Poverty, Racism and the Public Health Crisis in America

Although extreme poverty in the United States is low by global standards, the U.S. has the worst index of health and social problems as a function of income inequality. In a newly published article, Bettina Beech, clinical professor of population health in the Department of Health Systems and Population Health Sciences at the University of Houston College of Medicine and chief population health officer at UH, examines poverty and racism as factors influencing health.

“A common narrative for the relatively high prevalence of poverty among marginalized minority communities is predicated on racist notions of racial inferiority and frequent denial of the structural forms of racism and classism that have contributed to public health crises in the United States and across the globe,” Beech reports in Frontiers in Public Health. “Racism contributes to and perpetuates the economic and financial inequality that diminishes prospects for population health improvement among marginalized racial and ethnic groups. The U.S. has one of the highest rates of poverty in the developed world, but despite its collective wealth, the burden falls disproportionately on communities of color.” The goal of population health is to achieve health equity, so that every person can reach their full potential.

Though overall wealth has risen in recent years, growth in economic and financial resources has not been equally distributed. Black families in the U.S. have about one-twentieth the wealth of their white peers on average. For every dollar of wealth in white families, the corresponding wealth in Black households is five cents.

“Wealth inequality is not a function of work ethic or work hour difference between groups. Rather, the widening gap between the affluent and the poor can be linked to unjust policies and practices that favor the wealthy,” said Beech. “The impact of this form of inequality on health has come into sharp focus during the COVID-19 pandemic as the economically disadvantaged were more likely to get infected with SARS CoV-2 and die.”

A Very Old Problem 

In the mid-1800’s, Dr. James McCune Smith wrote one of the earliest descriptions of racism as the cause of health inequities and ultimately health disparities in America. He explained the health of a person “was not primarily a consequence of their innate constitution, but instead reflected their intrinsic membership in groups created by a race structured society.”

Over 100 years later, the Heckler Report, the first government-sanctioned assessment of racial health disparities, was published. It noted mortality inequity was linked to six leading causes of preventable excess deaths for the Black compared to the white population (cancer, cardiovascular disease, diabetes, infant mortality, chemical dependency and homicide/unintentional injury).

It and other reports led to a more robust focus on population health over the last few decades that has included a renewed interest in the impact of racism and social factors, such as poverty, on clinical outcomes.

The Myth of Meritocracy

Beech contends that structural racism harms marginalized populations at the expense of affording greater resources, opportunities and other privileges to the dominant white society.

“Public discourse has been largely shaped by a narrative of meritocracy which is laced with ideals of opportunity without any consideration of the realities of racism and race-based inequities in structures and systems that have locked individuals, families and communities into poverty-stricken lives for generations,” she said. “Coupled with a lack of a national health program this condemns oppressed populations such as Black and Hispanic Americans, American Indians, and disproportionately non-English speaking immigrants and refugees to remain in poverty and suffer from suboptimal health.”

Keys to Improvement

The World Health Organization identified three keys to improving health at a global level that each reinforces the impact of socioeconomic factors: (1) improve the conditions of daily life; (2) tackle the inequitable distribution of power, money and resources; and (3) develop a workforce trained in and public awareness of the social determinants of health.

The report’s findings highlight the need to implement health policies to increase access to care for lower-income individuals and highlight the need to ensure such policies and associated programs are reaching those in need.

“Health care providers can directly address many of the factors crucial for closing the health disparities gap by recognizing and trying to mitigate the race-based implicit biases many physicians carry, as well as leveraging their privilege to address the elements of institutionalized racism entrenched within the fabric of our society, starting with social injustice and human indifference,” said Beech.

Why Social Workers Should Address Economic Inequality

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I began discussing economic inequality in my classrooms more than a decade ago when President Bush successfully pushed through Congress another round of supply-side tax cuts. Since then, there have been continuous discussions about the consequences of having so much of the nation’s wealth concentrated in the hands of a few super wealthy individuals and families.

In remarks given at the ARC in southeast Washington, DC in December 2013, President Barack Obama called economic inequality the defining challenge of our time. That economic inequality is a phenomenon that needs to be addressed is hardly debated these days. However, no one seems to have a politically viable plan to reverse the current trend, so we can only expect it to worsen.

Researchers Emmanuel Saez and Thomas Piketty have been documenting trends in economic inequality for more than a decade. Saez, an economics professor at the University of California at Berkeley and director of the Center for Equitable Growth has published numerous research articles on economic inequality with Piketty and others.

A 2014 paper with Gabriel Zucman—Wealth Inequality in the United States Since 1913—documented the growth in the share of wealth held by the wealthiest individuals and families with slides that provide a visual representation of the largess. Piketty, an economics professor at the Paris School of Economics created a firestorm among conservative economists with his book Capital in the Twenty-First Century, in which he concluded unchecked economic inequality may not reach the destructive levels predicted by Karl Marx, but could begin to undermine democracy.

The Roosevelt Institute recently released a compendium of social and economic policies that, according to Nobel Laureate Joseph Stiglitz, will promote economic growth and more shared prosperity. Titled “Rewriting the Rules of the American Economy”, the report features ideas of top progressive economic thinkers and promotes policy changes that address financial regulation, labor unions, progressive taxation and human capital investments that they say will create broader opportunity and a more egalitarian society.

Stiglitz, the former chief economic advisor to President Bill Clinton and former president of the World Bank, stipulates that economic inequality is not inevitable—that the notion there is a tradeoff between economic growth and inequality is false, and that the market is not free and infallible but determined by the rules and policies that we have put into place. He says new rules are needed.

Across the pond, the renowned scholar Sir Tony Atkinson has been building a case for policies that promote social justice for decades. In his latest book—Inequality: What Can Be Done?released earlier this month, he lays out a 15-point plan to address economic inequality that includes raising the highest marginal tax rate to 65 percent. Take Jared Bernstein’s advice like I did and give a listen to this very compelling lecture and discussion by Sir Tony Atkinson. He says many things that are worth hearing. One thing he says that is undeniable is that neither side of the political spectrum has debated this escalating calamity in a meaningful way.

The American public has not made much of the issue despite the fact that 45 million Americans are living below the poverty threshold, many older Americans are facing a retirement crisis, and as Robert Putnam describes in his recent book—Our Kids: The American Dream in Crisis—for millions of children in the United States, the myth of the American Dream is little more than a fairy tale.

In a February AP/GfK poll, 68 percent of respondents say the rich are not paying their fair share of taxes. Yet all that we have seen in terms of public outrage was the relatively short-lived Occupy Wall Street demonstrations that never became the movement it threatened to be.

My understanding of being a social worker begins with a commitment to the pursuit of social justice for all Americans especially the most vulnerable among us. So the question is: what are social workers doing to affect social change? Are we merely helping people to cope with the status quo?

I am hearing from quite a few young social workers that they are not satisfied with what our profession is doing to change present circumstances. They believe that social workers must be more engaged in our nation’s politics and so do I. So does Nancy Humphreys and Tanya Rhodes Smith. There are enough social workers to lead the charge to demand that Hillary Clinton and other Democratic candidates address economic inequality.

As Frederick Douglass said: “If there is no struggle, there is no progress. Those who profess to favor freedom, and yet depreciate agitation, are men who want crops without plowing up the ground. They want rain without thunder and lightning. They want the ocean without the awful roar of its many waters. This struggle may be a moral one; or it may be a physical one; or it may be both moral and physical; but it must be a struggle. Power concedes nothing without a demand. It never did and it never will.”

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