INTRODUCTION

Who stays healthy and who falls ill is a complicated matter. Social context, environmental toxins, genetics, individual agency—all such factors influence and ultimately converge on particular health outcomes.
In this thesis, I explore how economic marginalization shapes health. I additionally analyze how redistributive institutions impact the link between poverty and disease. Throughout this work, I use redistributive institution and assisted navigation to refer to the following:

• A redistributive institution offers eligible clients subsidized goods and/or services.
• Assisted navigation is helping an individual find redistributive institutions that can meet one or more of his or her needs.

Part I: The Problem provides an overview of poverty and health in D.C., beginning with a general understanding and then moving to city-specific data. Chapter 1, based on the literature, explores how poverty can prove hazardous to a person’s health. Chapter 2 presents the history of economic and social marginalization in the nation’s capital. And chapter 3 explores the link between poverty and poor health in the District of Columbia.
Part II: The Response explores how redistributive institutions influence poverty and health. Against the backdrop of Part I, I present a case study of fifty individuals who try to obtain subsidized goods such as housing, food, and healthcare. Data is from my experience as a participant observer with the Family Help Desk (FHD), which is a small nonprofit that helps District residents obtain subsidized goods and services. Chapter 4 presents the experience of my FHD clients as they work alone with redistributive institutions. Chapter 5 narrates my experience with clients as we work together to obtain goods and services. And Chapter 6 proposes a model for why certain institutions are so difficult to work with. I conclude with suggestions on how redistributive institutions can become more efficient and cooperative.
Redistribution is an integral component in eliminating socioeconomic health disparities. Understanding its impact is therefore essential for achieving more equitable health outcomes now and in the years to come.
THE HEALTH CONSTRAINTS OF POVERTY

Within any society, certain groups have greater access to “desirable resources and rewards” (Williams, 1990:81). Health is one such social “reward.” Disease and premature death are not equitably distributed across socioeconomic strata. Individuals with the least income and least education—individuals living in poverty—are more likely to suffer from illness those farther up the socioeconomic ladder. It is certainly possible for the poorest to achieve and maintain health. But the literature, time and time again, confirms that while poverty does not necessarily cause disease, it restricts a person’s ability to stay healthy.
John Bowker, a professor of religious studies, argues that pathology is effectively understood using a model of constraints versus causality (1997). To justify his approach, he recalls Hume’s caution (Ibid, 372).

We never observe ‘cause,’ but only a constancy of conjunction from which we infer “cause.”

Whether or not a person falls ill, in short, is more complicated than matters of cause and effect. Even the “simplest” of relationships, such as the expression of a mutated gene that results in cystic fibrosis, is mediated by a larger context. A person’s access to knowledge, to medication, and even the development of an embryo’s genome are influenced by matters beyond the gene-phenotype “causal” chain. Overall, Bowker urges his reader to consider the following (Ibid, 374)

When we are trying to explain any complex phenomenon, we will always be wise to think of sets of constraints, even if we wish to isolate some among them as being proximate causes of particular outcomes. An explanation will then be an adequate specification of those constraints that have brought about the eventuality (or outcome) in question
The poverty-disease link is one such “complex phenomenon” that operates through a related set of constraints. There is not one, or even a set, of neatly defined causal mechanisms. There is, rather, a network of related and interacting restrictions that constrain physical and mental well-being. Though not a sociologist by trade, Bowker’s framework effectively organizes countless sociological studies that explore the stratification of health.
Applying Bowker’s approach, it is quickly clear that economic marginalization is about more than federal thresholds. Life at the bottom of the economic hierarchy subjects a person to health-hazardous constraints—constraints that are both internal and external to the individual. I first consider how poverty can degrade a person’s sense of self-efficacy. I then consider how even if a person is absolutely determined to achieve and maintain health, economic and social marginalization constrain their ability to avoid illness. Overall, I consider how poverty restricts health through perceived control, stress, purchasing power, education, employment, residence, diet and exercise, race, and generational experience.
These issues are central to the experience of my Family Help Desk (FHD) clients. FHD clients regularly expressed feelings of powerlessness and stress as they recalled the reality of redistributive institutions. My clients and I, moreover, worked together to obtain subsidized GED programs, housing, food and other goods and services. Overall, the experience of FHD clients and the reality of redistributive institutions do not occur in isolation. Such experiences enter into a broader picture of poverty and health.
As I will discuss, Bowker’s approach counters trends in both academic and popular literature. He ultimately shares the same end goal as many of his fellow theorists—that goal being to understand and alleviate socially-stratified suffering. But the path that Bowker advocates is a necessary intervention. He brings debate and discussion away from simple causal relationships and toward a broader picture of human experience (Ibid, 376):

