as the president-elect’s mocking impromptu performance and history of unethical practices regarding people with disabilities — I fear that the family’s worry that Daniela will end up in a horrid, underfunded institutional will happen sooner rather than later.

The first time I met Junie I mostly noticed the scars on her face. They were the result of a stove blowing up when she’d been left alone in the house at the age of three. As it turned out, that was only one in a long series of disasters she suffered throughout her life. Junie was the victim of sexual abuse and of trade in women’s bodies, of drug dealers who pushed crack through the streets and alleys of poor neighborhoods in the 1980s, and of the so-called war on drugs that utterly failed to get dangerous substances off the streets but that succeeded in destroying the lives of far too many African American men and women.

I had the honor of knowing Junie for close to ten years. There were times she’d drop out of sight, but we’d always reconnect and then she’d always thank me for not giving up on her. Each time we spoke it seemed like some new rotten thing had happened to her recently: She was arrested for stealing infant formula for a friend who just had a baby (she was indignant about this); she was kicked out of a homeless shelter for bringing in booze (she laughed about that one); she was turned down for housing for people who are HIV positive (she didn’t know why since she’d been HIV positive since the 1980s); she had a fight with the sister who had always been her most stable source of support (she understood her sister’s point of view: “she doesn’t like me hanging out [on the streets or using drugs]”); she was picked up on an old shoplifting charge by police doing random warrant checks on people socializing outside a homeless shelter, and spent two days in jail waiting for a judge to release her pending a court date (she took this in stride, seeing it pretty much par for the course.)

A few years before her death she and Joe, her beloved life partner, moved from Boston to the Midwestern town where Junie was born. They liked the slower pace of life, the lower rental prices (they were able to afford a small apartment, something that was completely out of reach for them in the Boston area), and the warm and and the welcoming church where Junie became a member of the choir.

She couldn’t however, get access to HIV care in the Midwestern town. When her viral load exploded and she developed full-blown AIDS she and Joe had to choose between housing in the Midwest and medical care in Boston. With her health rapidly deteriorating they returned to Boston where Junie eventually was placed in a nursing home twenty miles outside of the city. Three times a week she was brought into Boston for dialysis. In our last conversation, in late February 2016, I asked her if all of the travel back and forth was wearing her down. She told me that it was fine because dialysis appointments were the only time she and Joe could spend together; he had no way of getting to the nursing home to see her.

Last week Joe’s mother told me that Junie decided that she’d suffered enough and that “she passed” shortly after stopping dialysis. Devastated, Joe decided to turn himself and “clear up” an old warrant by serving a few months in prison.

Her death certificate likely reads “kidney failure due to complications of AIDS.” It should read “national failure due to complications of racism, poverty and violence against women.”

 

Note: I initially met “Junie” (a pseudonym) in the course of ongoing research with criminalized and homeless women in the Boston area. For more on Junie and on the project see Can’t Catch a Break: Gender, Jail, Drugs, and the Limits of Personal Responsibility.

Twelve years ago, I traveled around the country meeting individuals and families who were scraping by without health insurance. In 2015 I returned to the communities I had visited more than a decade earlier. I wanted to learn how the people I had met were faring in the era of the Affordable Care Act (ACA or “Obamacare”). Working with videographer Adam Cohen, and with the support of the Commonwealth Fund, I helped prepare a series of video essays with five newly insured Illinois residents.

When I first met the people featured in the videos, all were stuck in spirals of deteriorating health, low-wage employment and medical debt, with no obvious way forward.

Photograph by Adam Cohen.

Photograph by Adam Cohen.

Taneila was a college student with diabetes who was supporting herself with a part-time job. When she turned eighteen she was no longer eligible to remain on her parents’ health insurance, and as a part-time worker she was not eligible for insurance from her employer.

 

Photograph by Adam Cohen.

Photograph by Adam Cohen.

Cindy, a young mother, had left the workforce to care full-time for her special needs baby. Her husband’s employer did not offer affordable insurance to “dependents.”

Laura was working in the hotel industry, notorious for not providing health insurance for employees.

Joyce was working on and off as a nursing home aide and her husband, Marcellus, was working full time in a warehouse. Neither had ever been offered insurance by an employer and both were experiencing serious health challenges as a result of the heavy lifting required in their jobs.

Photograph by Adam Cohen.

Photograph by Adam Cohen.

All five people had applied for Medicaid but earned too much to qualify for assistance under the old (pre-ACA) eligibility thresholds that limited coverage to low-income parents and severely disabled adults.

Post-ACA all now are insured.

Taneila now has a factory job that provides health insurance benefits. She wishes that when she had turned 18 she could have remained on her parents’ coverage like young people until age 26 now can under the ACA rules. If she had been able to stay on their insurance, she believes, she would have finished college and would now have a better job than working in the factory.

Photograph by Adam Cohen.

Photograph by Adam Cohen.

Cindy continues to cycle on and off coverage with her seasonal job in the local school system, but at least she has insurance for most of the year, which has allowed her to manage her chronic health challenge and maintain a good level of health.

Marcellus became sufficiently disabled (as a consequence of poor working conditions in his jobs and poor access to healthcare) to qualify for Social Security Disability. As a consequence, he is now insured through both Medicare and Medicaid.

The ACA was crafted to include federal funding for expanding Medicaid eligibility for more Americans. However, the Supreme Court ruled that Medicaid expansion must be optional for states. In Illinois, like in other states that chose to expand Medicaid, there have been substantial drops in the numbers of uninsured residents. Joyce and Laura, both of whom work part-time, are now covered by Medicaid. (In contrast, most of the people I caught up with in Texas, Mississippi, and Idaho—states that so far have declined the Medicaid expansion—are still uninsured.)

You can access the videos here: http://features.commonwealthfund.org/faces-of-the-newly-insured

I encourage you to hear their stories!

 

rp_9780520282780_Sered-200x300.jpgThe past six months have been eventful: a birth, a death (see Eulogy for Nicole), a job gain and a job loss, family ties strengthened and family ties torn asunder. Eight years after first meeting the women of Can’t Catch a Break I still struggle to identify indicators or interventions that predict happy or sad outcomes. Secure and stable housing ups the odds that life will be on an even keel, and women who use drugs heavily are less likely to obtain or hold onto housing. But I cannot identify specific personal attributes or past histories consistently associated with continued heavy drug use, moderate use, or refraining from using. Nor can I figure out who makes it to the top of a housing list and who waits for a decade or more for housing. Strong family relationships do seem essential to women’s well-being; that is certainly the case for Daisy and Ashley. But as Vanessa’s and Joy’s stories show, family relationships alone are not sufficient to keep women off the streets or out of jail.  The good fortune to remain healthy should be relevant, and serious health problems can set off a cascade of other disasters. Yet for some of the women, including Andrea and Junie, deteriorating health has led to better access to a range of support services.

The sole pattern I feel confident pointing out is this. The women who seem happiest, most settled and most able to ride the ups and downs that are part of life are the women who have a sense of purpose, a sense that their lives are worth something, that they have something to offer others and — equally important — that others value what they have to offer. While some may argue that having a sense of purpose is a psychological or character trait, my observations suggest that opportunity may play a far bigger role.  In this update we hear from several women who landed a meaningful paid (Mary) or volunteer job (Tonya and Kahtia) or who have been landed with grandchildren to raise (Francesca). These women now feel that their unique contributions make a real difference in the lives of others; that they are good at what they do; that they are respected; and that they have better things to do with their time than chase after drugs or cater to abusive or controlling men.

