KEN FOX

HOTEPS STORY: EXPLORING THE WOUNDS OF HEALTH

VULNERABILITY IN THE US

ABSTRACT. A wide variety of forms of domination has resulted in a highly heterogeneous health risk category, the vulnerable. The study of health inequities sheds light
on forces that generate, sustain, and alter vulnerabilities to illness, injury, suffering and
death. This paper analyzes the case of a high-risk teen from a Boston ghetto that illuminates intersections between race and class in the construction of vulnerability in the
US. Exploration of his wounds helps specify how large-scale social and cultural forces
become embodied as individual experience of disparate health risk. The case demonstrates
that health inequities would not occur if resources employment, income, wealth, education, housing, profiling in the legal system, and health care were more justly managed
in keeping with standards outlined in the Universal Declaration of Human Rights. Professional responses to the wounds of vulnerability may reveal important aspects of who we
are and what our work as scholars, practitioners, and advocates must become.
KEY WORDS: health disparities, health and human rights, health inequalities, poverty and
child health, race/ethnicity, social class, and health, vulnerability

INTRODUCTION
Vulnerability is intrinsic to the human condition, as certain as death. No
one is completely invulnerable and everyone, eventually, will die. Yet
human vulnerability is inherently plastic; it is produced by human social
enterprise. Vulnerability is constituted by interactions between social
structures and individual agency. Vulnerability is produced by human
choices and behaviors within structural constraints historic, economic,
cultural, moral, psychologic, biologic and linguistic contexts, conditions
and positions.
This paper explores intersections between race and class in the
construction of health vulnerabilities risks of illness, injury, suffering,
death in the U.S. I will present the case of a young man who embodies the
stigmata of vulnerabilities generated in a particular place and time a
Boston ghetto, 20012002 where I work as a community pediatrician.
My analysis focuses on health inequities preventable health inequalities that emerge from social injustices like racism and socioeconomic
marginalization [1].
Theoretical Medicine 23: 471497, 2002.
2002 Kluwer Academic Publishers. Printed in the Netherlands.

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KEN FOX

The case and analysis are colored by a particular linguistic and conceptual inheritance. The word vulnerability is derived from the Early 17th
century Latin vulnerabilis, from vulnerare, to wound, from vulnus, a
wound [2]. Similarly, contemporary English usage of the word vulnerability refers to an openness to emotional or physical attack; a state of
being exposed and unable to resist harm, illness, injury, damage, debility
or temptation. In the study of health, vulnerability refers to attributes or
exposures that convey risk or probability of poor health. Individual,
community and ecological factors fall under the disciplinary gaze
that explores health vulnerabilities [3, 4].
Much has been made of the fact that vulnerabilities are unevenly
distributed across populations. Here the epidemiologic concept of relative
risk is usefully deployed [3]. Higher relative risk means greater vulnerability. But how are these relative risks constituted? Some risk disparities are
due to chance alone they are the consequences of random and unpredictable events. However, other risk disparities are the consequence of
premeditated human volition and effort they are patterned, predictable
and preventable if resources are managed differently. Many of the vulnerabilities discussed in the case and analysis would not exist if healthcare
and other resources were delivered on the basis of need rather than on the
basis of color, class, caste, or ability to pay.
According to an emerging health literature, the vulnerable are a
large and heterogeneous group: High risk mothers and infants, chronically ill, disabled, substance abusers, the homeless, immigrants
and refugees, racial and ethnic minorities, war veterans, children,
foster children, street children, persons with AIDS, etc. The
vulnerable are the underprivileged, underinsured, underserved,
and underclass. However, too often, critical questions are left underexplored. Who and what precisely, are the vulnerable under? And how did
they come to occupy this health harming position? In other words, our
language does not adequately account for the large-scale forces and forms
of domination that have resulted such an enormous, variegated and vexing
group the vulnerable.
A central aim of this paper is to explore the wounds of health vulnerability. I want to name and specify large-scale social forces that become
embodied as individual experiences of vulnerability. How do inequalities
rip bodies open and slip beneath the skin?

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HOTEPS STORY
Suffering Black flesh is [a] window onto the spiritual trauma that afflicts an entire
generation.
Michael Eric Dyson, Holler If You Hear Me [5].

When you see Hotep Johnson strut slowly down the clinic corridor in
his Angela Davis style oversized afro, hooded FUBU sweatshirt, fat
gold chain, and unbelted jeans drooping over plaid Tommy Hilfiger boxer
shorts and unlaced counterfeit-Timberland boots, vulnerable is not the
word that springs immediately to mind.
On a good day, Hotep might be called a 17 year old high risk urban
African American male from a Boston ghetto. He came to my Adolescent Clinic in September 2001 having as a chief complaint a ten pound
weight loss without dieting over the past one month. He reported poor
appetite and eating habits. However, he denied stomach pain, vomiting,
diarrhea, fever, rash or signs of hepatitis. He held no distorted notions of
his own body image nor other indications of an eating disorder. He was
a tobacco smoker (one half pack per day of Marlboro cigarettes) who also
used marijuana daily. He denied alcohol use.
The medical interview revealed that Hotep was also concerned about
whether he had gotten some kind of STD (sexually transmitted disease)
since he recently heard through the grapevine that his ex-girlfriend had
gonorrhea and he had had unprotected intercourse with her about six
weeks prior to the visit. Yo, my Nigga, a players gotta play. Word. You
know I be clockin the hos (i.e., having sexual intercourse with many
different female partners). While Hotep did not complain of pain on urination or urethral discharge (all signs of urethral infection from an STD),
he did report flu-like symptoms about one month prior to the visit. He
reported no cough or night sweats.
His past medical history was notable for a prematurity (born at 30
weeks gestation), a broken arm after being hit by a car (age seven),
moderate asthma (required four brief hospitalizations over the past four
years), mild environmental allergies, two prior STDs and multiple ER
admissions for evaluation and management of concussions and lacerations secondary to three motor vehicle accidents (in which he was an
unrestrained passenger).
Hotep lives with his mother and two younger brothers in Roxbury. His
social history is notable for persistent poverty, teen fatherhood (his son
was 10 months old at the time of the visit), and food insecurity (My mom
runs out of food sometimes at the end of the month, so we go to the food
pantry). He told me he had Caught a few cases over the years. In other
words, he had been arrested and detained several times: For drug possession, WWB (i.e., harassed by officers engaged in community policing

