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

This article was originally published by The Conversation; also see What Pennsatucky’s Teeth Tell Us About Class in America

When we talk about the successes and shortcomings of the Affordable Care Act (ACA) – and health care in the U.S. in general – little attention is given to dental care.

While the ACA defines dental coverage as an essential benefit for those under 18, insurers aren’t required to offer dental coverage for adults. Medicare, the nation’s largest insurer, doesn’t cover routine dental work. And coverage for adults through Medicaid varies from state to state.

It is estimated that 108 million Americans have no dental insurance, and that one in four nonelderly Americans has untreated tooth decay.

Oral health isn’t just about nice teeth. As the surgeon general noted in a 2000 report, oral health is intimately connected to general health and can be implicated in or exacerbate diabetes, heart disease and stroke, and complications during pregnancy.

The absence of comprehensive dental care exacts a toll on millions of Americans in terms of poor health, pain and the social stigma associated with bad teeth.

People receive dental treatment at the Care Harbor/LA free clinic in Los Angeles, September 27, 2012. Lucy Nicholson/Reuters

People desperately need dental care

In 2003 and 2004 (pre-Obamacare), I conducted a national study of uninsured Americans in southcentral Illinois, northern Idaho, the Mississippi delta, the Rio Grande Valley of Texas and in eastern Massachusetts.

I asked nearly 150 interviewees: “If President Bush were to declare universal health care for everyone starting tomorrow, what is the first problem you would take care of?” The most common answer by a landslide echoed this respondent’s: “I’ll be waiting outside the dentist’s office at 5:00 in the morning waiting for it to open.”

Many of the people I interviewed lived with untreated diabetes, asthma or even cancer, yet their oral health problems presented the greatest challenges to their quality of life.

Recently I returned to these communities to reinterview the people I’d met over a decade earlier. Very little has changed. While the majority of the people I interviewed now had health care coverage of some sort (for nearly 20 percent of them, it was as a consequence of becoming sufficiently disabled to be eligible for Social Security), very few had managed to secure dental coverage.

Then and now, people told me about visiting emergency rooms in hopes of alleviating pain or using addictive pain medications to make it through the day. People even told me that they had resorted to pulling out their own teeth.

Take Misty, for instance. When I met her 12 years ago in Mississippi, she was a “dirt poor” (her words) married mother of five, and she was living with diabetes, domestic violence and excruciating headaches. Despite all of these quite serious problems, she told me that she was more troubled by her bad teeth than by anything else. In fact, Misty told me that she’d had such bad toothaches that she pulled her own teeth. When I asked her how she can face the pain of pulling out her own teeth, she said:

[the infected tooth] hurts so bad… it’s a relief just to get it out of there.… I’ve gone two weeks with just being able to eat soup, because they are just so bad.

By 2016 Misty had left her abusive husband, moved to Arkansas and was accepted onto disability (SSI), which allowed her to get health care coverage through Medicaid. Still, however, she suffered because of her teeth.

It can be very hard to find dentists who accept Medicaid, and when Misty finally did, she had the rest of her teeth – 25 in all – pulled in one day.

Misty’s situation isn’t uncommon. I have met women and men of various ages who, like Misty, have pulled their own teeth. I’ve also met people who were able to get part of their dental needs taken care of during brief periods of Medicaid coverage but then were left with unfinished treatment when the coverage ended.

Teeth aren’t included in health insurance policies. Dental x-ray image via www.shutterstock.com.

Insurance stops at the teeth

Even though the link between dental health and overall health is clear, insurance plans tend to ignore teeth.

As health insurance began to appear to appear in the U.S. – initially in the 1920s and then more widely during World War II and in the postwar era – dentistry wasn’t part of the standard package of covered services.

As the nation’s largest insurer, Medicare plays an important role in shaping health care coverage norms. Medicare does not cover dental care. Today, according to government estimates, 70 percent of seniors lack dental coverage.

Since Medicare doesn’t cover dental, Dr. David Kroll, senior program officer at the Robert Wood Johnson Foundation, argues that this “inertia spilled over into the ACA.”

Americans who purchase dental plans typically find that the plans aren’t cheap, and often don’t cover much beyond routine preventative care. Plans often require hefty copays for procedures beyond preventative care and no or very limited coverage for dentures, bridges or periodontic work.

And, in recent years, the cost of dental care has increased faster than the cost of other medical care. For those without dental insurance, there are few low-cost services available.

The ACA provided for an expansion of Medicaid eligibility, though not all states accepted the offer of federal funding to expand Medicaid coverage. Even in the states that expanded Medicaid under the ACA, strict limits on oral health care remain for most low- and moderate-income Americans.

There is one bright spot: children’s dental coverage is a required benefit included on all ACA compliant plans, and Medicaid as well. According to national calculations of the Health Policy Institute and the American Dental Association, dental care utilization among Medicaid-enrolled children increased from 35.3 percent in 2005 to 48.3 percent in 2013.

Not just about nice teeth. Shannon Stapleton/Reuters

Oral health isn’t just about nice teeth

In the absence of coherent oral health services, too many Americans end up like Gina, a young Idaho woman who holds her hand in front of her mouth while she talks so that no one will see her rotted teeth. She can’t even get a job as a telemarketer because she cannot speak distinctly enough to be hired.

Many Americans incorrectly assume that rotten teeth are the product of bad decision-making; if someone had just brushed and flossed then they’d have nice teeth. But routine dental care – think of the twice-yearly checkups that are routine for people with dental insurance – keeps teeth healthy and can catch problems when they are easy to treat.