Andrea (now in her mid-fifties) recently called me, somewhat out of the blue, to tell me that she is in the hospital. In fact, she’d been in and out of the hospital frequently since the early Spring. She said she hadn’t called before “because people are too busy.” Indeed, she seldom has visitors. Her son hasn’t been to see her because he “doesn’t like hospitals.” Her boyfriend rarely comes. And her best friend wants to come but can’t always manage the public transportation system.

The hospital, she told me when I went to visit, “is my home away from home.” Though she is not quite clear about the cause or trajectory of her medical condition (Andrea struggles with reading and with comprehension of complex words and concepts), she likes the hospital and feels that the nurses are “nice to me.” As an example, “The nurse even said that if I’m bored I can come sit by the nurses’ station.” She especially loves the food because “I can ask for whatever I want in my salad.”

When she is not in the hospital, Andrea’s life seems to have settled into a stable routine. She is still living in a studio apartment in a low-income housing complex. She still finds it too small – especially because her boyfriend, who does not have a place of his own, stays with her nearly all the time. She told me that everyone in her building received notice that they are going to receive Section VIII vouchers so, in principle, she can look for a “real” (her word) apartment, but suspects that with her health problems that may not be realistic.

Despite the illness and hospital stay, Andrea (as always) looked nicely groomed. She was delighted when I commented on how beautiful her teeth are: “The woman in the next bed told me that when I smile it lights up the whole floor!”

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Carly (see “A New Home for Carly“) gave birth to beautiful and beautifully calm baby. For a couple of months all was going well. Carly had moved into her nice new apartment right before the baby was born and, with the help of a “pregnancy choice” organization, she set it up with a crib, changing table, baby swing and all of the other requisite baby paraphernalia. I had the good fortune to babysit a few times and even had the great pleasure of giving Baby her bottle and rocking her in my arms.

Then, everything fell apart. Carly became convinced that the baby’s father was trying to get the baby from her, through violence if necessary. A few weeks later, DCF removed the baby from Carly’s custody. Since then, Carly has been extremely distraught and distrustful. The situation is unlikely to improve before her September court hearing.

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Daisy (see “Outcast Island“), now nearing sixty years old, is still stably situated in a room that her adult children found and rented for her. She attends a daily program for people with mental health challenges. Though the program does not offer much in the way of services, Daisy likes it very much. She is a social person and enjoys the opportunity to be with other people. Weekends, which last for three days (the program is only open four days a week), are long and lonely, and the time she is most likely to find herself getting into trouble.

Whenever we speak Daisy updates me on her children, both of whom have solid careers and relationships with significant others. My sense is that her kids have set very sensible and mature boundaries that ensure their mother’s safety while also making sure that her problems do not take over their lives. Daisy is proud of her children, proud of how she raised them, and happy that they call her on a regular basis.

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Francesca‘s (see “The Bitch at the Welfare Office“) life has changed dramatically since the last update.

Both of Francesca’s sons have children. Though the children lived (until recently) with their respective mothers, Francesca has always made a point of encouraging her sons to be good fathers: to see their kids as often as they possibly can and to bring the kids to her so that they can have a relationship with their grandmother as well.

A number of months ago one of her sons received custody of his child. He realized that he would need help, especially during the hours that he is at work. The solution they came up with was for Francesca and her son to get an apartment and raise the child together. They found an affordable apartment in a semi-rural town (this has a serious downside since Francesca does not have a car, leaving her dependent upon her son to drive her everywhere) and quickly turned it into a warm home for the child. Francesca has embraced raising her grandchild. She has taught the child to read, tie her shoes and ride a bike. They adopted a dog and put up a swing set in the yard. Francesca also looks after a few other children in the neighborhood and takes them on “field trips” to the fire station and playgrounds. In a very short time she has created an extraordinary community of families who help one another out and whose children are growing up fast friends.

On some levels, Francesca is living out the fantasy she told me about when we first me: a house with a picket fence, a dog, and her kids with her. She has reconciled with siblings she hadn’t spoken with in years, and loved bringing her sons and grandchildren to a big Easter dinner with the extended family. She is not dependent on a boyfriend for a place to stay or for a sense of belonging, and for the first time since I’ve known her she is involved with a man who is stable, supportive, trusting and respectful.

But on other levels the demons that have haunted her never quite disappear. She still has serious health problems that have landed her in the hospital more than once. During her last hospital stay she re-developed a physical dependence on painkillers. Afraid to tell the staff about her drug history (she, rightfully in my opinion, suspected that if they knew her drug history the would focus on that rather than on her kidneys and liver), she went through withdrawal on her own after she left the hospital. But the more daunting demon is external rather than internal. She has no money, no job, little chance of employment (especially without a car), and a living situation totally dependent upon DCF keeping her grandchild in the custody of her son. Francesca knows all too well that this is a fragile house of cards. But in the meantime, she savors every moment of this “second chance at having a real family.”

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Ginger (seeThe New Price of Freedom“) has not been in touch with me since the winter. I’ve heard from people who have seen her hanging around downtown. I miss her!

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Isabella (see “Failure by Design: Isabella’s Experiences with Social Services“) continues to have a hard time. She is still grieving her husband’s sudden death. She still is on methadone and spends a great deal of time at appointments and meetings at the methadone clinic. She has not been able to hold onto a job and she cannot afford an apartment. As a consequence, she has stayed with a succession of friends. She contributes to paying the bills and pitches in on housework and childcare, but does not have the security of a place that is hers. Several times over the past few months she has been surprisingly upbeat, feeling that good job or housing opportunity is right around the corner. But more often she feels overwhelmed and paralyzed by the sorrow of her husband’s death.

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Joy, now forty years old, truly cannot catch a break. In January she was excited to report that, “I’ve been clean for five months.” She checked into a detox (for perhaps the hundredth time), but “this time I decided that enough is enough and that I’ve had enough.” She was put on Suboxone (similar to methadone) and reconciled with her mother. She was allowed to see her daughter often (her daughter lives with Joy’s father) and even had sleepovers with her. “I am happy that I have my family back.” She remembered that I had told her years ago that many people age out of drug use. “I didn’t believe it at the time but that is what has happened with me. I just don’t want to do it anymore.” While things in her life were not perfect, she was happy to live with her fiance in an apartment down the street from her mother. The day we spoke she had two job interviews: one at a retail store and one at McDonald’s. “I need to put myself number 1,” Joy exclaimed.

By July everything had fallen apart. Crying, she told me, “I do so good and stay sober but still have a shitty life. I don’t understand.”

On a hot summer day I picked her up outside a homeless shelter where she, together with other residents, hang around during the day waiting for the shelter to re-open. Over lunch she caught me up on the past few months. “My fiance beat me up — three times.” The first two she didn’t go to the hospital, but the third time was severe: broken ribs and facial bones. She didn’t press charges because she was afraid his family would come after her, but, she said, these days the state can go ahead and press charges without the woman because they know that women may be afraid. She is relieved he is in jail but nostalgic for her time living with him (she couldn’t stay in the apartment after he went to jail because the apartment and Section VIII eligibility were in his name). “I liked keeping house, cleaning, cooking. I wanted to marry him.” She still has the engagement ring he gave her.