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for Walking While Black), and for punching his babys mother in the
face in a domestic violence dispute. Hotep has a multiple tattoos including
a figure of Nefertiti on his right breast just like the rap music icon he
idolizes, Tupac Shakur (who was killed in a drive-by shooting in 1996).
Hotep told me his dream is to blow up and rock the mic (become a
big-time rapper) and to direct music videos.
Sitting naked but for his blue paper gown on the table after an unrevealing physical exam and STD testing, Hotep described his experience of
vulnerability: Doc, my life is already layed out for me.
What do you mean, man?
I mean I dont want to get into slingin rock and weed (drug trafficking
in crack and marijuana) but, yo, sometimes I feel so god-damned pressed.
My baby need (sic) milk and Pampers. What kind of father is that? I cant
think no more at school and I already missed classes including those on
the day of the medical visit (this, by the way, is Hoteps third time through
9th grade in a large Boston ghetto public school).
Hotep continued: It feel like somebody cut my insides out. However,
he refused an offer to talk with a social worker or psychiatrist. Nah, Im
straight, (i.e., not interested in pursuing this further) and I aint crazy.
Im just a Black man in this world. And these streets is a bitch. You
feel me? Anyway, he explained, social workers be wack (i.e., not
helpful or useful; a waste of time); Always be trying to take somebody
away from they family. At the time he expressed neither suicidal nor
homicidal thoughts and agreed to return to the clinic for follow up and
to discuss his medical test results in two weeks. In the 15 minutes that
remained, we discussed nutrition and food security (including referral to
the hospitals food pantry), condom use, smoking, asthma management,
school truancy and the possibilities of alternative school programs or job
training. Prescriptions and community resource numbers were written,
a peak flow meter and samples of condoms were given to him, and a
follow-up plan was arranged (including a home visit by me).
Though all of his tests were negative, Hotep never returned to discuss
the results. However, he came to the Emergency department late one afternoon in the spring of 2002 after he was stabbed seven times in the chest,
abdomen, left shoulder and forearm in a fight on the school yard. He
required an emergency splenectomy and a three week hospitalization. His
pain during the hospital course was well controlled with narcotics, and he
developed no infections. Assailants remained unknown and no arrests
were made in the case. Hotep held no plan for retaliation. He had not been
back to school since the attack.
He was eventually cleared by the general surgeons and instructed to
return to the Adolescent Center nine months after our initial encounter. On

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that day he presented the following chief complaint: Every time I stretch
it feels like Im going to tear open.
Hoteps physical exam and radiologic tests failed to reveal an unequivocal diagnosis that adequately explained the sources of his pain (though
I suspected it was related primarily to the formation of scar tissue as he
healed from his wounds).
Though Hoteps direct, visceral experience of pain subsided with
time and anti-inflammatory drugs over the weeks that followed, his case
embodies fundamental features of vulnerability. His suffering invites
reflection on the powerful confluence of forces at work in the construction of vulnerabilities to illness, injury and harm among certain kinds or
categories of person. Ultimately, theoretical understandings of how these
vulnerabilities are constructed may shape our commitments, approaches,
and capacities to deliver effective care.
HOTEPS VULNERABILITY I: POVERTY
Hotep grew up in persistent poverty. This critical aspect of his vulnerability is neither arbitrary nor accidental. Macroeconomic and social safety
net policy choices, the exercise of political power, have impoverished his
family made and kept them poor. In an age and place of plenty, Hoteps
impoverishment opens him to the risks he shares with the other 12 million
or so U.S. children (nearly one of every six) who live in poverty. This
proportion represents the highest poverty rate among any group in American society [6]. This condition is less an attribute than a predicament
generated by large scale socio-historic and cultural forces.
Poverty, at the start of the 21st century, remains the single most
powerful predictor of child health outcomes [7]. In a global context,
poverty refers to the absolute or relative lack of economic resources
required to meet the essential necessities of life. The World Banks definition of the poverty line has been set at $1 per day as calculated by
purchasing power parity the number of units of a countrys currency
required to buy the same amounts of goods and services in the domestic
market as one dollar would buy in the United States [8]. Approximately
1.3 billion people live below this definition of the poverty line [9].
The official U.S. federal government definition of poverty [10] is
designated the poverty line set according to a Social Security Administration economists 1967 invention at three times the cost of an Economy
Food Plan.1 This official definition takes into account total annual family
income (not including savings or assets), family size and an annual adjustment for inflation in consumer prices. In 1999, the federal poverty line
for a family of four was $17,029 per year.2 About one-fourth of poor

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children in the U.S. live in extreme poverty with family incomes less
than $6645/year for a family of three. In Hoteps neighborhood, Roxbury,
about 2/3 of African American children live below the federal poverty
line.3