The reality is that tooth decay signifies poverty in pernicious ways. Without expanding insurance to cover oral health, millions of Americans will continue to live with pain, stigma and the risks of systemic diseases that could be averted through an accessible and integrated system of dental care.

Courtesy of Independent 1.23.16

The emergence and spread of the Zika virus is worrisome on many levels: the impact of global warming on the spread of infectious and mosquito-borne diseases (see “Getting Dumped On: Snowmaggedon, Women’s Health and Human Rights“); indiscriminate aerial spraying of poisonous chemicals — especially in poor regions — whether well-intended or not; and the reality that the poorest families in Brazil and other countries disproportionately bear the burdens of global warming and are disproportionately exposed  to Zika virus due to living in crowded neighborhoods, reliance on public water pumps that often are surrounded by pools of standing water, and lack of adequate public health resources.

A related set of worries are products of structural gender inequalities: prohibitions on abortion in countries and US states at the same time as women are being warned not to become pregnant because of the presence of the Zika virus (see “Pregnant Bodies as Public Property“); the power of ‘rape cultures’ in which women may not be able to control access to their own sexuality and fertility (see “Fighting Rape Culture: Real Tips“); and a problematic history of public responses to viruses (such as HIV-AIDS) that may be spread through sexual contact, especially when the virus initially impacts disenfranchised or stigmatized groups.

In addition to alarm regarding the vectors of spread of the virus, there is cause for concern for the well-being of families affected by Zika virus. Here in the United States, Zika virus-bearing mosquitoes have shown up in Florida and other southern US states where many people are unable to access appropriate medical care because their state governments have refused to expand Medicaid under the Affordable Care Act (see “The State(s) of the Affordable Care Act“). Shocked and saddened by the pictures we are seeing in the press of babies born with microcephaly, the US’s continued refusal to sign the International Convention on the Rights of Peoples with Disabilities (see “Disabled Rights“) seems particularly indefensible at this time.

For updated (August 19, 2016) information and further analysis, click here: The Social Implications of Zika

See also this statement put out by the Women’s Global Network for Reproductive Rights: A Feminist Approach in Responding to the Zika Virus

Posted on February 5, 2016

In light of the recent outbreak of the Zika virus in Latin America and the Caribbean, the Women’s Global Network for Reproductive Rights (WGNRR) and the Latin American and Caribbean Women’s Health Network (LACWHN) join the voices of our feminist and women’s rights partners[1] in admonishing regional governments’ limited public health advisories for women. In particular we denounce the calls of countries such as Colombia, Jamaica, Ecuador, and El Salvador, advising women to delay pregnancy until the virus is eradicated, and particularly the call of El Salvador for women to avoid becoming pregnant for a full two years.[2]

Governments must recognize that when combatting the Zika virus, any public health strategy that does not have human rights, including sexual and reproductive health and rights (SRHR) at its core, will be limited in its impact and sustainability, while also creating massive grounds for human rights violations.

As a region, Latin America and the Caribbean is characterized by: high rates of unplanned pregnancy, where upwards of 56% of pregnancies are unintended;[3] high levels of sexual violence; limited access to contraceptives and sexual and reproductive health services; and restrictive laws on abortion, where in some cases such as El Salvador, abortion is prohibited under any circumstances and women are routinely persecuted and even criminalized on suspicion of having abortion.[4] Moreover, women who are young, from remote or low-income communities, and/or living in other vulnerable situations, disproportionately face multiple barriers when it comes to exercising meaningful decision-making power and control over their sexual and reproductive lives. In such a context, calls for women to simply delay or avoid pregnancy are not only unrealistic but irresponsible and negligent.

The rapid spread of the Zika virus and its strong association with marked increases in microcephaly and other neurological abnormalities is in many ways new terrain, with new elements continually coming to light, demonstrating a clear need for more research. This uncertainty makes it all the more imperative for governments to undertake from the beginning a holistic, sustainable, and rights-based approach to eradicating the virus and mitigating its effects. Anything less is careless and counter to governments’ human rights commitments under regional and international human rights law.

We thus urge the governments of affected countries both in Latin America and the Caribbean as well as other regions worldwide to undertake a rights-based, reproductive justice, and sustainable development approach towards the Zika virus and any other emerging health issue. Such an approach must be holistic, while recognizing gender equality and women and girls’ empowerment as a cross-cutting priority, in keeping with governments’ agreements and commitments under the 2030 Agenda.[5]

In practice, this approach to combatting the Zika virus must include:

  • Ensuring universal access to a full range of high-quality, voluntary, and user-friendly contraceptive methods, including barrier methods such as female and male condoms, and emergency contraception, as well as comprehensive SRH information and services, including antenatal services to enable early detection of microcephaly.
  • Targeting both men and women in public health awareness campaigns, especially in light of recent evidence that Zika may be sexually transmitted,[6] recognizing that the responsibility for safer sex methods falls on both men and women and cannot be shouldered by women alone.
  • Decriminalizing abortion, and removing all legal and implementation barriers to expand and ensure access to safe, comprehensive, free and high-quality procedures for pregnancy termination, free of requirements for marital or parental consent. As has been flagged by partners,[7] in the context of the many uncertainties and increasing public fears surrounding the Zika virus, calling on women to simply not become pregnant when access to safe abortion is limited or even completely criminalized will inevitably risk driving up rates of unsafe abortion, and ensuing maternal mortality and morbidity. Moreover, restrictive and punitive abortion laws that force a woman to carry an unwanted pregnancy violate women’s right to be free from inhuman and cruel treatment, as noted by Human Rights Bodies.[8]
  • Supporting pregnant women in Zika-affected countries who decide to remain pregnant to be able to carry the pregnancy safely to term, including access to comprehensive pregnancy, safe delivery, pre- and post-partum care and neo-natal care services; as well as the provision of special needs therapy, health and educational services as needed for children with microcephaly.
  • Systemic policy and programme changes that account for the intersections between climate change and SRHR.[9]
  • Immediate implementation of related recommendations under the Montevideo Consensus as well as targets under the Sustainable Development Goals of the 2030 Agenda, particularly those related to health and gender equality, in order undertake effective and holistic protection measures and help curb the spread of the virus.