For about eight months the Suboxone worked well, but then she started to have cravings for heroin and asked her doctor to increase her prescription. The doctor refused, “So I quit. I was okay for a while but then I relapsed.” In short, without an apartment, job or boyfriend (none of the job interviews panned out “because of my “record”), “I just decided to go and buy some heroin.” She shot up twice and each time she overdosed and had to be brought back to life with Narcan. (Many drug users now carry Narcan because overdoses have become increasingly common as Fentanyl is flooding the streets.) She OD’d a third time when someone stabbed her with a needle and stole her wallet right after she took out money from an ATM. She has not used since.

I asked her whether she has any leads for housing. Joy explained that she’s been “on the list” for eleven years but has not followed-up or made inquiries. She recently received a call from a town outside of Boston saying her name came up for housing because she had been a victim of domestic violence. She thought they were referring to her fiance’s beating her up but it turned out that they were talking about violence that was done to her twelve years ago. In the end they said she didn’t have enough evidence so she’s not eligible for housing.

When I dropped her off, she didn’t want to get out of the car outside the shelter. There was someone there she didn’t want to see so she had me drop her off on a side street. I had to make some phone calls so I sat in the car for a while. When I drove off I saw her walking down that street, phone in her hand. I wondered if that would be the last time I’d see her.

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Kahtia (See “Prostitution, Decriminalization and the Problem of Consent“) is still working hard towards getting her children back (see New Years 2016 update.) She has participated in, and graduated from, a succession of treatment programs. The certifications of completion will be useful when she finally has her day in court – a year after her children were taken away.

In addition to going to multiple twelve step meetings each week, Kahtia volunteers at a soup kitchen preparing ‘meals on wheels’ and serving lunch to anyone who needs a meal. She loves her work! Here’s an example of an email she sent me: “On my way to do my service work to give back to the public freely as was given to me love waking up and have a purpose today … feeling awesome and positive I thank my god for waking me up 👆 and pray for those who didn’t.”

At this point Kahtia is excited but nervous. She believes she will get her children back because DCF did not have a real case against her to begin with. But the kids have been in three foster homes and three different schools since they were taken. Kahtia knows that they will all have a lot of issues to struggle through when the are reunited.

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Mary, now in her late fifties, is doing fabulously well. She had been one of the fortunate few to receive an apartment in a mixed elderly/disabled public housing complex and has thrived for the nearly seven years she has lived there. Before getting that apartment she had been homeless for decades.

Mary’s big news is that she has a job as a PCA (patient care assistant) for a disabled younger woman in her building. Mary reminded me that she used to work as a nurses aid until, in her early thirties she realized that she wasn’t making a decent living and could earn more selling crack. At about the same time, her mother died and she had to move out of her mother’s apartment. She married a man who “wouldn’t let me out of the house. I cut my wrist so that I could get out [in an ambulance]. That is how I ended up in a battered women’s shelter for a few years. … I didn’t know how to go about getting my own apartment.”

Unable to read, Mary had struggled for years finding a job that does not demand at least some literacy (even just use of a computer to sign into work). Her new job as a PCA feels to her to be a great privilege. Though she only is paid for two hours of assisting daily, she volunteers many more hours because “I love it. I love taking care of people, taking care of someone. I’m a people person!”

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Melanie‘s doctors have not yet figured out a diagnosis to explain her enlarged spleen, liver pathology and diffuse pain. They are running multiple tests which seem to be scheduled weeks or months apart. Between the medical appointments and the pain, she has not been able to return to the work she loves at a homeless shelter. Much to her distress, she has been put on long-term Disability.

Melanie told me that her boss told her that the main reason she can’t come back to work is her mental health. Apparently she “snapped” at people at work a few times (this is very unlike the mild-mannered Melanie I’ve known for eight years). She clarified to me that the people she snapped out were not shelter clients but rather her boss and co-workers who “don’t treat me as an equal.”

On some level Melanie has bought into the idea that her main problems are mental health: depression and anxiety. She was told that all of the things she’s gone through in her life (rape, losing custody of her children because of a drug addiction she acquired after becoming hooked on pain medication in the wake of a botched c-section) have caught up with her. The theory is that the pedophiles she saw as work “triggered” her anxiety and depression.

But on another level Melanie does not agree with this analysis. She tells me that she has not repressed the memories of the awful things that have happened to her and that she has worked at homeless shelters and social service agencies with similar populations for eight years without any problems. The “trigger,” in this analysis, is physical health problems and the fear that she won’t be able to go back to work.

While she continues to express hope that her situation is temporary, she seems to be settling into a daily routine of going shopping and watching television with her disabled mother.

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Tonya (see “Knowledge is Power“), now forty years old, is living in the same apartment. She finally got the management company to take out the (horrid, uncleanable) carpet and put in flooring, so the place looks quite good. She also looks — and sounds — good. She still scrapes by on the welfare checks she gets. Though her son is now almost five years old, she received an extension on welfare (according to law, welfare ends two years after the child is born) because she has applied for SSI (Disability). The SSI was denied and she applied again, and her caseworkers at welfare keep changing, but somehow they’ve allowed her to stay on welfare as long as she does volunteer work.

She loves her volunteer work! Most days she volunteers at her son’s daycare, in part because she can’t afford to take the bus there and back twice so she just stays all day. But more important, “the staff ask me to stay. I gravitate to the arts and crafts table and I like that I can help.”

Her son is the center of her life and she sees him as her primary responsibility. She puts great effort into providing him with appropriate toys and food, and planning his education.

Like many poor and many African American women, her home — which she was eligible to receive because she is a mother — serves as the landing space for her relatives. The brother who had been staying with her last year finally moved out but then her other brother moved in. This brother has always worked and was married with a child but the marriage broke up. He’d never been homeless before so she took him in.

While all of this was going on, she and and her son’s father were fighting constantly. The key issue to Tonya is that he was working and earning a decent salary but was barely contributing to the household. She finally told him to get out. He now is staying with a family across the street and apparently has a new girlfriend somewhere. “I’m tired of it,” she said, “the men who don’t help but just pass babies around from woman to woman, expecting women to make ends meet. I’m fed up with my family too, but they’re my family and I’ll defend them against anyone else.”

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Vanessa, about to turn fifty, has not, according to her mother, settled down. When we first met Vanessa told me that she only had been an addict since she was thirty-seven years old. ““I’m late!” she said, with drugs as with most things. “Why did you start using?” I asked. “I was trying to follow everyone else, be like everyone else.” As she explained once I knew her better, she had lead poisoning as a child and as a consequence is “slow” (her word.) She continued living with her mother until age thirty-eight, when her mother kicked her out because of using drugs. “I wish I was still there,” Vanessa told me more than once. “My mother is a beautiful person. She is my Higher Power.”

By the summer of 2016, Vanessa’s mother had become exasperated. “I’m happy to talk to her if she makes sense but not when she’s not. She’s staying in different places. With a friend and then a homeless shelter…I can’t help her anymore. She’ll do good for a couple of days and then don’t do good. She’s grown. You can’t tell a grown up person what to do. I can’t be aggravated to death. I have my own health to deal with. I raised my mother’s children – she had nine and I was the oldest, and my cousin’s eight children, and my girlfriends’ kids and my own and Vanessa’s kids. I’ve done enough.”

Both of Vanessa’s kids (now in their twenties) are living with their grandmother. Neither is working at this time, though one had a fairly good job until recently. “They apply for jobs but it’s hard to get a job now,” Vanessa’s mother tells me.

