inequality – UAB Institute for Human Rights Blog

Human Rights in Appalachia: Socioeconomic and health disparities in Appalachia

The previous blog posts in this series are located here:
Human Rights in the Appalachian Region of the United States of America: an introduction
Human Rights in Appalachia: The Battle of Blair Mountain and Workers’ Rights as Human Rights

In the Appalachian region of the United States, there have long been overarching socioeconomic problems that have prevented the region from seeing the same levels of growth as other parts of the country, and even been part of its decline in other domains. Much of Appalachia’s population of twenty-five million people remains remote, isolated from urban growth centers and beneficial resources that exist in cities. The rural towns and counties in which many Appalachian people live have not had the ability to maintain the public infrastructure, furnish the business opportunities, or provide the medical services that are necessary to sustain populations.

There are three regions of Appalachia: the southern region, which covers parts of Georgia, Alabama, Mississippi, the Carolinas, and Tennessee; the central region, which covers parts of Kentucky, southern West Virginia, southern and southeastern Ohio, Virginia, and Tennessee; and the northern region, which includes parts of New York, Pennsylvania, northern West Virginia, Maryland, and northern and northeastern Ohio. While the entire Appalachian region struggles with higher levels of poverty, unemployment, and lack of services and infrastructure, some sub-regions suffer worse than others, and in different ways (Tickamyer & Duncan).

graph of people in poverty by age group — Percent of persons in poverty in rural Appalachia by age group: 2014-2018

Even when compared to other rural areas, Appalachia struggles on measures of educational attainment, household income, population growth, and labor force participation. Rates of disability and poverty are significantly higher in rural Appalachia than they are in other rural areas of America. In 2018, the number of Appalachian residents living below the poverty line was higher than the national average in every age group except those 65 and older. The largest disparity was among young adults (18-24), where the Appalachian population was more than 3% higher than elsewhere. From 2009 to 2018, median household income in Appalachia went up by 5%, not far behind the national average of 5.3%. However, the median household income in Appalachia remains more than $10,000 lower than the national median.

map of population age in appalachia — Map of population age in Appalachia

One area where disparities between Appalachia and elsewhere in the country are particularly noticeable is in healthcare. The Appalachian Regional Commission released in 2017 “Health Disparities in Appalachia”, which reviews forty-one population and public health indicators in a comprehensive overview of the health of the twenty-five million people living in Appalachia. The study found that Appalachia has higher mortality rates than the rest of the nation in seven of the nation’s leading causes of death: heart disease, cancer, COPD, injury, stroke, diabetes, and suicide. In addition, diseases of despair are much more prevalent in Appalachia than the rest of the country. Rates of drug overdose deaths are dramatically higher in the Appalachian region than the rest of the country, especially in the region’s more rural and economically distressed areas. Research indicates that diseases of despair will increase under COVID-19, as well. This will be especially true for women, who experience death from diseases of despair at a rate 45% higher than the national average in Appalachia. The ARC found that, while deaths as a result of diseases of despair were more numerous in metropolitan counties of Appalachia, rates of suicide and liver disease were higher in rural counties.

These issues are exacerbated by the fact that there is a much lower supply of health care professionals per capita, including primary care physicians, mental health providers, specialists, and dentists in Appalachia. The supply of speciality physicians is sixty-five percent lower in the central sub-region of Appalachia than the rest of the nation as a whole. Other factors negatively impact health in Appalachia, as well. Nearly twenty-five percent of adults in Appalachia are smokers, compared to just over sixteen percent of all American adults, and obesity and physical inactivity are extremely prevalent. However, it is worth noting that in some areas of public health interest, such as the occurrence of STIs/STDs and HIV, Appalachia does better than the rest of the country.   Healthcare disparities are an increasingly dramatic phenomenon. From 1989-1995, the cancer mortality rate in Appalachia was only 1% higher than the rest of the US, but by 2008-2014, it had risen to be 10% higher. In the same time frames, the infant mortality rate was 4% higher versus 16% higher, respectively. And, in 1995, the household poverty rate in Appalachia was 0.6% higher than the national average, but by 2014 was 1.6% higher. We like to think of these problems as things of the past, but the gaps are still very much relevant. Fortunately, people living in Appalachian communities are more likely to have health insurance coverage than other Americans. 8.8% of the population in Appalachia do not have health insurance versus the national average of 9.4%.

