Posted tagged ‘Poverty’

Inequality Kills. Policy Drives Inequality. Elections Matter

March 16, 2014

Annie Lowrey in The New York Times today:

Fairfax is a place of the haves, and McDowell of the have-nots. Just outside of Washington, fat government contracts and a growing technology sector buoy the median household income in Fairfax County up to $107,000, one of the highest in the nation. McDowell, with the decline of coal, has little in the way of industry. Unemployment is high. Drug abuse is rampant. Median household income is about one-fifth that of Fairfax.

One of the starkest consequences of that divide is seen in the life expectancies of the people there. Residents of Fairfax County are among the longest-lived in the country: Men have an average life expectancy of 82 years and women, 85, about the same as in Sweden. In McDowell, the averages are 64 and 73, about the same as in Iraq.

There have long been stark economic differences between Fairfax County and McDowell. But as their fortunes have diverged even further over the past generation, their life expectancies have diverged, too. In McDowell, women’s life expectancy has actually fallen by two years since 1985; it grew five years in Fairfax. [Links in the original]

Albrecht_Dürer_013

Lowrey is careful to note that the causal connection between poverty and longevity (or its absence) is hard to establish, and the data are both incomplete and fraught with co- and confounding factors.  But such caution does not in the end distract her from the basic point of her reporting:

It is hard to prove causality with the available information. County-level data is the most detailed available, but it is not perfect. People move, and that is a confounding factor. McDowell’s population has dropped by more than half since the late 1970s, whereas Fairfax’s has roughly doubled. Perhaps more educated and healthier people have been relocating from places like McDowell to places like Fairfax. In that case, life expectancy would not have changed; how Americans arrange themselves geographically would have.

“These things are not nearly as clear as they seem, or as clear as epidemiologists seem to think,” said Angus Deaton, an economist at Princeton.

Further, there is nothing to suggest that, for a given individual, getting a raise in pay or moving between counties would mean outliving her peers.

“The statistical term is the ecological fallacy,” Mr. Kindig said. “We can’t apply aggregate data to an individual, and that’s underappreciated when you’re looking at these numbers.” But, “having said that, I still think that the averages and the variation across counties tells us a lot,” he added. “We don’t want to let the perfect be the enemy of the good here.”

Despite the statistical murk, many epidemiologists, economists and other researchers say that rising income inequality may be playing into the rising disparity in health and longevity. “We can’t say that there is no effect, just because we don’t have clear methods to test the effect,” said Hui Zheng, a sociologist at Ohio State University…

Mr. Zheng has also posited that inequality, by socially disenfranchising certain groups and making them distrustful of public systems, may have a long-range effect on health.

To some extent, the broad expansion of health insurance to low-income communities, as called for under Obamacare, may help to mitigate this stark divide, experts say. And it is encouraging that both Republicans and Democrats have recently elevated the issues of poverty, economic mobility and inequality, But the contrast between McDowell and Fairfax shows just how deeply entrenched these trends are, with consequences reaching all the way from people’s pocketbooks to their graves.

I’ll mostly pass over Lowrey’s seeming willingness to take as hopeful recent Republican rhetoric on poverty absent any policy proposals that would do anything about it, whilst continuing to propose, inter alia, the destruction of Obamacare, the one program she cites as having the potential to help.  This kind of both-sides-ism seems to be an ineradicable MSM pathology.

What matters much more is the basic point to draw from the evidence within Lowrey’s piece:  poverty kills — or perhaps better, wealth saves. Increases in inequality correlate with an increasing gap between rich and poor on the most basic of measures, how long we all get to enjoy the pursuits of life, liberty and happiness.  Policies that drive such inequality, or do nothing to mitigate, are implicated in those lost years, in deaths before time.  Those policies are the current program of the Republican Party.

Literally:  Vote like your live depends on it.

Image: Albrecht Dürer, The Death of Crescentia Pirckheimer, 1504.

Poverty and Aids: Who Does What To Whom/Elizabeth Pisani edition.

December 4, 2008

So, to get back to business, a little follow up on the MIT talk by Elizabeth Pisani touted below.

Elizabeth, whose book, The Wisdom of Whores I admire both as a ripping read and as a powerfully argued polemic – with – the -facts, is a passionate advocate for clarity in our description of and response to HIV and AIDS.  A journalist, and then an epidemiologist, as well as a self-admitted member of the AIDS mafia, Pisani emphasizes that HIV is a virus that is transmitted by a few well known pathways: basically unprotected sex, unprotected anal sex, and needle sharing among IV drug users.

In her book and in her talk at MIT on Monday, Elizabeth admitted her own complicity in what she sees as the original sin (my phrase, not hers) of the public health community’s response to the epidemic.  In order to secure funds to fight the disease, public health folks and epidemiologists de-emphasized in public the central roles of commercial sex, homosexual sex and drug use in the dissemination of the virus, choosing instead to highlight more broadly sympathetic and politically acceptable potential victims:  children, “innocent” women, and the ultimately, the public at large.