 

To read previous updates click on:  New Years 2016   Summer 2015   Christmas 2014 / 2015    Fall 2014 

For more on volunteering see: Concrete Suggestions for Positive Change

On June 10, 2016, a little-heralded court ruling challenged one of the most powerful, pervasive, enduring and taken-for-granted practices in western culture. On that day, an Oregon judge granted Jamie Shupe’s petition to identify as neither male nor female, but rather as gender non-binary. According to Shupe, “After a historic court ruling, I am free. … My court victory has broken a gender binary that many said could not be dismantled. … As a transgender person who was forced to live as a male for nearly 50 years, and who then electively lived as a female for the following three years to alleviate my gender dysphoria, I have discovered that I am healthiest and best served by not being forcibly classified as either male or female against my will. … I am not ashamed of who I am. I was not born into the wrong body. My genitals are not a birth defect. And I am not to be sterilized by psychiatry and a medical establishment that has run amok.”

The Oregon ruling goes far beyond the more hoopla-generating ordinances (dis)allowing transgender people the right to use public bathrooms matching their gender identity. It even goes beyond the June 2016 ruling requiring California prison officials to allow transgender inmates access to “female-oriented commissary items” such as scarves and necklaces, and making California the first state to pay for an inmate’s sex reassignment surgery.

The decision to legally recognize Jamie Shupe’s “non-binary” gender status knocks out the foundation upon which the entire structure of gender inequality rests.

From the Mouths of Babes, and Their Teachers

Two decades ago, together with my family, I spent a year conducting ethnographic fieldwork in an island village in Okinawa (more on that below.) As an anthropologist who studies women’s lives, I initially was drawn to Okinawa because it is the only place in the contemporary world where women are the official leaders of the mainstream religion. Not a sect, cult, order or heresy, the women-led religion has been an integral and respected part of Okinawan life for centuries.

Priestesses in full garb ritually holding cups of sake

Priestesses in full garb holding ritual cups of sake.

My interest in Okinawa deepened when I learned that Okinawans are among the healthiest and longest-living people in the world, with Okinawan women enjoying a particularly long life-expectancy. (You can read more in my book Women of the Sacred Groves: Divine Priestesses of Okinawa.)

A month or so after we returned home from Okinawa, our four year old daughter announced that she is “dumb.” Baffled (to my maternal eyes she is perfect) I assumed that one of the mean kids in her nursery school must have called her a bad name. But no, she explained, it wasn’t a kid. She herself realized she was dumb because “I don’t know opposites.” The other kids in her nursery school, she told us, knew the correct responses to the “opposites’ song” but she hadn’t learned opposites in her Okinawan nursery school.

What is this “opposites’ song”? we asked her.

b5332870e225bf5ad5fbccd81150fdffShe chanted a few examples of a simple rhythmic call and response: The teacher calls out “up” and the kids sing back “down.” The teacher’s “night” is to be answered with “day” and “black” with “white.” The teacher calls out “mommy” and the kids are supposed to sing back “daddy.” The correct response to “boy”? “Girl.” All the kids know the “opposites’ song,” she told us, and they like to show off the correct responses.

Hold on here, I thought to myself. How are boys and girls opposites? As a mother of three boys and one girl I can vouch for the fact that all my kids have eyes (and tears), ears (and ear infections), mouths that laugh and scream, tushies that produce poop, and belly buttons where their little bodies formerly were attached to the umbilical cord. In fact, the differences between the boys and girl were far less obvious or significant than the differences between the oldest gregarious and energetic boy and the second shy and quiet boy.

Nor are mother and father are opposites. We had just spent a year in which my husband was the primary caregiver and homemaker while I was out exploring the Okinawan village. The previous year I had been the primary caregiver and homemaker while my husband worked in high tech. And over both of those years, hadn’t both of us fed the kids, changed diapers, cuddled crying babies and helped the older kids with homework? How could mothers and fathers be opposites? We both were parents fully engaged in raising our children in a loving and healthy environment; it’s not as if one was a parent and the other an anti-parent!

It had never occurred to my daughter that mother and father are opposites until her teacher taught and repeated the “opposites’ song”. (It also never occurred to her that she was dumb until she realized that she was missing an important category of cultural knowledge that all of the other children had already acquired.) As my daughter learned in her nursery school, teachers, like parents and other formal and informal sources of learning, have enormous power to shape the way we think – even to shape how we perceive the world.

The Okinawan nursery school, I concluded, had not done my daughter any disservice by not teaching opposites. Quite the contrary, her new nursery school was doing all of us a disservice by drilling children in the quite unfactual notion that the world is made up of dichotomous and opposing forces. It is that world-view, I have come to understand, that undergirds prejudice, discrimination and structural violence.

Binaries Run Amok

da5ed4e743392874ff94e856e53015e3Anthropologist Claude Levi-Strauss (1963) famously argued that there must be some sort of structure in the human brain that causes us to perceive the world in binaries: us and them, friend and stranger, good guys and bad guys. In the first wave of feminist anthropological critique, Sherry Ortner (1974) built on Levi-Strauss’s model and  argued that male dominance is universal because in all human societies women are more associated with nature (pregnancy, birth and lactation) while men are associated with the opposite of nature; that is, culture. And just as culture conquers nature through tools, agriculture and human settlements, men (as a class) universally conquer women.

Half a century later, these schemas may sound preposterous. Not even the most advanced brain imaging technologies have managed to locate Levi-Strauss’s binary “structure.” Nor have decades of gender-informed ethnographic fieldwork confirmed Ortner’s hypothesis regarding the universality of the “female is to male as nature is to culture” notion. Rather, we’ve learned that brains are far more complex and gender organizations are far more diverse than mid-20th century social scientists could have guessed.

But while Levi-Strauss and Ortner were wrong about the universality of binaries, they were on target regarding their power. Differences that are envisioned as being absolute are particularly compelling: binary distinctions leave no gray area, no room for doubt, no room to recognize commonalities, and no room to negotiate. The construction of two and only two sexes or genders leads to cultural understandings in which men and women are not only essentially different but also antithetical and mutually exclusive types of beings. A popular form of this kind of thinking is represented in books like Men Are from Mars, Women are from Venus in which men and women are characterized as species from different planets who need an interpreter in order to learn how to communicate with one another! While I certainly don’t blame this particular book for centuries of gendered economic and political inequalities and gendered violence, I do believe that that there are real dangers in efforts to reinforce, justify or prove that male and female stand in binary opposition to each other.

The “boy” “girl” binary was not the only insidious and false dichotomy the kids in my daughter’s pre-school were taught to chant. They also learned that “black” and “white” are opposites. Of course, we can look at any random gathering of people on the street and know that not only are skin colors a continuum rather than a dichotomous characteristic, but that there aren’t any actually white or black people: ebony and ivory describes a keyboard, not skin color. Yet, by construing race as a binary we easily tack on a plethora of other binary characteristics: black and white echo dirty and clean, bad and good, stupid and smart, them and us, sinner and saint, terrorist or law-abiding citizen. And that’s where all the trouble starts.

As Jamie Shupe learned over a lifetime of living first as a man and then as a woman, if people or things don’t quite fit into the binary categories, social forces exert power to force them into the binary structure, pretend that they don’t exist, or even eliminate them. Indeed, genocide depends on those in power convincing enough people that there is an essential, absolute divide between “us” (superior humans) and “them” (non-humans or inferior humans who, by virtue of that inferiority, should die).