Christmas House Decorations wallpapers

Maybe it’s because of the bitterly cold temperatures at night this week, or maybe it’s my own visceral response to overdosing on television shows with happy family Christmas scenes and neighborhood holiday lighting competitions, but I’ve been giving a lot of thought recently to how housing and homes impact health.

About a decade ago I traveled to the Mississippi Delta, Texas’s Rio Grande Valley, south-central Illinois, the mountains of northern Idaho and the cities of eastern Massachusetts to speak with individuals and families scraping by without health insurance. Most of these people worked in construction, retail, agricultural or service jobs. The details varied, but across the country I heard about spiraling poor health, declining employability and growing poverty. In 2015 I made return trips to check in with the people I’d met ten years earlier.[i] While I was able to locate nearly all of the original interviewees who owned their homes (including very modest homes of immigrants in colonias in the Rio Grande Valley), I only located a minority of the renters. Typically, their original phone numbers were disconnected and original addresses belonged to subsequent tenants. When I knocked on neighbors’ doors the most common response was, “I don’t know [so-and-so]. I’ve only lived here for a few months myself.”

In previous posts I’ve written about marginalized Boston-area women who cycle through shelters, jails and the streets. In those contexts the “problem of homelessness” is relatively easy to see and define – all I had to do was visit shelters or walk through the public parks in which people without homes congregate during the day. But for me, it took weeks of trudging through muddy housing developments on the outskirts of Mississippi towns and knocking on doors in public housing complexes in a central Illinois cities to get a glimpse of the lives of those less visible Americans who generally manage to rent housing of some sort for periods of time but teeter on a financial edge that keeps them moving from place to place.

Unfinished housing project at 47-04 198th St. in Auburndale stands abandoned for several years.

On my 2015 reprise tour I looked for a total of 145 people in five states and was able to locate 98 of them. The missing people were not evenly distributed either geographically or by race. In Mississippi, the state that consistently has the poorest health profile in the country, I managed to locate only 11 of the 28 people whom I sought. The utter disappearance of 17 of 28 people did not surprise one local healthcare advocate (he asked to remain anonymous): “People move away to Birmingham or Tupelo to look for work. There is very little home ownership in Mississippi. The common thing is ‘lease to own’ in which a developer arranges for people to ‘lease’ (pay rent) and after 20 years they have an option to buy – to switch the rent to a mortgage. But people almost never make it to the 20 years so the developers keep leasing the same houses over.” Many of these houses would not pass even the most cursory safety inspection in other states.

I was able to locate 70 out of 88 white people I’d originally interviewed and 21 of 28 Latinos / Latinas (mostly in the Rio Grande Valley), but I only found 10 of 29 African Americans. This is consistent with national patterns. According to the US Census, the homeownership rate for the fourth quarter 2014 for non-Hispanic White householders was highest at 72 percent. The rate for All Other Races householders was 55 percent. And for Black householders it was only 42 percent. According to researchers Gregory Sharp and Matthew Hall, “The 1968 passage of the Fair Housing Act outlawed housing market discrimination based on race. …  However, emerging racial disparities over the next three decades resulted in black owners who bought their homes in the 2000s being 50 percent more likely to lose their homeowner status than similar white owners.” Even after adjusting for socio-economic characteristics, debt loads, education, and life-cycle traits like divorce or job loss, blacks were more likely to lose their homes than whites.”

Shanice’s Story

I first met Shanice in 2003 at one of the larger Black churches in Decatur, IL – a church known for its strong fellowship and advocacy on behalf of the community. She was happy to share her story with me:

“When I was 18 I worked a job, it was right after coming out of high school. No insurance and they said I wasn’t eligible for Medicaid. My doctor said that I needed to get my tonsils taken out cause they were so swollen it was almost causing me not to be able to breathe. … And so I had to go on like a payment plan with the doctor. … The whole surgery, the surgeon, the day at the hospital and then I had a setback and had to go back into the hospital cost $15,000. During the following year collection agencies called day and night, often making threats. They’d [especially] call on Sunday nights. Said that I would be going to jail if I didn’t pay them.” At age 20, Shanice filed for bankruptcy.

A few years later Shanice gave birth to her daughter. By this time Shanice was working for a storefront loan company that provided health insurance for her, but not for her daughter (she would have had to pay a premium that she could not afford on her salary.) A few years later their statuses reversed: When Illinois expanded Medicaid for children (Kid Care) her daughter became covered but Shanice, having made the decision to go back to school and learn a skill, became uninsured. Shanice was well aware of the risk she was taking was determined to build a better future for herself and her daughter. “It wasn’t just me living this carefree don’t worry about tomorrow life. Now I have someone that was dependent on me so I had to make decisions for the future. … We moved into a nice apartment, we got power, cable, phone and I got a new car.” During that time Shanice began to eat healthier meals and lost over one hundred pounds. In order to pay tuition, “I got Pell grants and student loans.” I asked Shanice how she was able to get credit to buy a car so soon after declaring bankruptcy. “Oh, they go after bankruptcy people like crazy [to sell them stuff]. I was getting credit cards in the mail every night.”