HOTEPS VULNERABILITY II: INEQUITY

Hotep suffers economic deprivation in both absolute and relative terms in
the U.S. context. There is more wealth and consumption in the world now
than at any time in all of human history. The global economy facilitates the
profitable and increasingly unconstrained movement of goods, services,
labor and capital through integrated markets for trade on a worldwide scale
[11].
However, the benefits of this economic growth are unevenly distributed.
For example, just 40 years ago, the richest 20% of people had 30 times the
income of the poorest 20%. However, by late 1990s the richest 20% earned
82 times as much.
Inequities in consumption are equally striking. The 20% of the worlds
people in richest nations account for 86% of total private consumption
expenditures; the poorest 20% account for a mere 1.3% [9].
The U.S. also has the greatest degree of income and wealth inequalities
in the world [1]. As many observers have noted, here income and wealth
gaps between rich and poor have become a chasm. For example, in the
U.S., the top 1% of families owns over 40% of all household wealth in
the nation which is up from a level of 22% just 20 years ago [12].
When Hotep Johnson was born in the mid 1980s, the typical CEO of a big
American Company was paid 40 times the annual earnings of the typical
worker on the factory floor. By end of 1990s the typical big league CEOs
took home 475 times the earnings of the typical production worker [13].
U.S. child poverty rates are consistently twice those of Canadian and
German children, and six times higher than other developed countries like
Austria, France and Belgium, though none of these countries is as wealthy
as the U.S. [6]. In short, other countries distribute economic vulnerability
in different, more equitable ways.

HOTEPS VULNERABILITY III: THE COLOR OF MONEY

Over three fourths of U.S. poor children live in a family where someone
worked during the past year the largest proportion since the start of data
collection almost three decades ago [6]. Why are they poor? They are poor

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because in the U.S., as in the rest of the world, the overall generation of
wealth does not guarantee equity. For example, while the richest 20% of
American families saw their incomes rise by more than 40% (adjusted for
inflation) over the past two decades, the poorest 20% of American families
suffered a 4% decline in their incomes during this same interval [6].
The realities of economic inequality in the U.S. are colored by institutional racism policies, practices and structures that distribute resources
in ways that reproduce inequities in status or power on the basis of
racial/ethnic identity. For example, U.S. Blacks and Latinos were discriminated against in housing markets for decades after World War II on
the basis of racial/ethnic identity. One consequence is that these families
missed out on subsidized loans and mortgage deductions over subsequent
years. In turn, they built less equity [14]. Fewer assets were generated
and left to Black and Latino children than were left by white parents to
their children. These forces explain, in part, why to this day, Black and
Latino children consistently suffer poverty rates at least triple those of
non-Hispanic white children.
However, historical and ongoing forces of racial/ethnic and gender
discrimination contribute to the income/wealth gap. For example, years
of legal and de facto racial discrimination in education and employment
place African Americans as a group at a disadvantage in terms of the
accumulation of human capital. Income inequalities are closely tied
to educational inequalities. For example, inflation-adjusted wages fell at
every level except among college graduates over the past twenty years [6].
Unemployment among Blacks is consistently twice as high as among
non-Hispanic Whites. However, even among full time workers with equivalent educational backgrounds (at high school level), men earn more than
women, and White men earn more than Black men. Moreover, collegeeducated Blacks are four times more likely to experience unemployment
than their white peers [15].
Moreover, disfavored U.S. minorities decumulate wealth at faster
rates. Patterns of residential segregation forged by racial discrimination in
effect confine minorities to areas where they bear higher housing, food and
insurance costs for the value they receive. In other words, their relatively
hard earned dollars have less purchasing power in the places they are most
likely to live [16].
In Hoteps neighborhood, Roxbury, Massachusetts, over 3/4 of African
American children live in single female headed households. Much has
been made of changes in American family structure and their contributions to child poverty. Children are more likely to live in single parent
households now than twenty years ago and over 4/5 of single parents are

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KEN FOX

mothers. Children who live with two parents are far less likely to live below
the poverty line than those who live with a single mother: 8% vs. 42% in
1999 [6]. Most of these families do not receive child support from fathers.
Thus, gender inequalities in employment and wages take on even greater
significance.
Government safety nets hold the potential to address unmet needs.
However, like wages, government supports for families have also declined.
Before the Aid to Families with Dependent Children (AFDC) program
was abolished, inflation-adjusted benefits plummeted by 40% between
the 1970s and mid-1990s [17]. Welfare Reform involved the creation
of Temporary Assistance to Needy Families (TANF) legislation in 1996
which ended poor childrens entitlement to income support. Enrollment
time limits, work requirements, altered eligibility criteria and benefit
levels, and devolution of oversight from the federal government to the
states have all driven down welfare caseloads [18]. The number of children
receiving cash assistance has been cut in half since the enactment of TANF
legislation. However, most families leaving the TANF case rolls do not
earn enough to move them above the poverty line [6].
Thus, Hoteps vulnerability is met with a governmental response that
does less and less to ameliorate his declining social position by dismantling
the social safety net. In fact, many have aptly characterized this aspect
of poor families vulnerability as a race to the bottom.
Ultimately, social and economic policies and the cultural beliefs and
practices that aim to buttress and justify them advance the interests of
elites at the expense of the poor. Among racial and ethnic minorities in
the U.S. who are disproportionately represented among the poor, these
policies, beliefs and practices generate relatively heavier health burdens
and greater health risks. What forges the identity of the vulnerable is
their shared position at the bottom of the health-harming social order.
HOTEPS VULNERABILITY IV: CULTURES OF POVERTY
The meanings of poverty are not fully contained by their economic
dimensions. Poverty has many other meanings which generate additional
vulnerabilities. These meanings are shaped by cultures which allow us to
make sense of the world.4
The experiences and meanings of poverty vary between and within
cultures and societies. In every place, however, what matters most is
whether, how, and to what degree this particular type of vulnerability will
be allowed to shape life opportunities, choices, and values. A critical question is, How do poverty and inequality influence ones ability to exercise