Shupe’s courageous statement clarifies that punishing non-gender conforming people through formal institutions – transgender people in America experience particularly high rates of incarceration and informal practices – transgender people in America suffer particularly high rates of rape is part of the same falsely dichotomous worldview as fixing (curing) them of their “gender dysphoria” through therapeutic interventions to fix their brains and medical interventions to fix their bodies.

Okinawa

How would a world that is not divided into gender binaries look? In the Okinawan village of Henza, where I carried out fieldwork in the 1990s, I caught a few glimpses.

At the haari community boat race, a man in women’s clothing stood at the edge of the pier next to the mayor. Eager to understand this gendered twist, the next day I tried to ask villagers who he was. But first, I first had to dedicate quite a bit of time to clarifying to whom I was referring.

Susan: Who is that man who was wearing a woman’s dress at the boat race?

Villager: What man?

Susan: The man with the woman’s dress.

Villager: Oh, there was a man with a woman’s dress?

Susan: Yes, the man in the bright red dress, blond wig, and padded bra. You know, the man who stood right up in front of the entire audience at the edge of the dock and danced with the Master of Ceremonies during the climax of the race.

Villager: Oh, you mean Mr. Miyagi.

Susan: That’s right. Who is he?

Villager: A bus driver.

Susan: Why does he wear women’s clothes?

Villager: He likes to make people happy at festivals.

Susan: Does his wife mind that he wears women’s clothes?

Villager: Oh, his wife, she is the one with the garden next to your house.

Susan: Well, what do people in the village think of a man who wears women’s clothes?

Villager: He likes to make people happy at festivals.

Susan: Were there traditionally men who wore women’s clothes at festivals?

Villager: I don’t think so, I don’t know.

 

A similar conversation ensued after the san gatsu (third month) ritual, where I noticed a man wearing a woman’s bodice and a long red loincloth between his legs.

Susan: Who is he?

Villager: Mr. Arakaki.

Susan: Who is Mr. Arakaki?

Villager: He is a schoolteacher.

Susan: Oh.

Villager: But that isn’t why he wore those clothes. Teachers don’t have to wear those clothes.

Women enjoying usudeku group

Women enjoying usudeku group.

 

A somewhat different conversation with the same underlying theme took place at a neighborhood usudeku dance gathering. Many Henza women belong to one of three usudeku groups that practice and then perform elaborate traditional dances at the annual obon festival. Although these typically are all-women groups, I noticed an elderly (92 year old) man had joined one of the groups. He was pointed out to me by several women telling me with pride that there are many very old people in their group (all the others, of course, were women). His age rather than his gender is what elicited comment in this all-women’s group.

The women also told me that at san gatsu (third month) festival he dresses up in women’s clothes and makes merry for the people in the old age home. I asked why and was told, “Because he likes to, and because he has his late wife’s clothes. He put on make-up and a complicated kimono by himself. He has pictures. His wife died when she was 71 years old [tragically young, by Okinawan standards]. She did usudeku until she was 65, and he used to like to watch it.” At this point he joined the conversation: “Because my wife died, I take her to the san gatsu by wearing her clothes.” He and the women made it clear that by wearing his wife’s kimono he was not being outrageous but rather, in his own quiet manner, demonstrating or embodying the continuity between men and women, and between life and death.

These dialogues are a lesson in how not to do anthropological fieldwork. It is a great credit to Henzans that they were able to withstand my persistent efforts to put words into their mouths and to force them to share my own cultural categories. Clearly, the notion of a man wearing women’s clothes is not interesting to Henza villagers. No one remarked on it without my asking, no one drew my attention to it at the festivals, no one even realized who I was asking about until I repeated my question several times, and no one understood why I was interested in asking about this topic. Whereas to my western eyes these men were crossing gender categories, in the eyes of villagers they simply wore clothes that usually are worn by women but that have no inherent or permanent gendered attributes. What we in the West label as “cross-dressing” or “transvestitism” (and find funny, entertaining or abhorrent – depending on the person and the situation) is not a recognizable cognitive category in Henza.

What Does It All Mean?

American scholars have argued that transvestism ultimately reinforces gender divisions. In the West, when a man dresses like a woman and passes, he is gender-bending. If he really wants to pass, he needs to submit his body to surgical and chemical interventions. And if he does not pass, or if he deliberately shows a male trait (such as hair on his chest), the bizarre incongruity of his appearance strengthens the belief that the two genders are polar opposites. An individual who mixes the wrong gender with the wrong sex thus draws attention to the “naturalness” of the gender-sex association and the “unnaturalness” of detaching that association. Unless the situation is very contained (such as in a drag show), the obvious transvestite makes people uncomfortable, as evidenced by the hysteria over the idea that people can use the public restroom corresponding to their gender rather than the sex marked on their birth certificate.

In Okinawa, in contrast, gender is loosely constructed; it is not naturalized or supernaturalized; it is not enforced by powerful institutions or drilled by nursery school teachers. A person who usually is thought of as a man dressed in clothing that usually is worn by women presents no paradox, challenges no world-view, is given no label or diagnosis, invokes no strong emotional reaction, and does not risk punishment.

Okinawan drums typically are decorated with a three stroke swirl; not a binary yin-yang

Okinawan drums typically are decorated with a three stroke swirl; not a binary yin-yang.

The absence of a rigidly binary gender ideology in Okinawa precludes the development of rigidly binary gender dominance. Okinawan women do not suffer from threats and fears of sexual violence (except at the hands of American military personnel) that shape women’s lives in the West. Okinawan women do not experience lower social status, poorer access to resources or any of the other aspects of subordination experienced by women in many or most parts of the world. The fact that women are the priestesses in Okinawa does not grant women moral control over men. And Okinawan women live longer than any other women in the world.

When I think about the violence that transgender and other gender transgressing people experience in America, I wonder what Jamie Shupe’s life would have been like in Henza rather than in the United States. We have yet to see the implications of the Oregon Court’s ruling in Shupe’s favor – it may well be over-turned or ignored. But with that ruling, for the first time in a very long time, I can glimpse the possibility of a chink in the immensely strong fortress of drilled “opposites.”

 

Note: This essay was originally published in TruthOut, November 19, 2015. I’ve reposted it today because calls for involuntary hospitalization are again popping up around the country in response to the perceived opioid “epidemic.” The bill that was eventually passed by the Massachusetts House and then sent to the Senate did not include Governor Baker’s proposal to allow involuntary hospitalization of drug users. Click here for the text of the enacted AN ACT RELATIVE TO SUBSTANCE USE, TREATMENT, EDUCATION AND PREVENTION, signed by the Governor on March 14, 2016.

 

November 2015: Massachusetts appears to be on the cusp of adopting legislation proposed by Governor Baker (Republican) that would allow doctors to hospitalize drug users, involuntarily and without a court order, for 72 hours (H.3817). Previously, the power to order involuntary commitment of drug or alcohol users lay exclusively in the hands of judges under a Massachusetts’ law known as Section 35. At this time, few states give judges similar power to take away the freedom of individuals not accused of a crime. (1)

The proposed bill also would limit doctors to prescribing a 72-hour supply of opiate painkillers to patients receiving a first-time prescription for acute pain. While the second part of the plan has received criticism – concern that patients needing painkillers may not be able to reach their doctors for a refill in a timely manner – the first part of the plan has received virtual cross-the-board support. According to press reports, the majority of Massachusetts’ sheriffs as well as the association representing Massachusetts’ district attorneys have come out in favor of the bill. Hampshire County Sheriff Robert Garvey’s comments represent the growing opinion that, “The governor’s bill changes the attitude that addiction is not a criminal offense as much as it is a medical problem.”