In 2003, after spending time with Shanice and her daughter at the church where they sang in the choirs, participated in groups and clubs that helped them focus on making good decisions, and volunteered helping out the poor in their community, I described Shanice in my notes as “a young woman on the way up.” She was working part-time at her church with youth and looking for her first professional job. “I just completed 1540 hours of cosmetology school and I just graduated last Friday.”

When Shanice and I walked out of the small room where the church choir stored its robes, I asked her if as a cosmetologist she would get health insurance. She answered, “I can get a job but in this field they don’t give insurance. You have to arrange that yourself.”

….

A year or so later I spoke with Shanice again. With a sense of resignation, she told me that medical and credit card debt had piled up and she was preparing to declare bankruptcy a second time.

….

Fast forward twelve years. I returned to the address at which Shanice was living when I initially met her. She had moved on and none of the current neighbors even knew her name. On USSearch I found six other addresses for her and visited each one of them. Two of the addresses did not exist. One was in a decrepit housing project that had been shut down for several years, though some people continued to squat in the apartments. (I was warned that mostly gang members were there and that it wouldn’t be safe for me to go poking around.) One address was in a middle-class, white neighborhood – none of the neighbors whom I could find knew of anyone named Shanice. Two were inhabited by other Black families who had moved in recently. Stopping by her church, I was told that, “Shanice is no longer a member of this church. She’s moved.” No one at the church knew where.

Health and Housing

It’s not hard to understand the devastating health consequences of homelessness. Living on the streets exposes people to cold, rain and assault. Without a home it’s a challenge to eat proper meals, get enough sleep and keep oneself and one’s clothing clean. The stress of not knowing where one can lay one’s head contributes to misuse of drugs and alcohol. And infections of various sorts tend to spread quickly in crowded homeless shelters. Like the people in the shelters, these health consequences are easily identified and counted.

The health consequences of moving around are less immediately visible to the casual eye. But at a community health center in Decatur Illinois, nurse administrators Karen Schneller and Tanya Andricks elaborated on ways in which churn in housing is related to churn in healthcare. Different states and even different counties and towns have different healthcare resources available to residents. Different providers have different medication preferences and treatment protocols so people stop and start treatments. Even with dedicated staff efforts, it is impossible to provide follow-up care for patients who can’t be reached – whose phones are turned off and whose mail is returned “addressee unknown.”

Jenny Trimmell, public health administrator and Melissa Rome, community liaison at the Vermilion County (Illinois) Health Department explained that children like Shanice’s daughter particularly suffer from frequent moves. “When the Cabrini Green housing project in Chicago was closed to pave the way for gentrification former residents were offered vouchers by the Housing Authority and promised housing and jobs in towns in central Illinois. But there was not enough housing and not enough jobs, so people go back and forth to Chicago. There was a cultural adjustment for many moving from Chicago to more rural downstate.  People were unaware that services outside of the city of Chicago may be limited, such as access to health care providers; bus services that do not run 24/7, etc.  Everyone is frustrated. The kids are in and out of schools and medical records kept by parents are incomplete or non-existent. It is difficult for the Health Department to determine immunization status for these children and frequently immunization series have to be started over due to the unknown immunization status.” Trimmell and Rome went on to explain that without the kinds of community support children develop when they stay put in one school, “there are high drop-out rates, teen pregnancies and drug use.”

Musings

Getting to know and then losing track of Shanice and others in similar situations has made me more attuned to the health privileges of stable and secure housing. My home allows me to accumulate the material objects that anchor and enhance my life, both in immediate ways by giving me space to store medication and in less tangible ways by grounding me in the photos, books and furnishings that tie me to my past and to the people I love. My home provides a hidey-hole for times when the outside world feels overwhelming. It gives me a familiar bed and private bathroom when I am sick, and a kitchen in which I can cook the food that I want to eat when I want to eat it. My home allows me to cultivate neighbors who can lend a hand at times of need and offers me the space to nurture those special bonds with the family that looks out for my well-being. In my own home I have the power to keep out rats, roaches, mold and the dust and down that I am allergic to. I am not dependent on the vagaries of landlords or property management companies. No less important, my home gives me an address at which I receive and retain the paperwork that helps keep my financial, medical and legal life in order as well as reminders of when and where to exercise my right to vote (yes – for candidates who support legislation that makes my community healthier).

I plan to return to Decatur next week and resume my search for Shanice. Maybe she has found another supportive church community somewhere else in the area. Maybe she finally has her healthcare coverage straightened out. Maybe her daughter has escaped being one of the kids who’s been subjected to multiple rounds of vaccinations. Maybe she’s become the star of her high school marching band or debate team. I hope so.

 

 

[i] In each community I began with the contact information people had given me when we first met. Only a minority still lived at the same address or had the same phone number. Then I turned to phone books, social media, Google and other public-access online search engines, including USSearch that listed multiple address histories for many of the people. In each community, if my initial attempts to make contact failed, I then called on common acquaintances, knocked on doors of neighboring houses, and asked at local grocery stores, libraries and churches.

