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| Miranda Mason ('19) |
Who deserves to live a healthy
life? This question is of major concern
as health disparities become obvious. It
can be taken for granted that people deserve equal rights, but to what degree does
society have an obligation to guarantee equal access to healthcare and health
itself? I will herein argue that a
country, especially one with a history and culture such as the United States’,
must act to eliminate the inequalities that lead to health disparities. It is only by taking such action that a
country can guarantee that justice is served and that all citizens have equally
protected potential for success in their society.
It is notable that there are certain
disadvantages to being of any identity other than wealthy, non-immigrant,
educated, cis-gender, heterosexual, white Anglo-Saxon man in the United
States. This lengthy description
considers various socioeconomic and inborn traits about an individual that are
most privileged in our society. The
fewer of these traits one has, the more likely that one does not have access to
appropriate healthcare and has worse health overall. What is it about these features that grants
privilege and health? Some are obvious:
greater wealth guarantees one can afford care, as well as a healthy
lifestyle. The poor may live in
neighborhoods that lack affordable healthy food and that are more likely to be
polluted by industry. Education often
correlates with wealth and helps one to make wise decisions about how to
live. Other features may play out in
ways that are less apparent unless reviewed with historical context.
The inequality with the longest
history in the United States is that suffered by the American Indian
population. When Europeans entered North
America, they found many peoples that they considered primitive, despite
indigenous people’s cultural complexity and environmental control. Throughout the life of the colonies and the
development of the country, American Indians were displaced from their homelands
and abused by invading white settlers.
Not only were entire communities forced to move to land with fewer
resources, but their ways of life were destroyed. Their lifeways were subject to traditional
ecological knowledge that only applied in their homelands. Traditional tribal medicinal practices were
commonly adopted by white settlers, but lost among the original tribes as
access to supplies diminished and young people sought out lives away from the
reservations that their families had been assigned. Thus, the traditional role of healer was
lost, and it was not easily replaced by biomedical practices.[1]
As will be seen in descriptions of
other minorities later, past treatment tended to make American Indians hesitant
about trusting white Americans with their health. American Indians often live in reservations
with poor access to healthcare facilities and are less likely to have health
insurance than white Americans. When
American Indians do receive treatment from biomedical facilities, the care may
or may not address the specific culture of the patients. For example, smoking cessation programs may
not treat smoking within the context of tobacco’s cultural significance to some
tribes.[2]
Black people also face a long
history of oppression in America. African
slaves were treated worse than livestock and punished for developing culture or
kinship among themselves. Slavery was
banned in the United States in 1865, but Jim Crow Laws continued to afflict freedmen. For a long time, white Americans insisted
that black people were inferior in intellect and humanity to white people. This racism excused them to treat people
differently according to their skin color.
Slaves were used for medical experiments without anesthesia, and
freedmen were terrified at the thought of “night doctors” who would do the same
to them.[3]
Racism followed freedmen and their
descendants at every turn, allowing the existence of segregation and many other
injustices, including unfair hiring practices and mob lynching. After World War II, the laws that provided
homes and support for white veterans neglected to reward equally deserving
black veterans. The practice of
discrimination, specifically redlining, made it more difficult for black people
to buy homes, especially in suburban neighborhoods. Instead, most black people were forced to
live in impoverished neighborhoods in cities or as poor farmers in rural
areas. Unable to afford social elevation
and trapped by individual and institutional racism, black people were left in
neighborhoods with very little access to healthcare. Lack of resources put black people at risk of
real experimentation, such as that which took place in the Tuskegee Syphilis
study.[4] This history of abuse at the hands of medical
practitioners has encouraged a tendency to distrust doctors. History has also left many black Americans in
the most unfortunate position in our country.
They lack inherited wealth or status, continue to face racism that makes
it difficult to accomplish the same goals that come easily for white Americans,
and live in neighborhoods that lack health resources, including safe
playgrounds and parks, nutrition-rich food, and fully stocked pharmacies.[5]
Racism is one of many factors that
play into the health disparities of another group: recent immigrants and their
descendants. Quite often, immigrants
arrive in the United States with pre-existing conditions but no documentation
of these conditions. Diseases may be
known and treated differently across different cultures, with different
symptoms expressed depending on societal context. Add this issue to any language-barrier, and
an immigrant will have a very hard time getting the appropriate attention from
doctors. They may not know about local
resources for health. People new to the
country are often uncomfortable expressing themselves, especially in developing
English. Clinicians will often skim over
details of treatment in order to avoid difficult interpretations, thus not
offering the full gamut of treatment options for immigrants. Once again, the culture barrier between
doctor and patient must be overcome.
While not always the case, immigrants, especially refugees, often arrive
with very little wealth and are starting anew.
The limitation of financial resources may lead to poor living conditions
and minimal healthcare.[6]
The United States experiences an
influx of immigrants from all around the world, and the experience of
immigrants cannot be generalized. That
said, though, many experiences are shared.
Racism tends to impact all non-white groups entering the country, with
some groups more affected than others.