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agency the capacity to make decisions and act on them in order to

achieve a life of creativity, dignity, joy, and healthy growth and change?
Will impoverishment also be allowed to mean misery and suffering? In
some cultures a robust social safety net ensures that poverty and inequality
hold less power to constrain individual opportunity and agency. In these
cultures, poverty and inequality are interpreted more as systemic, political or social structural flaws rather than as stigmatizing moral failures of
individuals, their families and communities.
Historically, some have argued the existence of a Culture of Poverty.
First published by anthropologist Oscar Lewis in Five Families: Mexican
Case Studies in the Culture of Poverty [19], the concept denotes a set of
intergenerational behavioral and personality traits that allegedly define and
limit the capacities of the poor. The pejorative term emphasizes the role
of values and attributes of poor people in their conditions of poverty and
subordination rather than the role of values, interests and behaviors of
privileged, non-poor people or the thrust of social and economic policies
in the reproduction of conditions of inequity. Similarly, other labels like
female-headed black families, tangle of pathology and underclass
have shaped the meanings of poverty (and debates about anti-poverty
programs) in the U.S. context [20]. These meanings generate other vulnerabilities shame, stigma, low esteem, hopelessness, demoralization
which intensify the suffering of people like Hotep. Moreover, these additional afflictions of meaning increase the social distance between poor
and non-poor thus narrowing capacities for empathy in care settings.5
HOTEPS VULNERABILITY IV: POVERTY, INEQUALITY
AND HEALTH
A large and growing global health literature documents elevated death
rates among the poor [8, 2125] and in societies marked by high degrees
of social inequality [8, 2628]. Precisely how poverty achieves its health
harming effects on children in local U.S. settings even despite unusually high access to tertiary level services and an extensive network of
community health centers is well documented. For example, in a classic
study of racial and socioeconomic disparities in childhood death in Boston,
Massachusetts [29], the authors demonstrate that the bulk of the disparity
between poor and non-poor children in Boston is accounted for by five
conditions: low birth weight, respiratory disease, fire, homicide, and motor
vehicle accidents. Thus, a boy like Hotep literally and physically embodies
almost all of these vulnerabilities. While research shows that the strength
of socioeconomic effects varies across age, gender, race/ethnicity, place,

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and the particular health problem under study, a profound and pervasive
pattern is clear: poverty harms health.
As in Hoteps tragic case, poverty and inequity open, press, and
wound in pervasive, predictable, and preventable ways. The oppressive
facts of vulnerability sicken, injure, and kill. Poverty may act as an independent force in the generation of poor health outcomes or combine with
other large scale social forces like social marginalization (unjust exclusion
from essential resources on the basis, for example, of gender, racial or
ethnic identity) to achieve its health-harming consequences [30]. Povertys
effects are cumulative, pervasive, and persistent at points all along the
life course. Its impact as a social force in even the wealthiest nation is
tremendous as 1/3 of all American children will spend at least one year
below the federal poverty line before age 16, and since the highest U.S.
poverty rates register among those at greatest risk for lasting damage (in
terms of brain development) children under six years of age [6]. In short,
Hotep suffers in exemplary fashion [31].
Poverty and inequality place children in an awful position called
double jeopardy: they suffer both elevated risk that health problems will
occur and greater likelihood of harm once these problems do occur [32].
Likelihood of harm is forged by the severity at presentation and length of
course of problems as well as the physical, mental, material, and social
capacities to respond to problems.
However, double jeopardy represents more than inevitable misfortune randomly distributed among a luckless few. Scholars show that death
rates in high poverty areas in the U.S. particularly among blacks are
excessive when compared with national, age-standardized rates among
non-Hispanic Whites. For example, a poor Black boy of 15 in Harlem,
New York has only a 37% chance of surviving to age 65. This compares
unfavorably with an 80% chance of survival to age 65 for a 15 year old
non-Hispanic White boy from a more affluent New York neighborhood
[33].
Despite what the figures about life expectancy reveal about the tragic,
disparate and unjust ways children die, the data also offer a critical window
onto how children live [29]. Disparities in mortality are the legacy of
persistent and pervasive health and social inequalities inflicted over a lifetime. 12% of children from families with annual incomes less than $10,000
are reported by caretakers to be in fair or poor health compared with just
2.7% of children from families with annual incomes greater than $35,000
[34].
A growing body of research documents health disparities between poor
and non-poor children. The scale and consequences of economic dispar-

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ities in health vary across many dimensions of social difference: age,

gender, race/ethnicity, region/place. Disparities also vary according to the
particular health problem under study (see Appendix).
HOTEPS VULNERABILITY V: RACIAL INEQUALITIES IN
HEALTH AND CARE
Hoteps racial identity as an African American opens him to profound
vulnerabilities in a racist social, cultural, and political context that systematically devalues Black life. The generation of racial disparities in health
is a process that begins early in life and unfolds all along the life course.
Scholars like Navarro [35] have shown that health status differences by
socioeconomic status are larger than differences by race. In his analysis,
racial differences in morbidity are less than half of class differences in
morbidity.
Nevertheless, many have also shown that for a wide range of problems,
Blacks have poorer health status than Whites within any given socioeconomic category [36, 37]. Leading scholars in the field of racial disparities
in health demonstrate that socioeconomic status (SES) accounts for a large
proportion of the racial disparities in health. Statistical adjustment for
SES often eliminates racial disparities in health completely [15, 38] and
sometimes merely reduces those disparities [39, 40, 33]. However, a vast
body of work demonstrates that by most measures, African Americans
have poorer health status, poorer health outcomes, and lower life expectancies than their white peers. In fact, African American males have a higher
age adjusted death rate than any other racial/ethnic group [41]. Young
Black men (ages 1524) in Boston have a death rate that is about seven
times the rate for young White males.
How do racial inequalities register in terms of healthcare? First, insurance status in the U.S. is a critical predictor of whether healthcare happens
[42], and Blacks are less likely to be insured than whites. Almost 11
million U.S. children are uninsured [6]. However, racial/ethnic inequities
in insurance coverage are stark among the 11 million uninsured U.S.
children: one of six Black children and one of four Latino children is
uninsured compared with one of eleven White children.
Young men are less likely to be insured than older men or women. In
Boston, The Behavioral Risk Factor Surveillance Survey showed that less
than one third of young Black men (ages 1824) have health insurance
(compared to 80% of White males in this age category) [43].
Second, Blacks in fair or poor health status make significantly fewer
doctor visits than Whites of comparable self-reported health and insur-