Sheriff Garvey’s remarks are echoed around the country. For a variety of reasons – including a shift in media portrayals of the race of drug users — – we currently are experiencing a cultural and judicial movement away from criminalization and towards medicalization of substance abuse. Massachusetts might well be the vanguard of this movement. Not only is Massachusetts a relatively “white” state at a time in which the new face of drug use is Caucasian, but it also is the first state to have passed the healthcare coverage reform (“Romneycare”) that later became the law of the land nationally (“Obamacare.”)

Addiction Treatment and the Role of Physicians

Having worked for the past decade with criminalized women, most of whom struggle or have struggled with addiction issues, I am far from convinced that the Governor, sheriffs and district attorneys have got it right. While re-categorizing addiction as a medical rather than a judicial issue certainly sounds like step in the right direction, giving doctors unchecked power to hospitalize people against their will opens the door for serious human rights violations. Our legal system, like that of other modern democracies, insists that an individual should not lose his or her freedom without the due process of law. A doctor, committing people without an opportunity for those people to be represented by counsel, will be asked to serve as both prosecutor and judge – a position that directly contradicts principles of American jurisprudence and places doctors in an uncomfortable and untenable position vis-à-vis their patients. Knowing that doctors have this power will, I fear, serve to discourage people who could benefit from immediate medical attention from seeking assistance.

More broadly, the proposed bill puts the onus on physicians to fix social problems.

I understand that the motives behind the proposed bill are benign. However, I assume that the image of the doctor – patient relationship in the minds of the governor, sheriffs and district attorneys is most likely the kind of relationship they have with their own family doctors – a doctor who knows their history and their families, who has a good grasp of their patients’ medical and social backgrounds. However, it is likely that the doctors who will be committing patients under Governor Baker’s plan are emergency room doctors or hospitalists; that is, doctors who meet the patient for the first time at the encounter that leads to the commitment. Asking doctors single-handedly to take away the freedom of patients whom they barely know is not a reasonable burden to place on doctors.

I have great respect for doctors and I understand their frustration at treating patients for overdoses, only to watch these same patients walk out the hospital door immediately following stabilization. However, the bottom line is that there is no evidence whatsoever to indicate that three days of treatment will have any impact upon drug users. (The three day proposal, I assume, is based on the three day commitment for psychiatric patients under Massachusetts General Law, Section 12, though, since no reason is articulated for the three day idea it might just as easily, although perhaps subconsciously, follow the three days between the crucifixion and resurrection of Christ). In any case, there is little to no evidence showing that coerced drug treatment is effective. (2)

When patients are released after their three-day involuntary commitment, there is no reason to think that they will not return to their former drug use. In fact, having abstained from opiates for several days may set them up to overdose when they return to their former level of drug use but with a reduced tolerance for the drugs. (3) If a plan were in place to provide long-term, multi-faceted support after the three days I might have a different take on the proposal. But I do not see that Governor Baker’s bill includes such a plan, or a way to fund it. As I’ve seen repeatedly among the women with whom I work, even the “good” – that is, three month or six month – rehab placements end with people going back out into poverty, unemployment, scarce community support and (often) homelessness. These are sure recipes for sending them back into the drug use / detox cycle.

Blind Faith

We Americans have great respect for physicians and we trust that their medical training is the best in the world. However, addiction treatment is not a substantial part of most medical school curricula, and even in instances where doctors took a course (typically an elective) in the subject, given the rapidity with which the field of addiction treatment is progressing, their knowledge in the field may well be outdated. (4) Anecdotally, I personally have spoken with physicians who know nearly nothing about Suboxone and have never administered a dose of Narcan. Few hospitals in Massachusetts, and even fewer in other parts of the country, have more than one or two addiction medicine specialists on staff, which means that non-specialists will be tasked with the responsibility of deciding whether or not to commit patients who, in many cases, are seen as a nuisance or “revolving door” patient group.

I also know from having spoken with doctors around the country that they, like politicians around the country, tend to believe that twelve step programs are effective for treating addiction when, in fact, there is no evidence showing that Narcotics Anonymous participation (and especially coerced NA participation) leads to long-term abstention from drug use. (5) Indeed, I suspect that lying behind the proposed legislation is the notion, propagated by twelve step organizations, that alcoholism and substance abuse are “diseases” that take over one’s life; that people living with alcohol or substance-abuse disorders lack the capacity to make sound decisions (which is why they must turn themselves over to a “Higher Power.”)

Race Matters

I do not doubt that the vast majority of doctors are thoughtful, fair and knowledgeable. But I do know that there is a sufficient history of medical abuses – including medical experiments on prisoners and on African American men (the infamous Tuskegee syphilis experiment) to require all medical research to undergo thorough vetting and oversight by ethics reviews boards (IRB). In the frenzied panic over opiate deaths in Massachusetts, Governor Baker’s bill lacks a requirement for any sort of oversight. Decades of research show that doctors may tend to treat patients differently depending on the gender or the race both of the patient and of the doctor. (6)

It certainly should raise eye-brows that the popular push to re-label addiction and send addicts to ‘treatment’ rather than prison is taking place at a time when public attention has shifted from Black crack users to White opiate users. At the same time, as I have argued before, redefining people as “sick addicts” rather than “criminal addicts” is not as significant a social shift as one may think. In both cases they are labeled as flawed individuals who have failed to take responsibility for their own lives. In both cases, the onus for “deviance” lies on the individual rather than on the society that creates and sustains social and economic conditions that lead far too many people to feel that mind-altering and mood-altering substances are the best – or the only – means of making it through the day, the week or their lives. And clearly, those people labeled as “addicts” or “drug abusers” are not all that deviant. Throughout the United States, the normative way for dealing with misery is through doctors’ prescriptions for attention challenges, for anxiety, for depression and even for low libido. (7)

And Class Matters

The “epidemic” of opiate related deaths is not spread evenly across White America. In fact, the new attention to white opiate users exposes an important and seldom discussed reality of American society: Class matters. The white opiate users in Massachusetts overwhelmingly come from poor and working-class white communities – mostly non-urban — where good jobs are scarce and where young people see little hope for ever attaining the American dream.

The criminalized women I have come to know over the past decade are, for the most part, poor and white, and I believe that they represent a tragic social trend. According to research published in 2014 by sociologist William Cockerham “For the first time in modern history, the life expectancy of a particular segment of the American population— non-Hispanic white women with low levels of education and income living in certain rural counties—is declining.” And the same decline is happening among white men. (8) Opiate abuse is one of the factors explaining declining life expectancies in these communities, but it is crucial that we understand that opiate abuse is a symptom of hopelessness, disaffection, powerlessness and marginalization. Unless we treat those social forces we are deceiving ourselves if we think that allowing physicians to commit drug users for three days is going to do anything other than intensify those forces.