For more on this project:”The State(s) of the Affordable Care Act”

For more on housing struggles, take a look at this article about “Carly”

Last month Amnesty International came out in support for “the full decriminalization of all aspects of consensual sex work.” The reasons make sense: Decriminalization will eliminate the jail time and fines that punish (mostly) women for trying to make a living; it will give sex workers access to the health care and services that other kinds of workers benefit from; and it will allow sex workers to turn to the police for protection without fear that they themselves will be arrested. Amnesty International rightly asks, “How can we reduce the threat of violence to sex workers? What can be done to ensure their access to medical care and help prevent HIV? And how can discrimination and social marginalization that put sex workers at increased risk of abuse be stopped?”

But then I looked a bit more closely and two little words made me sit up for a double-take: “all aspects”? Seriously? An organization that I deeply respect has called for the decriminalization of pimping and procuring? Apparently, yes, for the reason that anti-pimp laws have been used to arrest sex workers who share a working space. Does that happen frequently enough to justify decriminalizing all pimping and procuring? It turns out that the answer is no – these laws are not used against sex workers anywhere near as often as they are used against actual pimps and procurers.

I took another look at the statement, and this time noticed a preemptive argument that, I would guess, was written to fend off attacks from people — like me — who would not be so thrilled with across-the-board decriminalization: “These questions about health, safety and equality under the law, are more important than any moral objection to the nature of sex work.” Oh no! My colleagues at Amnesty International could not possibly have used one of the cheapest tricks in the rhetorical arsenal — creating a straw man (“moral objection to the nature of sex work”) in order to imply that the only reason someone might disagree with blanket decriminalization is because of “moral objections” — a kind of objection that, in the current political climate, conjures up right-to-lifers, the Christian right, and other other enemies of human rights! Didn’t they understand that people – like me- might disagree for other reasons entirely?

The Question of Consent: Context Always Matters

Having spent ten years engaged in research and friendship with marginalized and criminalized women in Massachusetts – most of whom have exchanged sex for money at some point in their lives, I am most troubled by the words “consensual sex work.” Amnesty clarifies that they are not calling for the decriminalization of human trafficking or of people who force children or women into sex work. But this glosses over inherent problems in identifying any particular sex work situation as truly consensual.

Kahtia [not her real name], a woman I’ve known through many ups and downs, recalls with some pride a short-lived glamorous career as a prostitute and drug dealer in up-scale New York City clubs. Within a short time, however, “I became my own best  [drug] customer and had to go to the streets to make money for drugs.” Street level prostitution was not so glamorous. She learned to become totally numb and dissociate herself during sex. Kahtia demonstrates this by tipping her head back, closing her eyes, and dropping her jaw open. “It was just…wait for him to finish and give me the money.”

Was this “consensual”? One could argue that it was: She initially chose high-paying sex work and drug dealing (exactly the kind of “consensual” sex work Amnesty likely had in mind), and even the subsequent sex work could be seen as a choice she made in order to support her wish to use drugs. But, looking even further back:

Kahtia’s earliest memories are of Sunday dinners at the home of her Irish maternal grandparents. The clan, including Kahtia’s mother and white half-sister, would be seated around the family table. Kahtia and her brother – children of an African-American man — were told to eat in the hallway: Their dark skin color was not welcome at the dinner table. An under-the-radar heroin addict, Kahtia’s mother supported her own habit by shooting up Kahtia and her brother with drugs and receiving money from the men she invited to rape them. Kahtia remembers her father as a good but weak man (he was an alcoholic). She also remembers being told she exhibited “unruly behavior” due to which she was removed from home and placed into a residential program for “problem kids”. Child Welfare Services did not believe Kahtia’s stories of abuse, and she was sent home on weekends where the rapes continued. By the time she was ten Kahtia decided that anywhere she went would be better than home, so she ran away. Living on the streets as a very young girl, Kahtia encountered what she considers to be her first bit of good luck: She was adopted by a powerful gang. Emoting pride, Kahtia recounts how the gang leader heard of “the girl who kept a razor blade hidden inside her mouth” in order to defend herself, and supported her in her initial forays into drug dealing and upscale prostitution.

The details vary, but the broad outlines of abuse, time in juvenile institutions, an initially helpful older man, fear, anxiety and drug use are present in the experiences of nearly every woman I know who has ever worked in prostitution, even for a brief time.

One might be tempted to say that for at least some women, paid sex work constitutes disengagement from or resistance against traditional patriarchal practices of marriage — at least they are getting paid for what other women may be compelled to do for free. Marjolein van der Veen, a feminist economist, suggests that prostitution “opens up possibilities for commodification as a site for new economic alternatives of producing commodities in noncapitalist class structures.” Jane Scoular, a legal scholar, much along the lines of the Amnesty International statement, similarly argues that that there is nothing inherently harmful in sex work. Rather, the problem for women lies in specific temporal settings in which sex work is criminalized, marginalized and stigmatized.

While these contentions may have some intellectual merit, in my many conversations and interactions with Massachusetts women who have worked in prostitution I have never glimpsed even a hint that it’s possible to extract a neutral commercial exchange (sex for money) from the real life worlds of women who are poor, sick, homeless, abused, and / or trafficked. These contentions, as Rutgers University professor Barbara Foley writes, “tragically disregards the oppression that forces women into prostitution.” Indeed, every one of the women I know says, in one way or another, that working in prostitution, compared to even the worst marriages and lousiest jobs at fast-food joints, is like jumping from the frying pan into the fire.