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KEN FOX

ance status [44]. In fact, The National Ambulatory Medical Care Survey
showed that young men (ages 1524) have lower rates of physician visits
than any other age or gender category and that young Black men have the
very lowest rates [45]. Black children, like their parents, are less likely
than Whites to have a regular doctor [46]. Third, even for Blacks with
a doctor, they are more likely than Whites to report that their physician
did not inquire adequately about their pain, did not discuss their illness,
test results, medications or significant prognostic information [44]. Many
primary care clinics lack the resources and experience necessary to address
the complex and intertwined medical and social problems presented by
young men like Hotep Johnson [43].
In general, Blacks seem to receive different and lower quality healthcare than Whites [47]. In a 1996 study of Medicare beneficiaries, among
ambulatory patients, Blacks had less primary and preventive care with
lower rates of physician visits, less mammography use, and lower influenza
immunization coverage rates [48]. Among hospitalized patients, Blacks
get less professional attention, fewer lab tests and x-rays, and are less
closely monitored [49]. Others have shown that Blacks receive fewer high
tech interventions, even when analyses are controlled and adjusted for
severity of disease, comorbidity, insurance status, income, and hospital
type [50]. Fewer hospital resources were used to care for seriously ill
African American adult patients studied in five major medical centers than
for non-Hispanic Whites with similar severity of illness [51]. Compared
with Whites, Blacks receive less aggressive treatment for lung and prostate
cancer, fewer kidney and bone marrow transplants, and fewer antidepresssants and antiretrovirals when they are medically indicated [52, 53].
On the other hand, Blacks are more likely to undergo potentially avoidable
procedures like amputations and orchiectomies, more likely to have avoidable hospitalizations and readmissions, and are more likely to sign out of
the hospital against medical advice [53].
For the leading cause of mortality among Blacks cardiac disease
racial disparities in care have been well documented over two decades.
Blacks are less likely than Whites to receive coronary angiography,
angioplasty, and bypass graft surgery [54]. Notably, treatment decision
differences by race for coronary procedures seem not to be related to
differences in severity of disease [55] or hospital type [56]. A unique study
in 1999 by Schulman [57] and colleagues found that race and sex of the
patient affected physicians decisions about whether to refer the patient
for an important diagnostic procedure (cardiac catheterization) regardless
of the patients clinical characteristics, insurance status, or occupation.6
The study thus exposed the potential power of racism to slash deeply

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into healthcare encounters. Structures of racial inequality render particular racial categories of persons more vulnerable than others to harmful
distortions in provider-patient communication and to systematic disparities
in clinical decision-making that harm health.
HOTEPS VULNERABILITY VI: JUVENILE INJUSTICE
Hoteps encounters with the police and juvenile justice system are another
marker and source of his vulnerability. The political force of Get tough on
juvenile crime, Tough love, and Zero tolerance ideologies as well as
statutory changes in the states7 have swelled the numbers of detained and
incarcerated youth in the U.S. and shaped a policy context dominated by
harsher, more punitive, and less rehabilitative juvenile justice reforms. This
increasingly high volume system is also characterized by high turnover of
detainees [58].
The realities of the juvenile justice system have profound and disproportionate impact on young Black men like Hotep and the stigmatized,
marginalized populations he represents. For example, African American
teens (ages 1017) represent 15% of the U.S. youth population but account
for 26% of juvenile arrests, 32% of delinquency referrals, 41% of juveniles detained in delinquency cases, 46% of juveniles committed to secure
institutions, and 52% of juveniles transferred to adult criminal court [59].
While Black and Latino youth represent about one third of the U.S. youth
population, they account for over two thirds of detained youth and over
two thirds of youth incarcerated in secured facilities [58]. In turn, these
vulnerabilities further destabilize the besieged neighborhoods these young
men exist within and to which they return upon release from incarceration.
Detained/incarcerated youth are infamous for their high health risks
and notoriously poor health outcomes even in comparison to urban, poor,
minority adolescents in general. Many have demonstrated incarcerated
youths elevated vulnerabilities to substance abuse, early and frequent
sexual activity, sexually transmitted disease, violent intentional and accidental injury, as well as a host of chronic medical illnesses, dental problems, and nutritional deficiencies [60]. Moreover, detained/incarcerated
youth have poorer interpersonal problem-solving skills, school truancy and
failure, learning disorders, and psychiatric problems than non-detained
populations. In fact, some have assessed the rate of diagnosable mental
health disorders among incarcerated youth as high as 73% [61].
The provision of physical and mental healthcare in detention facilities
is critically important but structurally flawed. Under federal regulations,
incarcerated populations, (including detainees under 18), are ineligible for