Notes

  1. Testa, Megan and Sara G. West. 2010. “Civil Commitment in the United States.” Psychiatry (Edgmont). 7(10): 30–40.
  2. Urbanoski, Karen. 2010. Coerced Addiction Treatment: Client Perspectives and the Implications of Their Neglect.” Harm Reduction Journal. 7(13).
  3. Strang, John, Jim McCambridge, David Best, Tracy Beswick, Jenny Bearn, Sian Rees and Michael Gossop. 2003. “Loss of Tolerance and Overdose Mortality after Inpatient Opiate Detoxification: Follow Up Study.” BMJ (British Medical Journal). 326(7396): 959–960.
  4. Rasyidi, E, JN Wilkins and I Danovitch. 2012. “Training the Next Generation of Providers in Addiction Medicine. Psychiatr Clin North Am. 35(2):461-80.
  5. Dodes, Lance and Zachary Dodes. 2014. The Sober Truth: Debunking the Bad Science Behind 12-Step Programs and the Rehab Industry. Boston: Beacon Press
  6. Staton, LJ et al. 2007. “When Race Matters: Disagreement in Pain Perception between Patients and Their Physicians in Primary Care.” Journal of the National Medical Association. 99(5):532-8; Weisse, Carol S., Paul C Sorum, Kafi N Sanders and Beth L Syat. 2001. “Do Gender and Race Affect Decisions About Pain Management?” Journal of General Internal Medicine. 16(4): 211–217.
  7. Greenberg, Gary. 2013. The Book of Woe: The DSM and the Unmaking of Psychiatry. NY: Plume.
  8. Cockerham, William. 2014. “The Emerging Crisis in American Female Longevity.” Social Currents. 1(3): 220-227.

 

Acknowledgments: I wish to thank Barak Sered, MD for his expert advice and input into this paper. All opinions and errors are solely my own.

By Maureen Norton-Hawk, co-author Can’t Catch a Break.

If you were to meet Nicole you would never imagine that she had been battling a drug addiction for years. I can still see her sitting cross-legged on the lawn at the Common during one of our meetings.  Her long auburn hair framed her slender face as she chatted away, oftentimes not pausing between sentences.  She would talk about her love of making jewelry, her efforts to start a business, and the antics of her tiny dog. She was young, attractive, energetic and kind. Her desire to volunteer with the elderly was just one of many expressions of her deep desire to help others.

Unfortunately her giving nature made her vulnerable to those who would exploit her.  The combination of her youth and desire to please others made her an easy target to be used and abused physically, emotionally and economically by traffickers, boyfriends and some family members.

Nicole tried to stay off heroin, and succeeded for substantial periods of time. “I don’t want any more heroin. I want to live, I don’t want to die,” she declared shortly before her death.

Nicole died with a needle in her arm. Even the drug she ran to for relief took advantage of her.

I’d like to think that you are making beautiful jewelry in heaven. Rest in peace, Nicole.

For more on drug-related deaths see ““White Women, Opiates and Prison”   “The Opioid Epidemic: Just the Facts Please”

For previous eulogies see  “Orange-frosted Hostess Cupcakes”   “Eulogy for Elizabeth”

 

FotorCreatedHeadlines decrying the “opioid epidemic” have been in the news on a daily basis lately. Politicians, public figures and journalists here in Massachusetts as elsewhere around the country are practically trampling each other in their haste to jump on the “addicts are not criminals, they are sick and need treatment” bandwagon.

This sort of speedy 180 degree shift in public opinion calls out to me as a sociologist. How did it happen that after decades of quietly locking up people (disproportionately men of color) for drug crimes we now are approaching across-the-political-spectrum consensus in favor of treatment rather than punishment?

I’ve argued elsewhere (“White Women, Opiates and Prison“) that part of the impetus lies in recent spates of high-profile drug overdoses in white communities and an unspoken consensus that while it’s okay to send Black kids to juvenile detention “our” kids deserve better. While the poster-child for drug use in the 80s and 90s was – literally — African American, over the past decade, whites have experienced a greater rise than African-Americans or Latinos in drug-related death rates. According to the CDC, in 2000, non-Hispanic black persons aged 45–64 had the highest rate for drug-poisoning deaths involving heroin. In 2013, non-Hispanic white persons aged 18–44 had the highest rate.

Is There Really a Growing Epidemic?

FotorCreated2No and yes.

No, there has not been an increase in drug use overall, with the exception of marijuana (which is not implicated in drug deaths.) According to statistics released by the National Institute on Drug Abuse:

Marijuana use has increased since 2007. In 2013, there were 19.8 million current users—about 7.5 percent of people aged 12 or older—up from 14.5 million (5.8 percent) in 2007. Use of most drugs other than marijuana has stabilized over the past decade or has declined. In 2013, 6.5 million Americans aged 12 or older (or 2.5 percent) had used prescription drugs nonmedically in the past month. Prescription drugs include pain relievers, tranquilizers, stimulants, and sedatives. And 1.3 million Americans (0.5 percent) had used hallucinogens (a category that includes ecstasy and LSD) in the past month. Cocaine use has gone down in the last few years. In 2013, the number of current users aged 12 or older was 1.5 million. This number is lower than in 2002 to 2007 (ranging from 2.0 million to 2.4 million).

Yes, there has been an increase in the number of drug-related and particularly opiate related deaths. At this time, it is unclear whether that uptick whether that uptick is caused by bad drugs, stronger drugs, lower tolerances in people who cycle in and out of detox, or something else entirely. What we do know is that, according to researchers at the CDC, the primary culprits are prescription pain medication and poly-drug use:

[Our study highlights] the predominant role opioid analgesics play in pharmaceutical overdose deaths, either alone or in combination with other drugs. It also, however, highlights the frequent involvement of drugs typically prescribed for mental health conditions such as benzodiazepines, antidepressants, and antipsychotics in overdose deaths.

The issue, then, is not more drug users but rather higher rates of death from particular drugs and drug combinations. That distinction should be critical in terms of policy yet typically is overlooked. Take for instance, a recent article in the Boston Globe: “Boston Globe Game Changers: Four Innovative Ideas for Fixing the Opioid Crisis.” Three out of the four “innovative ideas” are aimed at helping individuals stop using drugs and assume that “treatment” (whatever that means) is effective, an assumption that, I have argued elsewhere, has little basis in evidence-based research. I  respect Gloucester Chief of Police Leonard Campanello for recognizing that arresting drug users is not helpful and I applaud CeltiCare for reducing bureaucratic hurdles for people struggling with addiction and I think it’s great that Massachusetts General Hospital recognizes that people struggling with addiction can use support – even when dealing with addiction treatment institutions. Yet only one of the four innovative ideas actually targets drug-related death: Healthcare for the Homeless has opened a safe space for people who are using drugs to sit down and get help — including Narcan (nasal spray for emergency treatment of suspected opioid overdose) – when they feel unwell.

The emphasis on treating people for drug use (in order to get them to stop using drugs) rather than minimizing drug-related deaths (harm reduction) is, I suspect, not going to change anytime soon. As a society we are far too invested – financially, politically, morally and culturally.

How (Not) to Treat an Epidemic

Ironically, despite public reiterations of the word “epidemic”, our public responses are not in line with standard protocols for tackling epidemics. Take this article which recently appeared in the local Wellesley Patch :

A change to Massachusetts Interscholastic Athletic Association regulations aims to encourage high school athletes struggling with substance abuse to undergo treatment. Under the new rule athletes can come forward and seek help for substance abuse without being penalized for violating the MIAA’s drug policy. “We wanted to change the rule for people who recognize that there’s a problem,” Norfolk District Attorney Michael Morrissey, who spearheaded the change, told Patch. “We don’t want to discourage people from coming forward.” Morrissey said athletes in particular are susceptible to abuse if they’ve used prescription drugs while recovering from sports injuries.