The Gazer and the Gazed

The women I have met make it clear that unwanted, repeated bodily penetration is not equal to other paid or unpaid labor. In order to work in prostitution they must disengage the self, “go numb.” Sex work – by its very nature — transforms the body into an object to be gazed at rather than a subject with the power to gaze. Olivia (pseudonym), a former stripper interviewed by law professor Jody Raphael, recounts her experiences working in a peep show: “I know how the animals in the zoo must feel as people walk by gazing at them.” Raphael, who interviewed Olivia over a period of many months, understood that Olivia dealt with this work, “By disassociation through alcohol and drugs, and through the fantasies of pretending she was someone else, Olivia left her true self behind. While in stripping, Olivia never used her real name.”

Raphael’s observations illuminate that problematic word in Amnesty International’s position — consensual. As Rachel Moran, an author and advocate who was pulled into the sex trade when she was fifteen years old writes, “I know from what I’ve lived and witnessed that prostitution cannot be disentangled from coercion.”

True consent, as understood by every university and hospital ethics committee in the country, requires explicit acknowledgment of the inherent power differential between the researcher and the study subject – between the gazer and the gazed. While messy and complicated everyday life is not the same as a controlled research setting, informed consent standards that reflect decades of legal, philosophical and ethical consideration point to the difficulties in assessing sex work as consensual. Informed consent standards adopted in the wake of Nazi medical experimentation and other blatant human rights abuses require that all possible risks be clearly spelled out and understood by the study subject; it requires the subject to be fully physically and mentally competent to give authentic consent; it makes explicit that the subject is free to end the encounter with no explanation and with no penalty at any time; it spells out to whom the subject can report problems with the study or the researcher; and — of particularly great relevance here – it disallows the researcher to offer payment or other forms of compensation that can be construed as unduly pressuring the subject into agreeing to the study.

By these standards, and in light of the real life experiences of most sex workers, decriminalizing all aspects of “consensual” prostitution, is likely to turn out to be, as Rachel Moran writes, “[I]n the name of human rights [a way to] decriminalize violations of those rights, on a global scale.”

For a deeper discussion of these issues see Susan Sered and Maureen Norton-Hawk. 2011. “Gender Overdetermination and Resistance: The Case of Criminalized Women.”   Feminist Theory 12(3): 317-333.

 

 

cartoon-trickle-down-economics-jpg

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

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

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

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

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

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

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

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

explaintrickledowneconomicssmall

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

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feature image via thebluedolphins.blogspot.com

A few days ago I listened while Francesca, a woman I’ve come to know during a decade of working with criminalized women, ranted about “the bitch” over at the welfare office who refused to give her food stamps. According to Francesca, “the bitch” didn’t believe that Francesca had not received the letter telling her that she needed to re-certify her eligibility. This, I thought, is a systematic problem: Access to vital services typically is tied to having a permanent address. As a consequence, the ability to receive services is linked to a level of financial stability that the people who most need these services are unlikely to have. Since Francesca had not had a secure place to live for over a decade, it’s no surprise that the letter didn’t reach her. But for Francesca, at least at that moment, the systemic problem was not on her mind. Rather, she focused her attention on “the bitch” who, so it seemed to her, wanted Francesca and her children to starve. Never one to hold back, Francesca had “let the bitch know what I thought about her” before she stormed out of the office.

Francesca is a fabulous raconteur and as I listened to her retelling of the food stamp office story I shared her outrage, and probably would have joined her had she proposed a return trip to yell at “the bitch”. But when I had the luxury of some time to think over what she’d told me I realized of course, that the welfare worker had no authority in this matter: However much she liked or disliked, sympathized with or looked down on women like Francesca, she was not authorized to give food stamps to someone who had not re-certified her eligibility.

Over the years Francesca has confronted two other “bitches” in my presence. One was a hospital nurse who “refused to let me see the doctor.” The other was a parole officer who told her that if she didn’t keep up restitution payments on an old crime committed by her ex-husband she would be sent to jail. Both times Francesca barraged the “bitches” with pleading, tears and finally curses. I don’t know if they felt fear, anger or shame (probably a combination of all three), but I do know that they are placed in untenable situations like this on a daily basis.

As the public face of social services, they face the despair and rage of people trying to maintain a sense of dignity – albeit sometimes in ways that backfire — in a culture that treats food and housing and freedom as commodities rather than as human rights. Perceived (mistakenly) as the gatekeepers to food, medicine and freedom, the “bitches” Francesca confronts are targets for the anger of hungry, sick, homeless, battered and poor clients who cannot access the help that they need, especially in this era of cutbacks in social services.

In popular culture, “Type A” men drop dead from heart attacks brought on by the stress of their powerful positions. Yet a weighty body of literature shows that the most severe job strain is not characterized by high levels of authority but rather by low levels of authority coupled with high levels of responsibility. Workers tasked with keeping people alive while lacking power over the necessary resources and policies to do so are especially likely to suffer poor health, chronic physical and mental distress, and greater risk of death.

The hundreds of thousands of women who predominate in the lower and middle rungs of the health and social service professions live with the heavy responsibility of granting or denying access to potentially life-saving goods and services to desperate women like Francesca. Deflecting the anger that should be directed at the (usually male, certainly higher paid) policy makers, administrators and supervisors, they are stuck enforcing rules that they have no power to shape or change.