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Medicaid benefits [62]. Poor systems coordination for these vulnerable

youth virtually guarantees that the care they receive will lack adequate
continuity and, thus, quality. According to a recent report by the Society for
Adolescent Medicine, When juveniles are released follow-up of medical
and psychological needs is often neglected [62:73].
HOTEPS VULNERABILITY VII: FIGHT, FLIGHT, AND
HEAVY BREATHING
Particular places are flashpoints for danger. For example, people in
Bostons Roxbury neighborhood suffer what some call a synergy of
plagues [63]. Businesses disappear, tax bases erode, health, education,
and social services are inadequate to meet the vast needs, chronic illnesses
like asthma and infectious diseases like AIDS and other STDs flourish,
and the threat of violence looms like a shadow over the routines of
everyday social experience. Underground economies, particularly street
drug markets like the one Hotep works within, thrive and exact a heavy
toll.
How are health vulnerabilities in places like Roxbury produced by
human social enterprise? In short, history matters. Globalization is at
work in places like this. Roxbury, once a major manufacturing center, has
faced economic decline and become a concentrated site of pariah land
uses [64] over the past four decades. Transnational corporations moved
with increasing speed and ease to meet the imperatives of global trade
and elite profit. Tax breaks, federally financed highway construction, and
differentially available business, home and auto loans (on the basis of
race), fueled a corporate exodus and residential White flight to Boston
suburbs. Patterns of urban renewal and gentrification have depleted the
citys stock of low-cost housing and dislocated the poor (and concentrated
residence patterns among the racial minority poor) on a grand scale even
as speculators on large urban development projects profited enormously
[65].
Just as in many other post-industrial northern urban centers, global
economic forces and processes of social marginalization like residential segregation on the basis of race/ethnicity, have shaped the demography of this neighborhood [66]. Over time, manufacturing jobs have
become scarce, leaving low paying service sector jobs, often part-time,
temporary and without health insurance benefits. Poor Blacks are poorly
educated in underfunded public schools as assignment is residence-based
and funded according to local property values [67]. Although the Civil
Rights movement conferred the full legal benefits of citizenship, racial and

HOTEPS STORY

485

ethnic minorities are underrepresented in city politics. As a consequence

city services in their segregated neighborhoods have declined. Moreover,
02119 became the Zip Code with the highest number of dumpster lots,
trash transfer stations, junkyards, and recycling plants in the city [68]. In
the late 1980s the decline in property values led to Roxburys infamous
designation, Arson Capital of the Nation; insurance values of property
outstripped the values of the properties intended, functional uses [65].
Overcrowding [69] in old, poor quality, substandard housing stock in
places like Roxbury, elevates health risks [70] as well as exposures to
cockroaches, mice, dust mites, and mold which increase asthma risks [71].
Billboards and other modes used in targeted ethnic marketing of cigarettes
contribute to increased asthma-inducing conditions in communities where
poor Black children are concentrated.
VIOLENCE AND VULNERABILITY
Interpersonal violence is an enormous problem in the U.S. and another
basic aspect of Hoteps vulnerability. Each year, there are about 25,000
homicides and two-thirds of these are gun-related. On an average day,
over 65 Americans die of homicide, another 18,000 are victims of violent
assault, and more than 6000 of these victims suffer physical injuries. The
scale of these figures distinguishes the U.S. from all other Western industrialized nations. In the epidemic of violence, place matters. For example,
rates are higher in larger cities and in the Southern and the Western regions
of the country.
There are also striking differences in rates of interpersonal violence by
gender and race. Comparisons of homicide rates among young adult U.S.
males by race demonstrate striking differences. The largest racial disparities in homicide rates exist among young men ages 1524 [72]. In this
group the homicide rate for African American males is over 15 times that
of non-Hispanic White males.
Overall (during the past decade) national homicide rates have decreased
and fallen to a level of about 6.2/100,000. However it is also fair to say that
despite these recent improvements, an epidemic of youth violence which
began in the mid-1980s remains concentrated among black make youths
[73]. In Boston, overall homicide rates are also falling. But again there
are striking differences between racial and ethnic groups: Blacks have the
highest rates (35 per 100,000); Latinos (13/100,000); Whites (4/100,000)
[43].
A growing public health literature increasingly focuses the analysis of
risks or vulnerabilities for violence away from the problems or pathologies

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KEN FOX

of individuals and toward the conditions and constraints of neighborhoods

and regions [74]. In short, the study of violence has become, fundamentally, the study of places [64]. Those communities characterized by
concentrated poverty, where economic capital and social cohesion are most
lacking, are also those most ravaged by the public health epidemic of
violence.
Ironically, Boston a medical mecca that receives about half of all
annual National Institutes of Health funding has become a national model
for violence prevention programming among youth. Nevertheless, literally blocks away from some of the most famous healthcare, research, and
teaching institutions on earth are places where people suffer the citys very
worst health outcomes, including the risk of violent interpersonal injury.
Gender, race, poverty and place matter immensely with regard to childrens
risk for violence. For example, in greater Boston, the risk of being shot or
stabbed is about 1-in-38 among Black male teens (ages 1519) compared
to 1-in-56,000 among white females in suburban communities [75].
Asthma
Poor children suffer higher asthma prevalence than their non-poor
peers [71]. While international data document increasing prevalence and
severity of childhood asthma, poverty and minority status seem to confer
heightened vulnerability. In the U.S., asthma is the most common chronic
illness of childhood and the leading cause of childhood disability [76].8
Poverty and racial/ethnic minority status are linked to more severe asthmarelated limitations in activity more missed days of school, days in bed,
and restriction from play [77]. Poor and minority children are more likely
to be hospitalized for asthma [76]. For example, children from low income
areas in New York City were over four times more likely to be hospitalized
for asthma than children from high income areas in 1997 [78]. Finally, poor
and minority children are more likely to die from asthma than non-poor
and non-Hispanic White children [79].
Children in Bostons Roxbury neighborhood, Zip Code 02119, have
one of the citys highest asthma prevalence rates and one of the worst
sets of asthma outcome statistics. For example, childhood asthma hospitalization rates are about 20/1000 compared to citywide rate of 11/1000
[68].
Unfortunately, heightened vulnerability does not confer greater access
to appropriate healthcare. Among hospitalized asthma patients, Black and
Latino children are much less likely to receive the standard of care,
whatever that may be. In a study of hospitalized children in Boston,
scholars showed that Black and Latino children were up to five times

