Blog | Thursday, October 11, 2012

Poverty and passing poor health to the next generation

The social safety net matters to us public health types because--and the evidence here is compelling and strong--the one consistent alternative to a reasonable social safety net is an increased number of body bags.

Now, I know those who lean left are nodding their heads; and those who lean right are rolling their eyes. I simply ask all parties concerned to stay calm, and carry on, and let's see where this takes us.

Politicians love to tell us rags-to-riches stories. Democrats do; Republicans do. Independents probably do, too.

Our president has one. So does our first lady. Both political conventions gave us heaping doses. And we are getting an earful at present from one of our Senate candidates here in Connecticut.

These tales ostensibly emphasize the American dream, and the land of opportunity. Indeed they do, but what of the generation in rags?

The tales generally give us a one-dimensional, naive, Pollyanna view of these people. They are mythical figures, people who labored 16 hours a day, seven days a week, and whistled while they worked. They lived in the days of the giants.

We get the same distortions in medical training. However inhuman the schedule of a medical resident may be, the senior physicians, attendings, tell trainees stories of how much worse it was back "in the days of the giants." So, newbies, you should suck it up and whistle while you work 100 hours a week! We worked 130.

I guess some of the myth might be true, but probably not much.

Every parent knows you don't dump your anxieties and burdens on your kids. Has it occurred to anyone that those heroes in rags never existed? That, in fact, they were dog tired and utterly spent at the end of those 16-hour days? That they really didn't enjoy earning less than minimum wage?

The "riches" generation doesn't know the harsh truth, because the parents in rags griped about their hardships only to one another once the bedroom door was closed. Maybe they were hoping the "to riches" part might happen during their own lifetimes, and they weren't totally thrilled to spend their whole lives destitute in the hope that their kids would not. The kids never knew that living the "rags" phase of rags-to-riches pretty much totally sucked!

It's not shocking that the kids who grow up to tell these stories wouldn't consider these things. I have five kids, and when I'm doing my job as a father well, they don't know when I've had a truly awful day. Most of all, you have to hide it from the kids, coo-coo-ca-choo.

There are a number of problems with the rags-to-riches narrative. As an epidemiologist, I am obligated to ask: What's the denominator? For every diligent, hardworking soul who spends a lifetime in rags to beget riches for the next generation, how many just like him or her begets kids in rags, too?

The narrative also ignores the fact that even the most extraordinary among us get by with a little help from our friends, and favorable happenstance. No one is truly "self"-made. Malcolm Gladwell, in Outliers, does a far better job making this case than I can do here, so I simply commend the book to anyone who doubts this reality. Think Bill Gates made it on his own? Steve Jobs? Guess again.

The narrative ignores the fact that riches and rags lie on a two-way street. I have a family member, universally respected for her resourcefulness, intelligence, gumption, and work ethic, who has nonetheless managed to live something of a riches-to-rags experience through no fault of her own. She worked hard her whole life, but suffered some misfortunes of circumstance and bad timing. It's also true that she has always liked the things money can buy, and has seemingly felt compelled to keep up with the Joneses, but these, too, I suppose, are time-honored Americanisms.

I note that this family member has very different politics than I. We've all drunk so deeply of the "rags-to-riches" Kool-Aid that her own experience hasn't affected her politics at all. She routinely votes against the very social safety net, but for which she would by now be destitute, if not roadkill.

But none of these is the truly big conundrum lurking beneath the rags.

Here it is: The people who wear the rags in these stories are NEVER lazy, listless slackers looking for a handout. They are the very opposite! Despite an incredible work ethic, they spend a lifetime in rags. Despite courage, fortitude, resolve, and stoicism, they spend a lifetime in rags. Despite being full-blooded, capitalistic, Calvinistic Americans, they spend a lifetime in rags.

There is a real problem with this. Because part of our current cultural narrative is that if you work hard in America, you get ahead. Part of the argument against a social safety net is that no truly hard-working person should need one. Our current cultural narrative is: If you need a social safety net, you don't deserve one; and if you deserve one, you don't need one.

The rags-to-riches stories served up all across the political spectrum belie this.

What about all the hardworking people in the rags-to-riches stories who, despite setting the example politicians of every stripe like to cite, managed to live their lifetimes in poverty? What about the fact that these heroes of ours are the very type of people most critically dependent on a social safety net? Both needy, and deserving.


Poverty rates in the U.S. rose throughout the Bush years, and throughout the great recession that has followed. If we are willing to call getting by "riches," then these are riches-to-rags stories. What are we to make of them?

Social disparities are a leading driver of poor health outcomes. That's established fact. So though I am no politician, I very definitely have skin in this game.

There is no need to guarantee that everyone does equally well. But there is a difference all should be able to agree on between the hand up we all need from time to time, and handouts. There is a great difference between having some manageable way to get there from here with hard work, and getting a lift in a limo.

We love to regale one another with rags-to-riches stories. But as we do, we need to attend more closely to two salient details.

First, these make rousing good tales only when about semi-mythical figures living in the past. When they are about the future prospects of the children of hardworking people transitioning from rags to rags, or even relative riches to rags -- not so much.

Second, every one of these tales is about people who are the very antithesis of the listless, lazy slackers who give the "welfare state" its bad name. They are the very opposite of people looking for a handout. These are legendarily hardworking, cheerful people who, despite their best efforts, spend their lifetime in rags. If we were paying any attention to what we were saying, they would seem to demonstrate, every time, how the very best of us could find ourselves in need of a hand up, and some few strands in a social safety net.

Apparently, my personal copy of The American Dream: An Owner's Manual is missing a chapter. It's the one entitled "Despite a Lifetime of Hard Work You May Pass Rags on to Your Kids and Society Won't Give a Damn."

We like to think rags-to-riches tales are testimonials to the American dream. But they are also stories of remarkably hardworking people who spend their lives in rags. They are stories that tend to ignore how often the children of such good people wind up in rags, too. We talk about rags and buy into the popular perspective on the narrative, as if we were seeing the emperor's new clothes.

And in doing so, in failing to see past the fantasy of the rags to the real people who spend lifetimes wearing them, we may just be ragging on America.

David L. Katz, MD, FACP, MPH, FACPM, is an internationally renowned authority on nutrition, weight management, and the prevention of chronic disease, and an internationally recognized leader in integrative medicine and patient-centered care. He is a board certified specialist in both Internal Medicine, and Preventive Medicine/Public Health, and Associate Professor (adjunct) in Public Health Practice at the Yale University School of Medicine. He is the Director and founder (1998) of Yale University's Prevention Research Center; Director and founder of the Integrative Medicine Center at Griffin Hospital (2000) in Derby, Conn.; founder and president of the non-profit Turn the Tide Foundation; and formerly the Director of Medical Studies in Public Health at the Yale School of Medicine for eight years. This post originally appeared on his blog at The Huffington Post.