Latinos have felt an intense backlash with results similar to those
found in black communities. Both groups
experience subpar care (IMA 178) compared to white Americans, even when
adjusted for socioeconomic status.[7] Yet another great worry for some immigrants’
health status is the fact that undocumented individuals risk being deported if
their attempt to receive medical care attracts attention. Much more writing would be required to
explain all the inequalities that face immigrants, but suffice it to say that
they endure a great many, all of which accrue stress that can impact their
health. This phenomenon of stress
affecting health is true of every group that suffers inequality. Even communities that have existed in America
for many years may continue to suffer from stereotyping and socioeconomic
disparity that lead to health disparities.
The LGBTQ+ community is yet another
group that suffers due to historically common prejudice. For most of United States history, being
non-heteronormative has been looked down upon and was often a punishable
offense. While one could hide this trait
and thus not suffer discrimination, the stress of doing so could be unhealthy. Many individuals still feel the need to hide
this part of themselves from unaccepting communities and may not feel
comfortable discussing it with clinicians, even if their health is at
risk. Sexual education courses do not
typically address sex and protection for couples that are not one male and one
female, thus LGBTQ+ individuals may have increased chances of sexually transmittable
diseases. For a long time, HIV/AIDS was
subjected to a shame culture, equating gayness with disease. This was another source of stress that was
detrimental to one’s mental and physical health. Until the past few years, many homosexual
couples could not share health insurance with their significant other because
they could not be legally married. This
barrier to care may have been torn down, but there are still attempts to implement
discriminatory legislature that could harm LGBTQ+ access to healthcare.[8]
Last, but not least, women are also
denied equality in healthcare.
Throughout much of history, women have been held in subservient
positions to men, often without the right to control their own bodies and make
choices about their welfare. Women have
been expected to give men sex and children, with much of their value being
assigned to their virginity and fertility.
Now, despite laws that dictate that women have de jure equal rights, they often do not have de facto equality.
Reproductive health allows for inequality because the ability to become
pregnant is unique to women, so there is no man-equivalent to compare a woman’s
rights to. However, it is obvious that
there are certain policies that do not protect women equally to men.
Women may work at the same job, but
are less likely to get promoted, partly because pregnancy and motherhood
require time commitments that are not typically expected of men, and partly out
of continuing sexist attitudes toward female employees. This places women in positions that receive
lower pay and less health benefits, not to mention, incite greater stress. There have also been attempts to give
employers the right to refuse to provide female employees with birth control in
order to favor employers’ religious freedom.
However, besides denying an important protection to women who do not
wish to have children at the current time, this policy hurts those women who
use birth control’s hormone regulation for other health issues. Other policies that put women’s health at
risk include closing Planned Parenthood (with the purpose of limiting abortions),
which offers many valuable services to help impoverished women to care for
their health and plan pregnancies so that they are not burdened in an unwieldy
way. These policies are often crafted by
male representatives without thought for the needs of women. Another, milder, but important concern is
that female hygiene products are charged with a luxury tax in most states. Women’s products of every kind are also
priced higher by retailers, as half of the population pays the “pink tax”,
furthering financial disparity between men and women. Men even enjoy privilege in pharmaceutical
research. Historically, many medicines
were tested on male subjects and assumed to be safe for both sexes without
testing their effects on women.
It is clear that economic and
cultural barriers create inequality that becomes health disparity for large
swathes of American society. What can we
do about it? The changes to society
would need to be sweeping, with governmental support, but does the country at
large have an obligation to get involved?
Indeed, it does. If the
government is supposed to be a bringer of justice among citizens, then it must
intervene in order to guarantee that all people have the ability to pursue a
healthy life. There are three main
theories of justice: egalitarian, utilitarian, and libertarian. Surprisingly, all three theories can
contribute to the understanding that the country should implement policy to
diminish health disparity.[9]
An egalitarian view argues that “important
benefits and burdens of society should be distributed equally.”[10]
Obviously, from the egalitarian
perspective, all people should have access to healthcare and the other
resources necessary to ensure health among the entire population. The utilitarian view argues that “a just
distribution of benefits and burdens is one that maximizes the net good
(utility) for society.”[11]
If all citizens but a privileged few
suffer disparity in the current format of society, then the utilitarian view
would lead one to believe that we should tear down the barriers that keep the
rest of society from enjoying such healthy lives. This would increase the net good for society,
as the privileged few do not suffer if other citizens live healthy lives, and
those citizens will be able to make greater contributions to society if they
live longer, more productive lives.
At first glance, the final view,
libertarian, is against the redistribution of resources that would be necessary
to bring about greater equality in society.
Libertarianism believes that “the benefits and burdens of society should
be distributed through the fair workings of a free market and the exercise of
liberty rights of noninterference.”[12] This theory sounds ideal, given the “fair
workings” of a free market and “liberty rights”. However, a libertarian perspective does not
make sense in the historical context of the United States. The view assumes that the market will be
fair, with the only discriminating factors of work ethic and luck, but the many
cases laid previously in the essay indicate why that is a false assumption. There are forces working against many
Americans based on race/ethnicity, sexual orientation, gender, socioeconomic
status, and other criteria that have no relation to their ethics.
