When we talk about healthcare, we spend a lot of time talking about individuals—patient’s rights, privacy, the doctor-patient relationship. Of course, it is as individuals that we experience our illnesses and our encounters with doctors. But medicine is by its nature a matter of populations. The meaningful relationship to discuss is not doctor and patient but medical professionals and the populations they treat—and the institutions in which they all live and work. No disease is cured by individuals or for an individual. They are cured by teams, often collaborating (and competing) across generations. They are cured forpopulations, whose odds improve as knowledge of the disease and its cure disseminates across the profession and roots itself in curriculum and practice.
When part of a population is subject to chronic illnesses—physical or mental—the whole population suffers. Yet, because we fool ourselves into thinking of health as an individual affair, this is not how we experience it. That this collective suffering is not recognized is due to the various materials we use to insulate ourselves one from another. These materials include, on one hand, the fantasy that we possess a right to privacy and autonomy, and, on the other, the fantasy that there is meaning to be found in the social categories of race, class, and gender—meaning which often works to deny privacy and autonomy to those whose race or ethnicity or socioeconomic status or gender marks them as other than the “we” that need not speak its name. When “they” suffer from medical problems “we” fool ourselves into imagining their problems are caused by something unique to their lives, their destinies. It has nothing to do with “us.”
What follows over the course of intermittent installments under this title will be a series of half-formed meditations on the relationship between illness, individuals, and the social identities in which we continue to be inordinately invested—with disastrous consequences for our collective health. I am no doctor, no public health expert—only an old professor who has spent a very long time as a patient and almost as long thinking about the politics and practices of identity, particularly in the U.S. If all this adds up to something it will be against some long odds; if it fails, it will not be for want of trying.
When my wife was pregnant with our first child, we had to have what the doctor in Iowa somewhat excitedly termed a “Jew Test.” Had there been more Jews in central Iowa, he would no doubt have used the more precise name ofAshkenazi Jewish Panel, a series of genetic tests to make sure we weren’t both carriers of genetic diseases particularly prevalent among Jews of Eastern European descent, including Tay-Sachs and Gaucher disease. The prevalence of such diseases among European Jews is almost certainly the result of population bottlenecks brought about by the centuries of pogroms and genocide—as well as by a religious mandate towards intramarriage and historic antisemitism that made ethnic intermarriage extremely rare until modern times. Population bottlenecks and endogamy are a recipe for genetic disease to establish themselves in a community.
In the case of the Ashkenazi the conditions leading to predisposition towards certain diseases likely developed over the course of many centuries or millennia. But there is evidence that genetic change has happened much more quickly—in the case of African American descendants of slaves over the course of three centuries. A study published in 2011 suggested that a genetic predisposition for such health problems as hypertension, sclerosis, and prostate and bladder cancers might well be the result of genetic adaption to a radically new environment among the descendants of African slaves.
In both the above cases, genetic predisposition towards certain disease is intimately connected with historic oppression. But one does not have to look to the genome or centuries’ old history to find such connections between health and all that artificially divides us. According to the CDC, the percentage of African American babies with low birth weight in 2013 was 13.1%, compared with 6.98% among non-Hispanic whites. The percentage of Latinos under 65 without health insurance is 30%, as compared to under 17% for whites. And the percentage of African Americans living in a neighborhood with at least one grocery store selling fresh fruits and vegetables is 8%, according to a recent State of Obesity Report, as opposed to 31% percent for whites.
These are just a couple of statistics from among a vast army one could muster, of course, but they at least serve as a starting point for demonstrating the ways in which the conditions that lead marginalized and oppressed groups to experience less health and unequal access to healthcare are re-inscribed daily in our present-day moment. Obesity-related diseases such as type 2 diabetes, heart disease and stroke are all more prevalent among those with unequal access to preventative care, and these conditions disproportionately impact African Americans and Latinos. Living in “food deserts” and “food swamps”—neighborhoods saturated with fast food, convenience stores and predatory marketing—makes it far less likely that healthier, happier outcomes can be achieved by those who are trapped in these communities by the accidentof birth and theintentionsof those who would rewire accident as destiny.
So it is that race and ethnicity become something akin to genetic destiny as far as the health of our fellow citizens are concerned. And those who do not live in food deserts or swamps, those who have access to good insurance and to attentive doctors (needless to say, we are talking predominantly about middle- and upper-class whites—and especially white men—here) can look at the statistics and shake their heads, perhaps sadly, perhaps contemptuously (or both) and imagine that none of this has anything to do with them.
And so the oppressed grow sicker while the rich grow healthier, imagining all the time that it is some kind of virtue or genetic purity (or both) that preserves them from the epidemics that impact the majority of their fellow citizens. Surrounding themselves in moated communities walled in by Whole Foods, Apple Stores, and yoga studios, we can fool ourselves that bad health—and most especially that related to “lifestyle” (as if those who live in food deserts chooseto avoid fresh foods or those who can secure no employment in their communitiesprefernot to work)—is the stuff of another country, another people, another world.
One does not have to be a compulsive reader of science fiction to know how this story ends. But it helps.
Jared Gardner is a professor and patient at the Ohio State University.