That spin worked, Elizabeth said, attracting a torrent of money. But there was a catch:  a ton of that new cash was restricted to taking care of the politically attractive categories, leaving the problems at the core of the epidemic — sex and drugs — still drastically under-addressed.

That’s the broad stroke argument, very broad — so don’t blame Elizabeth for my shorthand and no doubt inaccurate attempt at a gloss on her talk. Among her caveats:  much of what she had to say applied not to the two thirds of the epidemic taking place in southern and eastern Africa, but to the one third spread out over the rest of the world.  But the discussion that followed raised two crucial points of contention that are worth thinking about.

One was a reaction to Elizabeth’s complaint of what she did not call, but I will, AIDS whoring.  By this I mean the habit that Elizabeth pointed out of all kinds of (presumptively) well-intentioned organizations trying to claim some connection to the fight against HIV/AIDS, no matter what they actually do, just to take a sip or two from that river of money flowing towards the disease.

In particular, the trope that HIV is a disease of poverty got Elizabeth’s goat.  No, she argued. HIV is a virus, and to the extent that it is a disease of anything….wait for it…it’s one of sex and drugs.

Money spent on projects to alleviate poverty, or to increase women’s economic power, or any of the other entirely important and necessary development goals someone might have will not, in this view, do much of anything to deal with the problem of HIV and AIDS.  If you really want to deal with the disease, she argued, attack the problem directly. Needle exchanges work.  Proper prison HIV projects work.  Condoms work…that’s where the emphasis should lie.

Not so, argued one member of the audience in a conversation after the talk.  Too reticent to push the point during the q. and a., this person argued that Elizabeth was too much the epidemiologist.  From where she sat — a physician with experience in the Middle East, now studying the interface between technology, culture and history in the context of health and medicine — poverty was indeed a significant part of the equation.

That is hard won knowledge, and I’ve heard the same from other people up to their elbows in responding to the epidemic.

And yet, stripping down the question to its core — what will save lives most directly, right now — it’s hard to ignore Elizabeth’s central point:  the argument that addressing HIV/AIDS head on is not the same thing as saying that one should not attack poverty, the evils done to women and or children and so on.  It is just that improved sanitation installed over the next months or years; a new micro-loan program, even one laptop per child is not going to affect the infection being transmitted right now on a thin mattress in a brothel, in the passage from one arm to the next of droplets of blood mixed with heroin, in the late night, alcohol and dance fever-fueled “decision” to forget the damn condom after all.

In this view diseases are not — or at least not only — social phenomena.  From the point of view of someone actually about to be infected, they involve specific pathogens moving through known pathways to inflict harm on identifiable individual people.  And there are methods available, were political and moral will strong enough, to find both those people already suffering, and to reach those near them at risk. Given that capacity, what should the course of action be?

Look at another example:  Paul Farmer has achieved a justifiable fame (some would say apotheosis) through an approach that says you do what you have to do to make sure the miserably poor, no-hoper ten miles away across three mountain ranges takes his or her damn TB meds.

All the medical interventions that Farmer’s approach has generated have not transformed the fundamental conditions of poverty and oppression in Haiti or in other communities where his efforts have been directed.  But they do, of course, save lives — and I’m comfortable with the claim that basic health is a necessary pre-conditions to any such change. Even if you argue that there is an intimate connection between social pathologies and the medical ones associated with AIDS, there is the brute fact of a feedback loop:  poor and oppressed communities, marginalized and reviled groups (think junkies and whores) do not improve their ability to press a claim on the society or polity as a whole when they are mired in the struggle with a spreading infection.

All this, of course, is open to dispute on points of principle.  It is certainly true that absent structural change, the poor and the marginalized have more or less unlimited paths to suffering and death.  Hence, any given amelioration of suffering can be seen as the rearranging of the deck chairs on the Titanic. There is every reason to argue that what is needed is transformative change that addresses blighted lives and communities across the range of problems confronting them.

Fair enough — but in practice, as Elizabeth has described with potent fury in her book, the dilution of AIDS efforts into generalized anti- this or that has does not prevent infections, nor does it, so far at least, seem to have transformed the world of the poor.  There are the usual problems of aid:  those who live well off doing good are always with us, for example.

But more deeply, this seems to me to be a case of the best being the enemy of the good:   There is the blunt fact that structural change is slow and uncertain, and HIV infection and its consequences often are neither.  It is my hope that come January 20th, the worst diversions of effort and emphasis in US global HIV/AIDS policy will be reversed.  Just dumping the abstinence-only set-aside would be a major step forward.  Here’s hoping.

Of course — this begs the question of whether any policy involving culture, society and behavior can work, given the freight that comes with anything involving sex, drugs, conceptions of sin and purity and all the rest…and that came up too in Elizabeth’s talk.

But this post has gone on long enough.  I’ll write up the debate on this point that came out of Elizabeth’s talk in another one.

Jean Agélou, “French nude smoking opium” c. 1910.