HOTEPS STORY

487

less likely to receive anti-inflammatory medications and up to 15 times

less likely to be prescribed a home nebulizer upon discharge compared
to white, non-Hispanic peers even controlling for insurance status and
severity of illness [80].
Moreover, others have shown that Black asthmatics were more likely
to receive outdated oral therapies [81]. As therapeutic efficacy increases,
differential access to treatment (whether on the basis of ability to pay or of
disfavored racial/ethnic minority status) will exacerbate unequal outcomes
[82].
Increased morbidity and hospitalization plausibly lead to greater
parental stress and job absenteeism which may in turn reduce their job
stability and family income. Assets may be further depleted by greater
out-of-pocket expenses for prescribed asthma medications. Low literacy
may also hinder parents ability to adhere to medication regimens or make
use of educational materials if they are made available. All of these healthharming forces cluster to drive disparate health outcomes for this serious
illness. Some have called these forces structural violence [83].
Sexually transmitted disease
Rates of condom use are lower among young men of color like Hotep
than among other demographic groups [84]. This may, in part, explain why
young Black men (ages 1524) bear elevated risks for sexually transmitted
disease. For example, rates of chlamydia and gonorrhea among young
Black men in Boston are over twenty times greater than for White men
in the same age category [43].
These elevated vulnerabilities or risks of STDs (including AIDS) are
intimately linked to social inequalities and thus to places. For example,
cumulative AIDS incidence in the total population in Massachusetts is
seven times greater among persons living in poor areas (where >40% live
below the poverty line) compared with non-poor areas (<2% live below
the poverty line) [85].
Since the social geography of places like Boston is characterized by
residential segregation on the basis of race and class, some populations are
rendered more vulnerable than others. What is most relevant to the lives
of young, poor Black men like Hotep is that at all ages, Black men in
Boston die at higher rates from AIDS than any other racial/ethnic group.
According to the Boston Public Health Commission [43], AIDS death
rates among young Black men ages 2534 are almost twice as high as
those among young white men 137/100,000 vs. 74/100,000. For the
sexually acquired cases, the majority of infections were acquired during
adolescence.

488

KEN FOX

Moreover, these health inequities are widening. Increased health education, prevention, and treatment reach and transform the lives of some
groups more than others. For example, HIV death rates have fallen for
White men in Boston but increased among Black men during the past
decade [43].

HOTEPS VULNERABILITY VIII: CONSTRUCTIONS OF

MASCULINITY
Many scholars in the field of Gender and Health argue that many of
the very practices and behaviors that men use to assert their power as
men and to define and demonstrate their masculinity actually heighten
their vulnerability to illness, injury, suffering, and death. Hoteps ambivalence about the need for help, the misogyny evident in his language
and violent expressions of physical dominance over his babys mother,
his substance use, and his refusal to use condoms consistently even
when he has access to them are complex and multiply determined but
also related to hegemonic ideals of masculinity pervasive in the culture
within which he exists. One might even go so far as to argue that in
the bleak absence of opportunities to fulfill his aspiring role as head of
household and father/provider and in his role as a mule (a courier and
on the street sales man) in the underground drug economy, Hotep is left to
construct his masculinity by embracing risk [86].
Young mens health vulnerabilities are compounded by barriers to
mental health services. While lack of insurance erects a profound barrier to
mens mental healthcare access, many have argued that hegemonic cultural
ideals of masculinity, particularly in communities of color, may also deter
men from seeking the help they need. Though young men represent seven
of every eight suicides among those aged 1524, multiple studies show
that depressed men are less likely than depressed women to seek mental
healthcare. In Boston, among men ages 2534, Blacks have the highest
suicide rates [43]. Moreover, many clinicians lack of cultural competence
[41] and general under-diagnosis of depression among men who do seek
care [87] contribute to the observation guarantee that mens mental health
vulnerabilities often go unaddressed.

HOTEPS VULNERABILITY: A REPRISE

Hoteps clustered vulnerabilities illustrate broader mechanisms by which
social inequalities achieve their health-harming effects. One framework

HOTEPS STORY

489

identifies four fundamental pathways that produce health inequities [30].

First, stratification separates groups and places or values them hierarchically in a social order. Second, differential exposure links social position
and risk of encounter with health-harming agents in an inverse relationship
(i.e., lower position is associated with higher exposure). Third, differential susceptibility occurs when two or more exposures interact synergistically to generate a particular health effect (poverty, minority status in the
context of institutional racism/marginalization, chronic illness). Finally,
differential social consequences occur when illness itself exacerbates
low or declining social position and sharpens stratification.

