By DAVID INTROCASO, Ph.D.

Skid Row in Los Angeles

In May Philip Alston, the United Nation’s Special Rapporteur on Extreme Poverty, and John Norton Pomeroy Professor of Law at New York University Law School released his, “Report of the Special Rapporteur On Extreme Poverty and Human Rights on His Mission to the United States.”  The 20-page report was based, in part, on Alston’s visits this past December to California, Georgia, Puerto Rico, West Virginia and Washington, D.C.  After reading the report and the response to it, one is again forced to question how legitimate is our concern for the health and well being of the poor, or those disproportionately burdened with disease.

The UN report found over 40 million Americans live in poverty, or upwards of 14% of the population.  Those living in extreme poverty number 18.5 million and 5.3 million live in 3^rd World absolute poverty.  Among other related statistics, Alston cites the fact the US has the highest comparable infant mortality rate, 50% higher than the OECD mean, due in part to an African American mortality rate that is 2.3 times higher than that of whites.  The US has the highest youth poverty rate in the OECD.  In 2016, 18% of children were living in poverty comprising 33% of all people in living poverty and 21% of those were homeless.  These facts are explained in part by the report noting between 1995 and 2012 there was a 750% increase in the number of children of single mothers experiencing annual $2-a-day poverty.  US poverty, the report explains is due in part to the continuing growth in income and wealth inequality.  The report found in 2016 the top 1% possessed 39% of the nation’s wealth while the bottom 90% lost 25% of its share of wealth and income.  Since 1980 annual income for the top 1% has risen 205% and for the top .1% by 636% while annual wages for the bottom 50% have stagnated.  The report reminds us the US has approximately 5% of the world’s population but 25% of its billionaires.  The US in sum ranks 18^th out of 21 wealthy countries in labor markets, poverty rates, safety nets, wealth inequality and economic mobility.

While the statistics Alston presents are sobering, his assessment of the evidence is unsparing.  “Successive administrations including the current one,” Alston writes, “have determinedly rejected the idea that economic and social rights are full-fledged human rights . . . .  International human rights law recognizes a right to education, a right to health care, a right to social protection of those in need and a right to an adequate standard of living.  In practice, the United States is alone among developed countries in insisting that while human rights are fundamental importance, they do not include rights that guard against dying of hunger, dying from lack of access to affordable health care or growing up in a context of total deprivation.”  These rights have been ignored because, “for almost five decades the overall policy response has been neglectful at best, but the policies pursued over the past year seem deliberately designed to remove basic protections from the poorest, punish those who are not in employment and make even basic health care into a privilege to be earned rather than a right of citizenship.” This is particularly disturbing because, “in a rich country like the US,” Alston writes, “the persistence of extreme poverty is a political choice made by those in power.”  Alston concludes his report by noting that while “in the US it is poverty that needs to be arrested not the poor simply for being poor,” “the United States already leads the developed world in income and wealth inequality, and it is now moving full steam ahead to make itself even more unequal.”

The Trump administration’s response to the UN report was unsurprising.  On June 21^st, or the day before Alston presented his findings to the UN Human Rights Council meeting in Geneva,  US Ambassador to the UN, Nikki Haley, in a letter in response to Senator Bernie Sanders and 20 other Congressional members, argued it is “patently ridiculous for the UN to examine poverty in America.”  Two days before that, the US withdrew from the Council calling it a “cesspool of bias.”  The decision to withdraw was also unsurprising.  The US has at best a mixed record on human rights.  For example, though 150 other countries have done so, the US has yet to ratify the 1966 International Covenant on Economic, Social and Cultural Rights that protects the right to health, an adequate standard of living and other human rights.

