Disparities in healthcare are composed of several interconnected layers – multiple layers joined together like the bricks of a divisive wall, separating better health from poor health. And while we must acknowledge the pre-eminence of personal responsibility, we must also address the uneven distribution of mountains and valleys on the American playing field.
Disparity sometimes begins before one is born; before one is conceived – it may begin in-utero, with the absence of adequate prenatal care, with maternal co-morbidities and high-risk behavior, long before one is old enough to assume personal responsibility within an “inherited” landscape or community that is filled with steep climbs and dark valleys. Many of us are familiar with root causes of healthcare disparities – the four components or foundational bricks that sustain physical and economic health in capitalist societies.
- Educational status
- Employment status
- Insurance status
- Income level
Individual or combined deficits in these components typically lead to accumulating disadvantages within which good health is considered an outlier. It is often these environmental factors, and not genetic ones or racial ones that are largely responsible for the disproportionate morbidity and mortality we witness all over America – especially in Harlem – the site of my neurological practice.
A young child is born on Malcolm X Boulevard in central Harlem. He is the most beautiful baby I have ever seen. And yet, his passage into the world is not without hardship. His single mom, a sixth grade dropout, did not have health insurance even though she worked two minimal wage jobs. She did not receive adequate prenatal care. Indeed, the only time she visited the hospital was to fix the broken bones in her face she sustained from domestic violence. Fortunately, she escaped from that life by fighting back with everything she had. Even her child was born through conflict – amidst the peril of eclampsia. It was a stormy delivery in a safety net hospital. Luckily, she survived and the beautiful baby boy thrived.
The early years of the child’s life were spent with grandma, until she died when her grandson was only 9-years-old. Mom had nobody else to help her, and there were no breaks in Harlem. She could not afford the childcare she needed to keep her second job, which she fought so hard in vain to keep. She became homeless. After squatting with her son in an old boyfriends house for a period of time, they finally moved into a housing shelter and were placed on a waiting list for section 8.
Mom was born poor; she had no successful role models; no good yardsticks with which she could measure herself against. Everyone around her seemed resigned to the status quo, which they would refer to as “the hustle”. She did not make it to high school; she fought for her minimum wage; she had no health insurance; and yet she worked hard to provide basic needs for her and her son. Each brick of disparity – educational status, employment status, insurance status, and income level – formed a wall so tall that it was hard to imagine how she would get to the other side.
Depression crept in – an irrepressible feeling of worthlessness and hopelessness. A feeling that no matter how hard she tried she would always fail. Most of her girlfriends were already on the streets or in jail. Their children had dropped out of school to join gangs or resort to petty crimes. She promised her own mother long before she died that she would never resort to crime. She would fight a good fight for her son and herself. But depression dug deeper, breaking her will, piece by piece until she finally succumbed to the twin pressures of emotional and economic desperation.
We all have limbic needs. For some, these needs are nurtured by loving hands that paint lasting portraits of hope inside our souls. Expressions of hope hanging on the walls of our heart chambers: a mother’s attention; a father’s approval, a caregiver’s warmth, a schoolteacher’s encouragement. For other’s, there is insufficient nurturing – these limbic needs are not met; rather, they are torn down – left out in the cold, often on impoverished streets – unanchored, undermined, forced to adapt alone in a Darwinian society.
In my next post, I will finish this story. I will describe the boy’s life and his ultimate stroke in an attempt to show the interconnectivity of health and the four components of healthcare disparities.