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The website 538.com has posted an essay (found here) about the great state of Alabama. Unlike most click bait-y articles that Alabamians seem to be attracted to on Al.com (i.e. What are the 11 greatest barbecue places within 30 miles of Bryant-Denny stadium?) but instead an in-depth look at healthcare in Greene County, Alabama. Greene county is currently the least populated Alabama county (9,045 people, 81.5% black or African American). In 1860, the county had about 30,000 people. Well, kinda depends on your definition. 23,598 of those “people” were actually enslaved human beings. Although the math works out to approximately 4 enslaved humans for every 1 “person,” in fact it was almost 7000 enslaved humans were owned by about 50 folks. As described in the Encyclopedia of Alabama, this was not a bad thing

In the decades leading up to the Civil War, Eutaw experienced a golden era as the mercantile and legal center of the Black Belt. The first courthouse, built in 1838, burned in 1868. The current courthouse was built in 1993.

The county is in a region of the state known as the “black belt”, named not for the color of the population but for the color of the soil. The slow slide to economic despair over the last 150 years has taken a toll on the region. Immediately after the civil war, the region was home to 40% of the “citizens” of Alabama. The systematic oppression of former slaves and the descendants of former slaves has lead to the growth and development of many civil rights leaders, blues musicians, and story tellers. It has also lead to a bunch of people moving away. The region, once the economic engine for the region, is now home to 12% of Alabama’s population. In the words of one Percy County resident

“The only reason people come to town now is for funerals, and they leave as soon as they’re over ’cause there’s nothing to do and nowhere to stay,” said Walker, 64, the son of sharecroppers

For those who have stayed, economic prosperity has been an uneven proposition. The racial makeup of the Black Belt region was 52.2% African American, 45.8% White, 0.2% Native American.

The poverty rate among [Wilcox] county’s white population is just 8.8 percent, which is lower than all but five counties. The poverty rate among the county’s much larger black population is 50.2 percent. The 41.4 percentage point gap is the largest in the state.

Other Black Belt counties have a similar dynamic. Lowndes County has a 4.1 percent white poverty rate – the lowest in the state – but a 34.5 percent black poverty rate. In Perry County, the white poverty rate is 8.1 percent, while the black poverty rate is 32.7 percent. In Marengo County, it is 5.6 percent and 40.8 percent respectively.

So why worry about these folks? Can’t they continue to vote with their feet?

“The Black Belt is a road map,” said Patrick Sullivan, a professor at the Rollins School of Public Health at Emory University who previously worked on HIV surveillance at the Centers for Disease Control and Prevention. “That’s what’s so tragic and so compelling. It’s an endgame depiction of what happens when you have social and structural inequalities. It’s the vestiges of slavery and inequality, and in the long run those things do play out as health inequalities.” Sullivan and colleagues have studied why HIV rates are so much higher among African-Americans and Latinos than other racial groups3 and found that health insurance is the most important mediating factor. People in both racial/ethnic groups are more likely to be poor and have less education, which are related barriers, but insurance coverage is where the local and federal government could improve access to treatment, Sullivan said.

Alabama is not a Medicaid expansion state. Our Doctor-Felon-Former-Governor decided it was a political chance he did not want to take, even after his re-election into a term limited position. Remember, adults who are employed but make less that 138% of poverty uninsured are not eligible for Obamacare. In counties like Greene, where 40% of the population is below the poverty level, that is a lot of folks, almost all of them black. When the median household income is $20,000, people are going to choose food when having to decide regarding food vs insurance, every time. So what is the right thing to do? In the words of my friend and colleague John Waits, quoted in the article:

“Nothing happens without Medicaid,” Waits said. “It is the No. 1, the No. 2, it is the top 10 solutions.”

I’m beginning to think this is about something other than partisan politics.

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I grew up in Baton Rouge, Louisiana. My parents moved there in 1959 so my father could go to graduate school at LSU. After a couple of non-academic jobs my father took a job at LSU in academia and we moved to an area near campus. So near, in fact, that on Saturday night I could see the glow from the lights at Tiger Stadium. The Baton Rouge I knew was mostly college professors and their kids and mostly “white” although my neighborhood had it’s share of brown and black college professors kids. The schools I attended were good schools. The Baton Rouge I knew was a good place to grow up.

I looked at Google Maps to try to get my bearings and determine if I knew the area where Alton Sterling was shot. I realized that though I didn’t know the area, I KNEW the area. Some auto repair stores, several convenience food stores, a dialysis center, and a couple of cell phone shops. The area is over 80% minority and has lost 10% of its population in the past 10 years. The median household income is less than 50% that of the Louisiana average and Louisiana is a poor state. I suspect you have driven through this area as well. Often by accident. Checking the door locks to make sure the doors are secured.

Race is a funny thing. The construct of race dates from the 1700s and, though there is some controversy, seems to be more tied to a desire to boost folks of certain color or ethnic make-up than to be a clarifying concept with any basis in science. Though life expectancy clearly does track with self identified race, many “whites” have African ancestors and many “african-americans” have more native American than African ancestry. Some point to sickle cell disease as evidence of a racial component of disease but the disorder clearly  tracks with factors other than black skin color.

A better construct is this study,  reported by Vox last year. Instead of being a dichotomous variable (black-white) or even a categorical variable (race is now often sorted into as many as eight categories, including “two or more”) the investigators suggested that how you self-identify your  “race” is actually a compilation of attributes that include skin color and genetics but also include such attributes as religion, social-status, power relationships, and dialect. Instead of being assigned at conception, race becomes a more dynamic construct. Other research identifies the act of ANTICIPATING being a victim of racism is clearly harmful to the health of the victim, regardless of any objective, “scientific” status of the victims “race.”

None of this brings back Alton Sterling. If, however, we could stop seeing things in the South as “black-white” maybe we could make some progress. Once we do that, here are some other things to work on:

  • Improve public transportation
  • Acknowledge that access to healthcare is a right
  • Hire public servants who are of the community and train them appropriately.
  • Demilitarize the police force.
  • Disarm the citizenry.
  • Stop being scared of “the other” because they live in poverty
  • Most importantly, stop making the poor and disenfranchised the victims of our fear.

 

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