This year, in the midst of the coronavirus pandemic, some factors of the Appalachian population have put people living there at greater risk of COVID-19. 18.4% of people living in Appalachia are over age sixty-five, which is more than two percent higher than the national average. In more than half of Appalachian counties, over 20% of people are older than 65. This, combined with high rates of obesity and smoking, put many people in the “high-risk” category. COVID-19 has affected Appalachian communities in ways that don’t result in death but make surviving even more difficult. Food insecurity, for instance, is an increasingly severe problem. At one soup kitchen, “…we were serving about 200 people a day, and our numbers have nearly tripled since COVID started,” social worker Brooke Parker, from Charleston, West Virginia, said.
However, perhaps due to the isolated nature of many Appalachian communities, mortality rates from COVID-19 have not been markedly higher than the national averages.

With schools moving to online learning, problems with access to internet in Appalachia become more relevant and pressing. Around 84% of Appalachian households have a computer, which is five percentage points below the national average. 75% have access to reliable internet, which is also five percent lower than average. There is no easy solution to this lack of access to education. Even in non-Appalachian counties, students are being severely impacted by the disruption to their normal education activities.

Human rights organizations ought to keep a close eye on Appalachia as we see the results of COVID-19 on an already vulnerable and at-risk population. The ultimate consequences of the pandemic will likely be more severe here than elsewhere in the country. People living in Appalachia deserve the same assistance being offered to and resources being put towards urban centers in other parts of America. Too often have they seemingly been forgotten.

Additional References:
1. “Health Disparities in Appalachia”. Marshall, J.,Thomas, L., Lane, N., Holmes, G., Arcury, T., Randolph, R., Silberman, P., Holding, W., Villamil, L., Thomas, S., Lane, M., Latus, J., Rodgers, J., and Ivey, K. August 23, 2017. https://www.arc.gov/wp-content/uploads/2020/06/Health_Disparities_in_Appalachia_August_2017.pdf. Retrieved December 3, 2020.
2. Population Reference Bureau. https://www.prb.org/appalachias-current-strengths-and-vulnerabilities/. Retrieved December 9, 2020.
3. Tickamyer, A., Duncan, C. (1990). Poverty and Opportunity Structure in Rural America. Annual Review of Sociology. 16:67-86.

Unequally Disconnected

by Grace Ndanu

As the novel corona virus spreads across the world, states and localities are faced with mounting pressure to close the school doors. The closing of schools has left children, teens and young adults with nothing to do because there was never a notice. Before the introduction of online learning, which was first provided through the radio and the television and then through Zoom and Skype, Kenyan children ended up walking through all the neighborhood while many teens and the young adults ended up engaging in dangerous activities like drug abuse, stealing and sexual activities that resulted to so many girls being pregnant. This became a very big concern to the nation apart from Covid-19. When the number of new cases were being aired, the teenage pregnancy cases were aired alongside it.

The purpose of closing the schools was to curb the spread of the virus. And hence transitioning to online learning became the only option, which was and is still not easy. Among many challenges from providing meals, proper clothing, proper health, to proper housing for the low income families it will never be easy. In Kenya, a person is considered poor when they lack the most basic needs. Also as long as a family has somewhere to lay their heads at night or has a shelter to keep them off the storms, cold and the hot sun, that family is regarded as okay they do not have to worry because they are surviving. This suggests that technology is not a necessity or a basic need. In Kenya, we are in need of technological empowerment.

