In Mama Might Be Better Off Dead: The Failure of Health Care in the United States, Laurie Abraham argues that the health care system in the United States has indeed failed miserably, specifically in treating poor people. Abraham adds that the system has not only failed but has also caused misery for poor and helpless sick people. The story takes place in North Lawndale, a neighborhood that lies in the shadows of Chicago’s Loop. Although surrounded by some of the city’s finest medical facilities, North Lawndale is one of the sickest, most medically underserved communities in the country.
The author follows the Banes family describing the family’s experiences through home and community life, dialysis counseling and treatment, hospital visits, and doctors’ appointments. The family is headed by Jackie Banes, who cares for her diabetic grandmother; her husband Robert, who suffers from kidney failure; a sick and dependent father; and three children. The author guides us through many complex medical issues that confront some of America’s poor daily issues and throws light on various medical scenario in which the Banes family is forced to adjust to their depressing dilemma. Jackie Bares the primary caregiver experiences struggles on a day to day basis. For example, Mrs Jackson (Jackie’s grandmother) has many complications from diabetes and suffers from incontinence which makes her a candidate for adult diapers. However, Medicare sees adult diapers as more of a convenience item and does not see them as medically necessary. Medicare also covers a large portion of health visits and treatments but fails to cover transportation needs of disadvantaged patients. As a result, she misses many scheduled appointments. Her diabetes had also gone untreated because she was unable to afford treatment and transportation costs to help her infection. Consequently, she is forced to have her leg amputated because of an infection. To add to the misery, Jackie also rationed her grandmother’s medication. When a doctor told Jackie that her grandmother’s blood pressure was good, Jackie skipped her medication for the rest of the day as Medicare would not cover the $100 worth of the medication each month. Other horrific instances in the Banes family include her father (Tommy) getting a stroke, her husband (Robert) not contributing equally to tackle the family problems and facing the rigor of kidney dialysis three times a week, traveling to the clinic at the crack of dawn and sitting in rooms waiting for his name to be called. The author gives many examples throughout the book describing the difficulties faced by the Banes in obtaining and maintaining government insurance to cover their medical expenses. One such example is that although Mrs. Jackson received Medicare benefits, the amount was not adequate to cover the cost of her medications and other personal daily need. Also, none of Robert’s low-paying, short-term jobs had provided health insurance and he could not get the government-sponsored insurance.
The author also vigorously reports on the inequalities and politics of substandard living conditions, patient and caregiver issues, mental health issues, emergency room care, personal responsibility, preventive care, interaction with medical professionals, and quality-of-life issues. Additionally, the book discusses a very important issue in the United States healthcare i.e. the overrepresentation of minority groups in emergency rooms which can create apathy among providers causing follow-up services to be inadequate. Some other instances in the book which are disturbing include the unwillingness of an African-American to use a clinic located in an adjacent Hispanic neighborhood. Although the culture gap between poor African-Americans and relatively affluent whites is huge, the communication gap between African-Americans and Hispanics is wider.
Many research findings can be applied to the lives and experiences of Banes family. First, linking transportation issue faced by Mrs Jackson, Walker and colleagues, too reported that patients staying in rural areas had longer driving time to access to endocrinology care.1 The inability to travel to outpatient clinics and doctors’ offices due to transportation problems is very much prevalent. Moreover, like Mrs Jackson reports about her missing appointments, Nwabuo and team analyzed 185 African-Americans admitted to an urban medical center in Maryland and concluded that appointment non-adherence among African-Americans was associated with many markers of inadequate access to healthcare, knowledge, attitudes and beliefs.2 Additionally, just like Mrs Jackson had to skip medicines due to the cost, many studies have confirmed the same. Zhang and researchers aimed to assess the prevalence rate of cost-related medication non-adherence (CRN) and the patterns of CRN behaviors in Medicare-Medicaid dual eligible with diabetes and found high cost-related medication non-adherence (CRN). This demonstrated that cost is a significant access barrier for diabetes patients.3 These similar findings were observed in other studies as well.4,5
Second, linking the issues faced by Robert, studies have demonstrated that black patients waited significantly longer for ED care than nonblack patients. Qjao and colleagues analyzed 34,143 patient visits in 353 hospital EDs using the National Hospital Ambulatory Medical Care Survey. They concluded that black patients experienced significantly longer mean ED wait times than white patients (69.2 vs 53.3 minutes; P < 0.001).6 Additionally, Okunseri also reported that Hispanics and Blacks waited longer to receive care for nontraumatic dental condition in EDs than Whites.7 While looking at the overall picture for problems faced by minorities, patient level factors, provider level factors and system level factors could have contributed to such overwhelming disparities.8 In terms of patient level factors, African-American may find medication treatment less acceptable than whites and may prefer counseling to drug therapy. It is believed that they are more likely to seek care from informal sources such as pastors, spiritual healers, family, and friends.9,10 This may lead to mistrust in a physician’s recommendation of treatment. Provider factors must also be considered, and the possibility of stereotypes or bias such as the word ‘‘black woman/man’’ cannot be excluded. Moreover, the patient-physician relationship where trust and effective communication must occur for appropriate diagnosis and treatment appears to be weaker for African Americans as also depicted by the book.11
Mama Might Be Better Off Dead is a perfect example of how African Americans, who live in poverty in the United States are overrepresented in and grossly underserved by the United States medical community.
1. Walker, A. F. et al. Geographic access to endocrinologists for Florida’s publicly insured children with diabetes. Am. J. Manag. Care 24, SP106–SP109 (2018).
2. Nwabuo, C. C., Dy, S. M., Weeks, K. & Young, J. H. Factors Associated with Appointment Non-Adherence among African-Americans with Severe, Poorly Controlled Hypertension. PLoS ONE 9, (2014).
3. Zhang, J. X. & Meltzer, D. O. The High Cost-related Medication Non-adherence Rate Among Medicare-Medicaid Dual-Eligible Diabetes Patients. J. Health Med. Econ. 2, (2016).
4. Morgan, S. G. & Lee, A. Cost-related non-adherence to prescribed medicines among older adults: a cross-sectional analysis of a survey in 11 developed countries. BMJ Open 7, e014287 (2017).
5. Bhuyan, S. S. et al. Does Cost-Related Medication Nonadherence among Cardiovascular Disease Patients Vary by Gender? Evidence from a Nationally Representative Sample. Womens Health Issues 27, 108–115 (2017).
6. Qiao, W. P., Powell, E. S., Witte, M. P. & Zelder, M. R. Relationship between racial disparities in ED wait times and illness severity. Am. J. Emerg. Med. 34, 10–15 (2016).
7. Okunseri, C. et al. Racial/Ethnic Variations in Emergency Department Wait Times for Nontraumatic Dental Condition Visits in the United States. J. Am. Dent. Assoc. 1939 144, 828–836 (2013).
8. Mosadeghrad, A. M. Factors influencing healthcare service quality. Int. J. Health Policy Manag. 3, 77–89 (2014).
9. Ward, E., Wiltshire, J. C., Detry, M. A. & Brown, R. L. African American Men and Women’s Attitude Toward Mental Illness, Perceptions of Stigma, and Preferred Coping Behaviors. Nurs. Res. 62, 185–194 (2013).
10. Whaley, A. L. Cultural Mistrust and Mental Health Services for African Americans: A Review and Meta-Analysis. Couns. Psychol. 29, 513–531 (2001).
11. Mauksch, L. B., Dugdale, D. C., Dodson, S. & Epstein, R. Relationship, Communication, and Efficiency in the Medical Encounter: Creating a Clinical Model From a Literature Review. Arch. Intern. Med. 168, 1387–1395 (2008).