Now let’s break this article down.

First, readers unacquainted with Massachusetts need to know that Wellesley is one of the wealthiest and whitest towns in the state and that Norfolk County is the 28th highest-income county in the United States with a median household income of $81,899. In other words, we learn that substance abuse is a disease that afflicts even the most respectable people (student athletes in wealthy, white suburbs) and that requires treatment.

Second, while individual student athletes with substance abuse issues are urged to seek help, the MIAA did not question why so many athletes are injured. Are there particular teams in particular towns that are more injury-prone? If so (and I believe that to be the case), what is it about these teams and towns that make them fertile for the spread of opiate overuse? Are severe injuries due to the culture of hyper-masculinity in the sports world driving boys (and coaches) to reckless behavior? Are kids learning that real men should suck up pain? Alternatively, given the widespread use of prescription pain medication, are they learning that every pain needs to be medically treated? Maybe they are learning that only those who are the best at something really count? Or are they picking up the message that success in high school sports may be their last chance in life to shine, that from here on it’s all down hill? Full disclosure – I do not know if any of this is the case, and that is the problem. No one knows because these sorts of social and cultural questions are not being studied.

Follow the Money

There are huge profits to be made in drug treatment, though there is very little rigorous evidence showing that addiction treatment of any sort actually works. Not so much money, however, to be made in changing social values.

Given the public consensus that addiction is a manageable yet essentially incurable disease (“once an addict, always an addict” is a mantra promulgated by the 12 Step movement; there is no actual evidence for this notion), the treatment-industrial complex stands to be even more profitable than the prison-industrial complex. Prison sentences and parole eventually end; the treatment of chronic disease can go on forever.

According to the American Civil Liberties Union:

As incarceration rates skyrocket, the private prison industry expands at exponential rates, holding ever more people in its prisons and jails, and generating massive profits. Private prisons for adults were virtually non-existent until the early 1980s, but the number of prisoners in private prisons increased by approximately 1600% between 1990 and 2009. Leading private prison companies essentially admit that their business model depends on high rates of incarceration. For example, in a 2010 Annual Report filed with the Securities and Exchange Commission, Corrections Corporation of America (CCA), the largest private prison company, stated: “The demand for our facilities and services could be adversely affected by . . . leniency in conviction or parole standards and sentencing practices . . . .”

Fortunately for their stockholders, private prison companies are moving into the lucrative treatment field. Take a look at this excellent article by Deirdre Fernandes in the the Boston Globe:

The $35 billion-a-year addiction treatment industry is gaining more attention from investors of all sizes, including private equity giants like Boston-based Bain Capital, which owns the largest chain of detox clinics in Massachusetts. Large investors are capitalizing on the increasing demand, changes in health care law, and opportunities to scoop up smaller facilities, reduce their costs, and sell them at a profit. American Addiction Centers, a Nashville addiction treatment company, went public in late 2014, raising $75 million. Its profits climbed from $871,000 in 2011 to $11.2 million last year, a more than twelve-fold increase. So it’s no surprise that individual investors are piling in, too, said Philip Levendusky, the director of psychology at McLean Hospital, an affiliate of Harvard Medical School. “Everybody is chasing the pot of gold at the end of the rainbow of the opioid issue,” Levendusky said. “There’s an epidemic of opioid abuse, so there’s a tremendous demand.”

A Real Response to an Epidemic

In order to get a sense of what a real public health response to an epidemic looks like I turned to the CDC’s webpage on Zika. Medical attention for affected individuals is part of the picture, yet the CDC focuses more on understanding the underlying causes of the problem, tracing how it spreads, and taking pro-active measures to prevent its proliferation. This includes identifying exactly where there are clusters of Zika-carrying mosquitoes and clusters of affected humans, pinpointing exactly how transmission occurs, and taking concrete steps to minimize the possibilities of transmission.

Imagine if efforts to stop the Zika virus were limited to offering individual treatment (the treatment consists of rest, water and Tylenol since there is no known cure for the Zika virus) and counseling sufferers about the importance of staying away from mosquitoes (where exactly does one go to hide from mosquitoes in the tropics?)! Imagine if there were no efforts to assist communities in removing stagnant water from yards and streets or to encourage governments to build systems that distribute safe water (so as to minimize mosquito larvae survival as well as the need for households to store water in buckets and pools)!

Yet that essentially is how Massachusetts, like other states, is tackling its opioid epidemic. For instance, just a week ago, Marian Ryan, district attorney in Middlesex County, issued a press release addressing the epidemic by offering a list of resources for people struggling with addiction and for “their loved ones.” The list turns out to be a hodge-podge of treatment and support agencies and organizations, many of which are not licensed by any local, state or federal office and some of which are for-profits corporations (LLCs or others) while others are entirely lay-led quasi-religious 12-Step groups. (The statuses of the agencies and organizations are not indicated on the list.)

In terms of opiate over-use, what would be the equivalent of cleaning up the pools of stagnant water in which mosquitoes breed? The equivalent of wide-scale public investment in safe water for all communities?

Having spent the past decade working closely with women who are former or current illicit drug users, I have seen how gender inequality (machismo and sexual abuse), crummy schools, reiterated messages that ‘if you are not wealthy and beautiful you are a failure,’ and over-reliance on pharmaceuticals of all kinds (licit and illicit) play the role of mosquito-breeding pools of standing water. In line with these observations, I believe that public investment in good schools and in facilities for worthwhile leisure time activities for people of all ages, legislation ensuring living wages and paid family leave, and a fair economy in which the majority of people can realistically strive for good and meaningful lives, play the role of investment in safe water.

If we really are in the midst of an opioid epidemic then it is foolishly short-sighted for us to focus our efforts on individual rather than public measures. To be clear, I am not suggesting that drug users who wish to stop using should not receive appropriate, evidence-based support and treatment. I am, however, pointing out that giving drug abusers the equivalent of rest, water and Tylenol will not protect them — or anyone else — from the stagnant pools of sexism, poverty and hopelessness.

See Thinking Outside the Cell: Concrete Suggestions for Positive Change and A Feminist Sociologist’s Thoughts on the Zika Virus.

Images taken from headlines of the following articles:

http://www.pbs.org/wgbh/frontline/article/how-bad-is-the-opioid-epidemic/
http://www.desmoinesregister.com/story/opinion/columnists/2016/05/24/grassleys-help-needed-fight-against-opioid-epidemic/84857302/
http://www.theatlantic.com/health/archive/2014/10/the-new-heroin-epidemic/382020/
http://www.reuters.com/investigates/special-report/baby-opioids/
http://www.nationalreview.com/article/431486/heroin-prescription-painkillers-new-drug-epidemic
http://observer.com/2016/05/the-opioid-epidemic-its-time-to-place-blame-where-it-belongs/
http://www.huffingtonpost.com/entry/opioid-epidemic-medical-students-harvard_us_573e35c9e4b045cc9a707ca0
http://www.huffingtonpost.com/kristine-scruggs-md/the-opioid-epidemic-where_b_10112096.html
http://republicanherald.com/news/heroin-opioid-epidemic-grabs-attention-of-lawmakers-1.2045645