There are so many private schools compared to government schools. In these schools the majority of the students are from rich families, that is 70%, while 30% are there because of sponsorship and scholarships. The government schools holds more of Kenyan children because majority of Kenyans are technically poor. There is no option of private school to these parents because even most of them send their children while they are still under age just for them to go and eat their lunch because when they stay at home they will have nothing to eat, instead as little they are they will have to wait till dinner. That is a bonus for the government.

In Kenya advanced technology was just introduced a few years back, meaning technology is still young. There are still households with no electricity, a radio or a simple mobile phone for just communicating. Technology courses were also introduced and they are improving since the stereotype of saying that technology courses for example computer science is made for boys is fading away and now even girls are doing better than the boys in the course. That is the good news about technology, the bad news is that, around 60% of the poor children in Kenya have little or no access to technology for learning that is the smartphone or the computer and the internet to make the learning easy.

A photo of two children's computers sitting on a desk — African children need better access to technology in order to continue their education during the pandemic. Source: Creative Commons

This makes only children from the private schools able to continue learning. But not all who continue learn online 20% are left out. Also the troubling gap in the opportunity to continue learning emerges between privileged and vulnerable children when looking at responses by other markers of economic advantages such as employment and food security status. 10 in 60 children of employed parents have access to both a device and the internet for learning always, or most of the time. This on demand availability drops where other children living in households where the parents are unemployed.

There is an extent where families who afford two or one meal a day, give it up and instead of eating or have little small that day, what was to be used to buy food will be used to pay for the virtual education by purchasing some internet bundles and if there is no a gadget to be used, the child will have to walk miles away from home in order to access cyber. The long walk will make the child tired even when it is time to concentrate, he or she is tired even to listen. The long walk is also exposing the child to sexual abuse by strangers and before they get to speak out it is too late, which will even make the concentration more difficult hence dropping of the performance.

Many people in Kenya acquire phones only when they are already at their 18^th year and some even at their 20s. Considering this, the children who were and are still learning online are really struggling because they are not familiar with the gadgets or the process itself. If the class was to start at 8am and end at 10am through zoom, the child will join the class at 9:30am or even she will never join basically because she does not understand which button is which.

The government or the stakeholder responsible for children and everyone’s right, make technology as a basic need, with that learning will become easy and efficient to everybody, be it grandparents, parents and the children.

Black and Blue: What’s Causing America’s Bruise?

By Stacy Moak, UAB Professor of Social Work

This article was originally published on the Lister Hill Center for Health Policy blog on June 19, 2020.

Discussions of police in everyday life have triggered strong reactions from citizens as long as we have had the concept of police. Arguments over whether they should wear uniforms, whether they should be paid, and whether they should carry weapons have all persisted throughout time and across multiple countries. The concept of the police in America was borrowed from the British system of having “beat cops” or officers who patrolled at the local level. In England, still today, these community officers do not carry weapons. The British police force was established in 1829 and employs the concept of police by consent, not by force. As a result, the general opinion is that arming the police sends the wrong message to citizens and creates more problems than it solves. Yet, in the US, officers cannot envision a police force that is not armed with firearms. Policing in America has evolved over time and developed into a punitive system of “enforcement” that has pushed the entire system away from community problem solvers and toward a militaristic mind set of reactions to certain situations, often without rational analysis of what is actually occurring. Thus, policing has evolved more toward fighting a war– the war on drugs, the war on poverty – in which police are the soldiers and citizens are the subjects. However, the evidence is clear that overuse of police as a form of social control has devastating consequences for the health of communities (Public Health Behind Bars, Robert Greifinger, 2007). Such over-policing leads directly and indirectly to destabilized communities and overall social injustice. Further, it creates a system in which activities of the poor and minorities are more highly policed and punished than activities of the wealthy or white majority. Communities that suffer the most from over-policing generally suffer from a host of other deprivations and become tangled in a web of instability. Once that occurs, perceptions of destabilized communities begin to shape the ways that people outside the community view persons who live in those communities. Persons from those communities are often portrayed as more violent, more aggressive, and less likely to respond to reason. These labels apply to everyone from that particular community, including children, and often follow those children as they enter school. Children from these communities are labeled trouble makers at very young ages (as young as 3 or 4) and are often pushed out of mainstream educational facilities. Because of interaction with the criminal justice systems, adults have trouble finding jobs and/or stable housing, and family dynamics are disrupted. A cycle of negative police/citizen interaction begins to occur because of overuse of punitive approaches to address social problems, and police officers are tasked with providing interventions across a wide array of social services more appropriate to social workers, school and marriage counselors, substance abuse counselors, soup kitchens and homeless shelters, and general mechanic and car maintenance.