The “bitches” at whom Francesca vents her (righteous) anger are butts of nasty comments about government bureaucrat “fat cats” though they often earn salaries that are barely above minimum wage. As women they most likely carry the double load of paid employment and house / wife / mother work – the impossible task of trying to raise healthy, well-adjusted children in a world of violence, air pollution, aggressive consumerism and 24/7 headsets. It’s likely that they themselves have applied for – and perhaps been denied – food stamps; that they have children or siblings struggling to pay court fees in order to stay out of jail; and that they too can’t get the kind of medical attention that they need.

I’m not sure how I’ll react the next time Francesca blows up at a clerk or a caseworker. I’d like to think that I’ll be able to persuade everyone concerned that the real enemy is not the woman on the other side of the desk but rather the powerbrokers who keep them there. But in truth, I’ll probably be so wracked with feeling both responsible for keeping Francesca in line and powerless to ameliorate her situation that I’ll come down with a migraine.

 

Long_Island_Bridge

October 9, 2014 marked the end of an era for Boston’s homeless, ill and marginalized residents when the sole bridge to Long Island was closed after a state inspection declared it too unstable for vehicles. One of several small islands (“Harbor Islands”) of the Massachusetts Bay, Long Island’s geographic separation from the mainland has made it a prime location for isolating social outcasts over the years. In 1882, the City of Boston purchased property on Long Island for an almshouse, a residence for unwed mothers, a chronic disease hospital, a nursing school and a “Home for the Indigent.” In subsequent decades, a treatment center for alcoholics was added. Recently, it’s the site of homeless shelters, Boston Public Health residential facilities and a variety of residential programs for “recovering” addicts and people involved with the Courts.

According to reports in the Boston Globe, the decrepit state of the bridge was well-known to government officials. But it’s been years since the City or State has invested resources in replacing or fundamentally repairing the bridge to the metaphorical “nowhere” of shelters for the homeless and other social undesirables. Reachable only by limited shuttles, Long Island effectively served to keep homeless and sick people out of sight and out of mind for over a century.

Isolated from the mainland, people who stay at the various shelters cannot get to the Island before 2 PM or after 9 PM; once there, they cannot leave after the shuttles are finished running for the day; and (except on rare occasions such as blizzards) shelter residents must depart the Island no later than by the 9 AM mainland-bound shuttle.

Elizabeth, a woman who has navigated what she calls “the homeless life” for ten years explains, “Everyone knew the bridge was dangerous. I always went on the bus [that crosses the bridge to the shelter] with my heart in my throat and just prayed to God that we’d get across. But I had nowhere else to go.” Francesca, insecurely housed for nearly as long as Elizabeth, declares, “I hate that bridge. I always felt that if it went, I’m gonna be swimming with the fishes.” Continue reading

brain science

This article was first published by The Conversation.

Recently I’ve seen news reports with headlines like this one: “Can Brain Science Help Lift People Out Of Poverty?

This particular article described the near miraculous recovery of a woman who grew up surrounded by violence in the housing projects, became a “single mom on welfare” who wasted her money and damaged her health with a pack-a-day smoking habit, and was stuck in an abusive relationship. Then, with the help of “a novel program that uses the latest neuroscience research to help women dig themselves out of poverty” by making better choices, she quit smoking, got rid of the bad boyfriend, earned a business management degree and landed a job as an administrative assistant. It’s not the only article I’ve seen recently that is looking at brain science as a way to cure poverty.

The enchantment with neuroscience to explain social misery has spread among individuals and organizations with longstanding commitments to progressive social change. “What the new brain science says is that the stresses created by living in poverty often work against us, make it harder for our brains to find the best solutions to our problems. This is a part of the reason why poverty is so ‘sticky,’” explained Elisabeth Babcock, chief executive of the nonprofit Crittenton Women’s Union. Recent research from Princeton University has suggested that living in poverty can have an impact on concentration. Other research has found a similar correlation between poverty and neuroscience.

There is growing public discourse invoking neuroscience to re-emphasize that poverty really is bad, that bullying and abuse really hurt children, and that someone who has experienced rape or torture really is suffering. But uncritically invoking neuroscience is a risky propositionContinue reading

The two images reprinted below have appeared widely in media outlets over the past weeks. Eerily similar? Both show armed police or soldiers carrying shields facing off against unarmed people of color. Without careful perusal, it’s hard to tell which caption belongs with which photo.

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ferguson

“Liberian Soldiers Seal Slum to Halt Ebola” Associated Press, Aug. 20, 2014

“Photo Essay: Police and Protesters in Ferguson” St. Louis Post-Dispatch  Aug. 14, 2014

The Stories Behind the Photos

In Liberia’s capital city last week, residents of a densely populated, poor neighborhood protested when security forces sealed off their community as a quarantine measure in response to the Ebola outbreak. According to reports, residents asserted that not only had they been cut off from their homes but also that they were being disproportionately exposed to the virus because sick people from outside their community were being brought into an Ebola screening center set up in their neighborhood by the government.

In Ferguson, Missouri, when residents took to the streets to protest the shooting by a police officer of Michael Brown – an unarmed African-American youth, thousands of law enforcement officers as well as National Guard were deployed to contain the demonstrators. As of this writing, several hundred protesters have been arrested.

Poverty, Inequality and The Burden of Disease

Liberia is among the poorer nations of the world. In 2012 the gross national income per capita was $580; 75 babies out of 1000 could be expected to die before the age of five; and the total annual expenditure on healthcare was a meager $102 per capita. The top causes of mortality in Liberia include malaria, diarrhea, respiratory infections, AIDS and malnutrition.  Neither money nor the burden of disease is distributed evenly in Liberia. As calculated by the GINI index, Liberia is one of the least economically egalitarian countries in the world.