The point of reformulating the boundaries should be to shake loose the narrow concentration on single causes (important and successful though it may often be) in order to realize how profoundly the wider circumstances of existence constrain human lives into distress, some of which presents itself in what we now define as medical symptoms
Bowker’s approach, in short, treats poverty as a “wider circumstance of existence that constraints human lives into distress.” This approach yields insight into the myriad connections between economic marginalization and disease. And his approach is a necessary intervention in the current debate on poverty and health.
THE PSYCHOLOGICAL CONSTRAINTS OF POVERTY: PERCEIVED CONTROL

There is a permanent and persistent tension between individual agency and external conditions. Human experience is necessarily a synergy of the two. Social hierarchy impacts health not only through extra-individual constraints, such as institutional racism, but also through psychological, or intra-individual, restrictions. Through external restrictions on life outcomes, poverty can foster a sense of inefficacy and powerlessness that is ultimately health-hazardous.
Poverty implies relatively limited access to material goods, which can translate into relatively low control over life events. Martin Segilman (1975) offers several illustrative examples rooted in past research. Babies usually cry to elicit a desired response. But if a caregiver fails to render food, perhaps due to poverty, then an infant will experience a disconnect between effort and outcome (1975:160). Peasants in South Italy, to cite another example, are frequently subject to uncontrollable and devastating eventualities (1975:160):

What for others are misfortunes are for [the peasant] calamities. When their hog strangled on its tether, a laborer and his wife were desolate. The woman tore her hair and beat her head against a wall while the husband sat mute and stricken in a corner. The loss of the hog meant they would have no meat that winter, no grease to spread on bread, nothing to sell for cash to pay taxes, and no possibility of acquiring a pig the next spring. Such blows may fall at any time. Fields may be washed away in a flood. Hail may beat down the wheat. Illness may strike. To be a peasant is to stand helpless before these possibilities.

The experience of American poverty is different in many ways from the daily life of a mid twentieth century Italian peasant. But poverty, across national and chronological boundaries, exacerbates the eventualities of life. What are “misfortunes” for middle and high income individuals can become “calamities” in the context of poverty.
Constraints, again, are not just about extra-individual control. As explored by Martin Seligman (1975), individuals can internalize a feeling of helplessness. Repeated experiences where effort fails to yield positive results can lead to a persistent perception of powerlessness, or learned helplessness. Seligman explains how humans, like animals, can be conditioned to feel powerless even when their actions can yield desirable results (1975:164):

People, dogs, and rats first learn that relief is uncontrollable. Then, because the experimenter has changed the conditions, relief actually becomes attainable; but because of their expectancies of independence between relief and responding, the subjects have difficulty forming a new, hopeful expectancy.

A learned sense of inefficacy can pervade all aspects of an individual’s life. And even when a person has the opportunity to perform productive action, she may choose to refrain based on the expectation that “it doesn’t matter anyway.”
Perceived control and learned helplessness are central to poverty and disease. Albert Bandura formalizes the concept of perceived self-efficacy as follows (1995:3):

Perceived self-efficacy is a person’s belief in [his or her] capabilities to organize and execute the courses of action required to manage prospective situations.

In extensive studies, Bandura and his colleagues have confirmed that perceived self-efficacy is a powerful predictor of actual life outcomes. The old adage of “if at first you don’t succeed, try, try, try again,” in light of Bandura’s work, is more than popular knowledge. It is scientifically verifiable. Locke and Lantham (1990), among others, have confirmed that “the stronger the perceived self-efficacy, the higher the goals people set for themselves and the firmer is their commitment to them” (cited in Bandura, 1995:6). When it comes to disease, a wealth of studies substantiate that individuals with a higher perceived self-efficacy are more likely to not be depressed, to be academically successful, and to engage in health promotive behaviors (Bandura, 1995:26). People with a higher perception of their self-efficacy, moreover, are less likely to become stressed in difficult situations—allowing them to think more clearly and to avoid the physiological effects of stress hormones (Ibid, 8)
The psychological constraints of poverty have been attacked and maligned by many leading sociologists and anthropologists. Judith Goode and Edwin Earnes (1996), for one, offer a counterargument in “An Anthropological Critique of the Culture of Poverty.” The popular presentation of a “culture of poverty,” however, strays from Seligman and Bowker’s approach. Neither Seligman nor Bowker proposes that poverty inevitably engenders feelings of powerlessness and lowers motivation. Seligman himself prefaces his discussion of poverty as follows (1975:159):

It would be glib to equate poverty with helplessness. Having an annual income of $6,000 per year, instead of $12,000, does not automatically produce helplessness. The lives of poor people are replete with instances of courage, of belief in the effectiveness of action, and of personal dignity.

Poverty, nonetheless, is characterized by lived exclusion from the economic, political, and social domains of society. And real and repeated experience of having little control over life can degrade a person’s determination to keep a “can-do” attitude. There are, as Seligman points out, many “instances of courage” and “belief in the effectiveness of action.” But the issue is not about causality. It is about constraints. Poverty as an experience of economic marginalization constrains a person’s perceived self-efficacy, and can condition a person into persistent feelings of helplessness. And perceived self-efficacy, as explored by Bandura, is about more than mental motivation. It manifests in very real ways, including physical and mental illness.