When police are the first responders to social problems, punishment is the response most often handed down. Punishment, enforcement, and restraint are the skills for which police receive most of their training. Examples of this problem can be noted across the life span, but are perhaps most easily demonstrated in adolescents. For example, white youth and minority youth participate in delinquency such as recreational drug use, underage drinking, skipping school, fighting, and other types of delinquency at similar rates. Self-report studies indicate that delinquency is almost universal as a part of adolescent development. However, black and brown youth are held in juvenile detention centers at 3 to 4 times the rate of their white counterparts. Their numbers continue to increase even when juvenile crime statistics drop. Part of the reason for the disproportionate numbers of youth in juvenile detention stems from the presence of police officers in schools. Because these youth are identified as more dangerous and less amenable to treatment, school-based police officers respond with punitive practices that work to remove them from school. Once removed from school, the only real intervention at the community level is the juvenile court. Most black and brown youth live in urban areas with larger public schools. More police officers are assigned to these schools; therefore, more poor children and children of color are victims of overusing police and courts for behaviors more appropriately handled by schools and parents. Overuse of punitive practices creates a school to prison pipeline that suspends and expels more minority youth from school than their white counterparts. Even when youth are “caught” for the same activity, the minority youth is more likely to be arrested, petitioned to juvenile court, and detained in a detention center which sets off an array of negative interactions and social stigma that is almost impossible to overcome. The school to prison pipeline creates generational disenfranchisement, poverty, and systematic oppression of entire communities.

Graphic of rates of drug use and sales by race next to graphic of drug-related arrests by race — Source: The Hamilton Project

But problems in school are not the only contributor to the overuse of police in society. Lack of adequate health care also works to ensure that poor people and people of color will go to prison instead of to mental health clinics or rehabilitation centers for substance abuse and mental health issues. Instead of having diagnoses that are recognized and treated, even at very young ages, people without adequate health insurance or preventative health care are labeled by the symptoms of their illnesses. As services shrink in the community, law enforcement is used as the social service delivery system for this group. Instead of citizens receiving counseling and accurate mental health diagnosis that could treat their health issues, they are arrested, incarcerated, and offered very few if any services. For a drug charge, a person with insurance will likely go to a rehab facility. A person without insurance will likely go to prison. Studies indicate that 20% of jail inmates and 15% of prison inmates suffer from major depression or psychosis and as many as 87% of those have comorbid substance abuse issues. Citizens without insurance in our society are more likely to have unresolved trauma, which is often exacerbated by interaction with poorly trained police officers. Those same individuals are more likely to be perceived as dangerous, more aggressive, and not amenable to treatment. As a result, they are more likely to be arrested, more likely to be detained prior to trial, and more likely to be incarcerated. When they are eventually released (95% will return to communities) they are sent back to communities with little to no continuity care plan which almost insures that they will encounter the criminal justice system again.