If justice is getting what one
deserves, then the United States is doing its citizens an injustice by allowing
the quality and length of one’s life to be determined by factors that one
cannot control. No one deserves a better
or worse life because of their born station.
People who are born into a system that has already determined their
lives will be more difficult cannot be said to have liberty in the same sense
as those born with greater privilege.
Intersecting disparities in the United States may limit a person’s
choices so greatly, that they cannot be held accountable for the misfortunes
that befall them, and yet our current system applies incomprehensible burdens
upon those who are already burdened at the start of life. If libertarian thought is founded on letting
equals compete for resources, then it has failed already. A comprehensive solution to guarantee that
all Americans have true liberty in a fair market is to violate the very
principles of libertarianism, by helping those who are inherently
disadvantaged. Though libertarian theory
is opposed to government intervention, by observing the flaw in practiced
libertarianism one can recognize how necessary intervention actually is.
What solutions may lead to a more
just society with less health disparity?
For starters, the country, as diverse as it is, must be represented in
its government. The socioeconomic and
cultural barriers that keep minorities, women, and the poor out of governmental
positions must be eliminated. We are
beginning to see greater diversity in our representative bodies, but wealthy,
non-immigrant, educated, cis-gender, heterosexual, white Anglo-Saxon men
continue to dominate positions, due to the same advantages they have in the
field of health. However, by showing our
support for diverse candidates, American citizens can put people into office
who understand the predicaments of the less advantaged. Those representatives can protect the
interests of non-elites.
We need to put an end to
discriminatory legislation and practices by drawing attention to them in the
public sphere. The Affordable Care Act could
be expanded to ensure that all people in America would receive health benefits
at a reasonable cost. More tax breaks
could be implemented for people of lower socioeconomic status. College education could be subsidized more
fully by the federal government. More
governmental resources could go toward building healthcare infrastructure in
underserved urban and rural areas, as well as improving community access to
other resources. Community gardens and
green spaces would encourage healthy eating and exercise. Local grocery stores and pharmacies would
improve access to resources that are often lacking in certain communities. However, the flaw with the suggested changes
is that they do not address the aspects of ongoing racism and sexism or
continued socioeconomic inequality.
Neighborhoods could be refurbished but may fall into disrepair with time
unless other reforms were made. These
problems could only be remedied by more drastic change.
Some medical anthropologists have
suggested that the only way to bring about truly equal access to resources
would be a new world order.[13] Issues of inequality are not specific to the
United States and are symptomatic of the consequences of capitalism and
globalization. Inequality will continue
to exist as long as resources are concentrated in the hands of the few. There are always some populations being
exploited or continually affected by historical exploitation in this country
and in others. Those with an eye on
global health have rightly questioned why individuals in America would ever be
able achieve equal access to healthcare when the same inequalities are
maintained internationally. If disparity
is not considered injustice everywhere, then why here? In fact, global inequality is part of the
reason that domestic inequality can be maintained, thus some people argue that
a “global democracy” may be the only way to bring true liberty to all people
locally and abroad.[14] This concept in utopian thinking would be
ideal in the long run, but for the current moment, our country is obligated to
at least ascertain that more care, resources, and cultural change are
implemented to ease the burdens of underprivileged members of our society.
Miranda Mason, of Corinth, Ky., is a senior McConnell Scholar at the University of Louisville, where she is an individualized major in medicine and society.
References
Gamble, V N. “Under the
Shadow of Tuskegee: African Americans and Health Care.” American Journal of
Public Health, vol. 87, no. 11, 1997, pp. 1773–1778.
Singer, Merrill and Hans
Baer. Introducing Medical Anthropology, A Discipline in Action. 2nd ed.,
Altamira Press, 2012.
Vaughn,
Lewis. Bioethics: Principles, Issues, and Cases. 3rd ed., Oxford University
Press, 2017.
Wasserman, J, et al. “Rasing
the Ivory Tower: the Production of Knowledge and Distrust of Medicine among
African Americans.” Journal of Medical Ethics, vol. 33, no. 3, 2007, pp.
177–180.
[1]
The knowledge recounted here was
obtained in the honors seminar “This Land Was Theirs” in Fall 2018.
[2] (Singer and Baer, 201)
[3] (Gamble)
[5]
The ideas discussed here came from
class discussions in Medical Ethics and knowledge about the local and national
history of discrimination.
[6]
The issues discussed in this
section are from conversations with members of the immigrant community in Louisville
and conversations with (as well as observations of) their healthcare providers.
[8]
Most of the ideas in the
discussions of LGBTQ+ and women come from a class that focused on topics in
women and gender studies, as well as following ongoing political battles and
being a woman.
[9] (Vaughn 723-725)
[10] (725)
[11] (724)
[13] (Singer and Baer, 207-241)
[14] (Singer and Baer 238)