Fifteen years ago, Ferguson was a predominantly white middle class suburb of St. Louis. By 2010, the population was two-thirds black . Elizabeth Kneebone, a fellow at the Brookings Institution, notes that in 2014 every Ferguson neighborhood but one has a poverty rate over 20%, “the point at which typical social ills associated with poverty like poor health outcomes, high crime rates and failing schools start to appear.”

In the state of Missouri, the rate of poverty among Black men is twice that of white men (22.5% vs. 11.6%). Among Missouri women, 24.3% of Black women vs. 14.5% of white women are living in poverty. In St. Louis County (where Ferguson is located), the rate of emergency room visits due to asthma among children under 15 years is 52% higher than the overall rate for the state. (High rates of childhood asthma are associated with environmental pollution and substandard living conditions.) The rate of infant mortality is 9% higher than the state’s rate and 21% higher than the U.S. national rate. The rate of babies born with a low birth weight (an excellent indicator of women’s overall health status and of the child’s future health status) is 8% higher than the state’s rate, and 20% higher than the national rate.

The Legacy of Injustice: War on the Poor and the Ill

Liberians are struggling with the aftermath of two recent civil wars. “Liberian scholars offer a range of explanations for the years of conflict including ethnic divisions, predatory elites who abused power, a corrupt political system, and economic disparities. The Truth and Reconciliation Commission found that underlying those proximate causes, the seeds of conflict were sown by the historical decision to establish Liberia as a state divided between natives and settlers, and the use of force to sustain the settlers’ hegemony.” While many Liberians are incarcerated for the “crime” of being poor or disliked by the police, perpetrators of crimes against humanity during the civil war have not been punished. Following the civil wars, according to Amnesty International, “Senators, Deputy Ministers, police officials, Special Security Service agents and Liberia National Police officers were allegedly engaged in or ordered beatings, looting, arbitrary arrests, abductions, shootings, ritualistic killings and other abuses. In most cases, no investigations were carried out and no action was taken against alleged perpetrators. … Law enforcement forces were reported to have unlawfully arrested and detained people and to have used torture and other ill-treatment, including during attempts to extort money on the streets. … Conditions in police lock-ups were appalling, with juveniles and adults routinely held together. Detainees were often subject to abuse by police and other detainees. … The formal justice system often failed to deliver fair trials and due process. Lengthy pre-trial detention beyond that allowed by law was the norm, with roughly 90 per cent of prisoners being pre-trial detainees. As well as corruption and inefficiency, the system suffered from lack of transport, court facilities, lawyers and qualified judges.”

Residents of Ferguson are struggling with the historical legacy of legally sanctioned racial discrimination, nearly four decades of ‘trickle-down’ economics that have eliminated middle and working-class jobs in the mid-west and throughout the country, and housing policies that price low-income Americans out of the housing market and segregate people of color in densely populated neighborhoods with lousy schools and housing and crumbling infrastructures.

Ferguson residents are also struggling with what Michelle Alexander aptly calls the “New Jim Crow” – decades-long ‘tough on crime’ policies that primarily targeted men of color and have led to the United States claiming the highest incarceration rate of any nation in the world. In 2012, one out of every 200 Missouri residents was in prison or jail serving a sentence of one year or longer. And, unlike in much of the rest of the country, Missouri’s prison population actually rose 1.3% in 2012. Incarceration rates for white men in Missouri in 2012 were 650.6 per 100,000. Among black men in it was nearly six times that: 3,640 per 100,000. Law enforcement personnel, like members of all three branches of government in Missouri, are overwhelmingly white.

Last year, Ferguson used municipal court fines to fund 20.2 percent of the city’s $12.75 million budget. (Just two years earlier, municipal court fines had accounted for only 12.3 percent of the city’s revenues.) Incarceration rates specifically for Ferguson are not available. But, statistics posted on the Ferguson municipal website hint at the facts on the ground. In 2012 (the last year for which data are posted) Ferguson exhibited a striking gender imbalance in its population.

Male population 9,279  (43.9%)
Female population 11,856  (56.1%)

Women do live longer than men in most of the world, but the gender disparity in Ferguson is more in line with war zones – with countries like Liberia that have experienced lengthy civil wars — than with American “suburbs.” If I had to make an educated guess as to the whereabouts of the missing men I’d guess dead or in jail. The face-off in the photo above certainly makes that guess plausible.

For What It’s Worth

We Americans like to believe that “this kind of thing” could never happen “here.” We’re shocked by the egregious killing of a young man in Ferguson, by the outraged community response and by the overtly militarized law-enforcement response. We’re less shocked by the circumstances surrounding the outbreak of Ebola in places like Liberia. But – as we’ve seen over the past few weeks – the systemic inequalities that give rise to poverty  and disease “over there” also drive anger, distrust and mass incarceration right here in America.

With a nod to the Buffalo Springfield’s 1966 masterpiece: “There’s something happening here / What it is ‘IS’ exactly clear / There’s a man with a gun over there / Telling me I got to beware / I think it’s time we stop, children, what’s that sound / Everybody look what’s going down.”

Please check out my new book Can’t Catch a Break: Gender, Jail, Drugs, and the Limits of Personal Responsibility

And for more on the social context of responses to the Ebola outbreak check out: Ebola and US and Ebola, Secret Serums and Me