CONCLUSION: HEALTH, VULNERABILITY AND THE ROLE

OF CARE AND SCHOLARSHIP
Not everything that is faced can be changed, but nothing can be changed until it is faced.
James Baldwin

This paper focuses on intersections between race and class in the

construction of health vulnerabilities in the U.S. Attention to health
inequities preventable health inequalities that emerge from social
injustices like racism and socioeconomic marginalization makes visible
the forces that generate, sustain, and alter vulnerabilities to illness, injury,
suffering, and death.
Exploring the wounds of vulnerability requires that we name and
specify the forces that become embodied as individual experiences of
disparate risk. Hoteps story demonstrates that social forces cluster to
harm health and generate disparities between groups (and between individuals within groups) in patterned and predictable ways. For example,
overt and implicit discrimination against Hotep, and the categories of race
and class he represents, violates fundamental principles of human rights
and lies in the deepest layers of his wounds. Inequities in health risks
and status between racial and class groups are largely the consequence
of human volition and enterprise far beyond the agency and power of
any individual sufferer. Tragically, health inequities would not occur if
resources employment, income, wealth, education, housing, profiling in
the legal system, and healthcare were more justly managed in keeping
with standards outlined in the Universal Declaration of Human Rights
(UDHR), the International Convenant on Economic, Social and Cultural
Rights (ICESCR), and the Convention on the Rights of the Child (CRC).9
One of the great lessons of medicine and the knowledge on which it
is based is that healthcare has a powerful but limited capacity to achieve

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KEN FOX

the high aim of equity. As many have argued, only a small proportion of
the variance in health status among populations can be attributed to healthcare [88]. Illumination of the facts of inequity and the power of technical
efficacy is never enough to close health gaps. The struggle for health equity
requires the light of knowledge, technology, and expertise as well as the
ardor of political engagement for change.
On another level, healing the wounds of vulnerability also requires
empathy and passion, from the Latin passio or suffering which refers
to Christs scourging and crucifixion. As scholars, healthcare providers,
and advocates, we must come to see and feel the ways in which Hoteps
story also wounds us. Only then will the radical political and cultural
changes required for a more equitable balance of power required for lives
of health and dignity find their way beneath our skin.
A fundamental purpose of health scholarship is to draw the intellectual
connections required to uncouple social inequalities from their healthharming outcomes [82]. A fundamental purpose of care is to build human
connections required to apply the insights of scholarship to individuals and
communities. The skillful deployment of evidence-based health interventions on the basis of need is a central challenge and drama of medicine we
must face in an increasingly global age. Advocacy around these matters
is a key function of professionalism in health scholarship and care. Our
responses to the wounds of vulnerability may reveal important aspects of
who we are and what our work must become.

NOTES
1 EFP estimates were originally intended to signify the cost of a diet adequate in most
nutrients in situations for temporary or emergency use when funds are low [10:pg#].
2 US median family income for 1999 was $47,949.
3 This measure of the federal poverty line has come under significant criticism because
it is based on 1955 family expenditure and homemaking patterns which are dramatically
outdated and also allow for none of the extant geographical variations in the cost of living
[10]. For examples, contemporary family spending patterns include child care (as now
3/5 of mothers of preschoolers are in the labor force), and a greater required proportion
of income committed to housing costs. Moreover, for a variety of compelling reasons,
contemporary homemaking patterns no longer include daily baking and cooking without
benefit of prepared or canned foods. In fact, according to most experts, adjustment of the
federal poverty line according to contemporary spending patterns would raise the line by
about two-thirds [10].
4 Cultures are dynamic human social forces that generate structures and meanings
of thought and action. Cultures allow us to interpret the meanings of ideas, actions,
experiences, places, things and relationships [89].

491

HOTEPS STORY

5 Careful attention to the sociology of knowledge the study of how ideas are created
and promoted has unmasked the many ways in which these and other ideologies
masquerade as science in medicine and health research.
6 In logistic regression analysis Blacks were less likely than whites to be referred for
cardiac catheterization: Odds ratio 0.6; 95 percent confidence interval, 0.4 to 0.9; P = 0.02.
7 For example of state legal reform see the Illinois Juvenile Justice Reform Act of
1998 which reshaped the states system in ways that emphasize its punitive more than
its rehabilitative orientation.
8 Childhood asthma among the US poor illustrates the global child health problem of
double jeopardy. Nationally, poor, urban minority children bear increasingly disproportionate burdens of asthma morbidity. For example, the gap in asthma prevalence between
Black children and non-Hispanic white children has increased over the past two decades
and is now over 30% [76]. Some studies indicate that racial disparities in asthma prevalence
disappear when controlling for income [90]. However others argue that racial differences
in asthma prevalence remain even after controlling for socioeconomic factors [91].
9 See UDHR Article 25 and ICESCR Article 12. The US is a signatory of the CRC but
has not ratified it. CRC Article 2(1) is of particular relevance in this paper: States Parties
shall respect and ensure the rights set forth in the Convention to each child within their
jurisdiction without discrimination of any kind, irrespective of the childs or his parents
or legal guardians race, color, sex, language, religion, political or other opinion, national,
ethnic or social origin, property, disability, birth or other status [92].

APPENDIX 1
RELATIVE RISK FOR SELECTED HEALTH PROBLEMS,
POOR VS. NON-POOR FROM FOX AND WISE
(COMPREHENSIVE PEDIATRICS, IN PRESS)
Low Birthweight [93]
Neonatal Mortality [94]
Infant Mortality (28 days1 year) [93, 95, 96]
Prone Sleep position [97]
Fe Deficiency anemia [98]
Hunger [99]
Chronic undernutrition [100]
Plumbism [101, 102]
Pneumonia [103]
Frequent Diarrhea or colitis [103]
Meningitis [102]
Complications of meningitis [102]
Complications of appendicitis [102]
Diabetic ketoacidosis [102]
Functional visual impairment [104, 77]
Impaired hearing [104, 77]
Untreated cavities/missing teeth [104, 77]

1.32x
1.54x
1.33x
2x
34x
7x
1.52x
34x
1.22x
1.52x
2x
23x
23x
2x
23x
1.52x
36x

492

KEN FOX

Asthma hospitalization [78]

Fire mortality [105]
MVA mortality [105]
Pedestrian mortality [105, 106]
Poisoning hospitalization [10]
Accidental injury mortality [107, 93]
Child deaths (overall) [10, 102]

24x
24x
23x
26x
5x
23x
34x

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Boston University School of Medicine

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