The correlation between poverty and disease, or the social determinants of health, are well documented.  Nevertheless, Kaiser Health News, Inside Health Policy, Politico and other major healthcare media outlets chose not to cover the UN report.  It is worth noting the report was also ignored by prominent healthcare trade associations including the American Medical Association (AMA), the American Hospital Association (AHA) and America’s Health Insurance Plans (AHIP).  This, again, is unsurprising.  These organizations similarly ignored the Human Rights Watch’s (HRW) February report, “They Want Docile, How Nursing Homes in the United States Overmedicate People With Dementia.”  The report documented the continuing massive misuse of antipsychotics in nursing homes that, HRW concluded, “are inconsistent with human rights norms.”  These organizations also have had nothing to say about seemingly never-ending reports of childhood sexual abuse including the 2016 revelation that former House Speaker, Dennis Hastert, sexually molested boys while employed as a high school wrestling coach.  The AMA still honors Hastert as the 2006 Nathan Davis awardee for “the betterment of the public health.”  (Ohio House Republican, Jim Jordan, is currently accused of ignoring the sexual assault of Ohio State wrestlers he coached.)  The organizations also continue to ignore global warming that will continue to have an increasingly disproportionate adverse impact on the poor.  For example, these organizations were silent when the Obama administration released its exhaustive 2016 report, “The Impacts of Climate Change on Human Health in the United States: A Scientific Assessment.”

Indifference aside, in his report Alston argues further the US relies “on criminalization to conceal the underlying poverty problem.”  He characterizes the US criminal justice system as one that is “effectively a system for keeping the poor in poverty.”  For example, he notes in 2016 LA police arrested 14,000 homeless persons, an increase of 31% over 2011, while city arrests overall decreased by 15%.  These arrests for minor infractions like public urination in a city that fails to even meet the minimum standard number of toilets the UN sets for emergency situations, lead to misdemeanors, to warrants, to incarceration, to un-payable fines or bail and to criminal convictions that ultimately prevent employment and access to housing.  “Punishing and imprisoning the poor,” particularly the homeless, he writes, “is the distinctly American response to poverty in the twenty-first century.”  This century’s response is a continuation of last century’s response to imprison a large portion of the US population even before Bill Clinton’s 1994 Violent Crime Control and Law Enforcement Act contributed to the further criminalization of the poor and the era of mass incarceration.  The US, again with approximately 5% of the world’s population, currently accounts for over 20% of the worlds prisoners, or over 2 million, who are moreover poor and disproportionately African American and Hispanic.

The criminal justice system is used Alston notes to “make social problems temporarily invisible and to create the mirage of something having been done.”  This is exactly right when you consider how the US largely addresses mental illness.  It’s an arrestable offense.  Today, US prisons and jails constitute the largest providers of housing, or warehousing, for the mentally ill.  In her recent work, “Insane, America’s Criminal Treatment of Mental Illness,” Alisa Roth notes approximately 50% of those incarcerated, and over 75% of women incarcerated, have a mental illness.  Approximately 80% also have an accompanying substance use disorder that explains, in part, why they are incarcerated.  Roth finds the treatment these inmates receive is terrible.   One of her chapters is titled “sanctioned torture.” In his investigations of prisons the forensic psychiatrist, Dr. Terry Kupers, has found conditions where “prisoners are isolated, abandoned, forced to live in abject filth and darkness, subjected to violence and danger, denied care for the most basic human needs.”   Mental illness, as one prison official candidly tells Roth, is the new Jim Crow.

If both imprisoning the mentally ill and ignoring or denying them medical treatment does not beg human rights concerns, torturing them should.  Though the practice became viewed as cruel 200 years ago, Tocqueville and Dickens criticized the practice as well the Supreme Court in an 1890 case, today on any given day between 80,000 and 120,000 men, women and children are held in solitary confinement in US prisons and jails even though no court ever sentences anyone to solitary and those in isolation, even those held in isolation for decades, are without any due process rights.  Approximately one-third of individuals placed in “the box” suffer mental illness and a similar percent develop psychiatric symptoms if not complete decompensation after being confined over an extended period.  While those in isolation make up 5% of the general prison population they account for over 50% of suicides by, for example, self-amputation of the testicles, biting through the veins in the wrist or by jumping headlong off a bunk.  In 2011 the UN’s Special Rapporteur on Torture, Juan E. Mendez, a victim of solitary confinement himself, concluded the practice of solitary confinement be absolutely prohibited for those with mental illness and juveniles and limited to no more than 15 days for others.

He wrote, “Considering the severe mental pain or suffering solitary confinement may cause, it can amount to torture or cruel, inhuman or degrading treatment of punishment.” In their 2016 edited work, “Hell is A Very Small Place, Voices of Solitary Confinement,” Jean Casella and her coauthors moreover offered 16 first-person accounts by current or former long-term solitary confinement inmates.  William Blake, who has been held in isolation for three decades summarized his experience by writing, “set me afire, pummel and bludgeon me, cut me to bits, stab me, shoot me, do what you will in the worst of ways, but none of it could come close to making me feel things as cumulatively horrifying as what I’ve experienced through my years in solitary.”

When not criminalizing the poor state human services agencies in partnership with private sector contractors monetize poverty or turn the poor into a source of revenue.  Daniel Hatcher’s 2016 work, “The Poverty Industry, The Exploitation of America’s Most Vulnerable Citizens,” details at length how, for example, foster children have become “revenue generating mechanisms” by state agencies by, for example, presumptively assigning the state the role of the foster child’s representative Social Security insurance payee.  The poor are also exploited under rampant Medicaid money laundering schemes, for example, through the use of so-called bed taxes, enhancement or quality assessment fees used to fund state agency maintenance fees or state programs entirely unrelated to Medicaid.

Concerning the adverse health effects of rising wealth inequality described by Alston as “a dramatic contrast between the immense wealth of the few and the squalor and deprivation in which vast number of Americans exist,” the healthcare sector appears unmoved or indifferent.  For example, when Thomas Piketty’s highly acclaimed and influential “Capital in the Twenty-First Century” was published in 2014, where he argued the US is on a path back to patrimonial capitalism and where concentrated wealth and social programs like healthcare insurance are incompatible, the work was ignored in healthcare policy circles.  For example, the sole mention of Piketty in Health Affairs was a blog post that noted Piketty “is French, after all” and to argue income inequality “might be a good thing for sustainable health care spending.”  How healthcare is designed and delivered in the US also remains ignorant of the realities of being poor.  Leaving aside continuing efforts to dismantle the Affordable Care Act, more than anything it is impossible to believe US healthcare presumes an option for the poor.  Dr. Elisabeth Rosenthal begins her 2017 work, An American Sickness, How Healthcare Became Big Business and How You Can Take It Back,” by candidly admitting, “the American medical system has stopped focusing on healthcare or even science. Instead, it attends more or less single-mindedly to its own profits.”  In dollars, this means Americans are every year forced to pay approximately $1 trillion in low or no value healthcare.   It is no wonder why health care is increasingly unaffordable for not just the poor.

In his 2017 work, “The Moral Economists, R. H. Tawney, Karl Polanyi, E. P. Thompson, and the Critique of Capitalism,” Tim Rogan explained “single-mindedness” has its origins in the late 18^th century.  Via the works of T. R. Malthus, David Ricardo and Joseph Townsend western political economy became estranged from moral rules. Utilitarian reasoning became inexorable.  As for poverty, Townsend argued in his 1786 “Dissertation on the Poor Laws,” it should be left to the cruelties of nature.  This perspective, that our only interests are our self-interests, persists.  It explains why, as Alston noted in a June 3 Huffington Post editorial, the administration wants to gratuitously triple rents, cut food stamp funding and allow states to drop Medicaid lives.  This perspective, however, leaves us, as Umair Haque observed last year, without moral universals or public goods everyone should have including healthcare, welfare, education, and transportation.  These civilize us. They would allow, for example, the recently injured Boston subway commuter to afford emergency care.  They also allow for democracy and upon which democracy depends.

David Introcaso, Ph.D., has been doing health care delivery, payment and related research in Washington, D.C. for over twenty years at, for example, AHRQ and ASPE, for Congressional leadership and for numerous trade and professional organizations from the American Heart Association and the American Public Health Association to UnitedHealth Group.