So, what alternative police practices and systematic strategies could we envision that would work to dismantle this perpetual cycle of violence, trauma, and overall injustice that is levied disproportionately on poor and minority communities? First, I would propose that police agencies examine the role of police in everyday life and create policies that actually reflect those defined roles. The role of the police is “to protect and serve.” Let’s unpack that statement – to protect and serve – not to arrest, apprehend, serve as judge and juror, intimidate, harass, incarcerate, shoot, bully, or kill – protect and serve. Yet most of our emphasis in police departments across the US revolves around tactical weaponry, restraint techniques, defensive driving, and legal procedures of arrest that will lead to convictions. Perhaps refocusing training on de-escalation strategies, trauma informed care, and implicit bias could provide better understanding and more opportunities for officers to assist in resolving conflicts peacefully. Do police officers really need full armored SWAT gear? And military grade weaponry? When police posture defensively as if their role is to protect themselves against dangerous citizens (again as if they are soldiers and citizens are the subjects) the response from citizens is likely also to be defensive and reactionary. Beyond new recruits at the police academy, officers who have been on the force for long periods of time and serve as field training officers need the same training as new recruits on the above-mentioned issues. Many times, they work to undermine positive training received in police academies. If these more seasoned officers resist training, or refuse to comply with new protocols, they should be reassigned to departmental activities that do not require citizen interaction. We can no longer afford to have business as usual and rely on statements like, “that’s the way it has always been.” Agencies must be proactive in removing old ways of thinking and performing and replace them with more educated and better-informed practices that work to restore police-community relations. A merit system could be implemented that rewards positive behavior with pay incentives or merit toward promotions. Police should be treated as professionals, paid as professionals, and held accountable as professionals.

Secondly, I would propose that we examine the services for which police are being used in place of other, more appropriate social service delivery specialists. For example, commissioned law enforcement officers are not the proper authority to handle adolescents in schools – especially when dollars spent to employ the police could be redirected to employ social workers and counselors to address the underlying causes of much adolescent behavior. The experiment with School Resource Officers (SROs) was intended to create trust among students and police where police would function in a counselor/educator role. However, the reality has been that schools have turned over general disciplinary actions as well as drug/alcohol enforcement provisions to SROs. They do not work as much in an education/counselor capacity as they do as the enforcer for a host of school-based rule infractions that lead to more kids being suspended, expelled, or processed in juvenile court. Instead of fostering healthy relationships with police and students, students do not trust them and try to avoid them. A better alternative seems to be to employ a school based social worker at each school instead of an SRO. One argument for SROs has been the prevalence of school shootings and the need for student safety. However, school shootings were not the original intent of SROs, and school shootings remain very rare occurrences. When these tragedies do occur, it is rarely an SRO who protects students or who intervenes during these instances, which makes school safety concerns an inadequate argument for placing police officers in schools. Their presence adds to the school to prison pipeline and works to create hostility between youth and police very early in life. Zero tolerance policies should be replaced with restorative community policies within schools to teach negotiation strategies that students could actually use in future interactions. Dialogue about complex issues should be encouraged among students and opportunities should be seized to provide education around community health, community harm, and community restoration.

This conversation would not be complete without recognizing that the work of policing a community is stressful. Rarely do police officers receive adequate training for the job. Even more rarely do they receive counseling and support for their own trauma that they experience on the job. For example, one of the most stressful parts of law enforcement jobs is not the hostage negotiation that ends in a shoot-out; instead, it is responding to traffic accidents. Officers might retire from the police force without ever using their firearm, but the chances of them viewing a dead child in an overturned car after a crash are high. When officers’ trauma is not addressed, that trauma becomes the lens through which everything else is viewed. A normal response is to have a heightened sense of self-preservation – and every possible encounter with a citizen presents the possibility of a negative outcome. Some of the resources within police departments should be reinvested in the officers to provide training, support, and counseling that they need to be healthy community members both on and off the job. To complement these resources, the culture within the department must also change to promote positive mental health among officers. Currently the stigma of mental health issues as signs of weakness permeate police culture. Changing those views will take time, but the culture of health that is discussed in communities must also apply to police agencies throughout the US.

Graphic showing 85% of first responders have experienced mental health problems, graphic of mental health stigma at work — Source: University of Phoenix

Graphic showing rates of mental health stigma at work — Source: University of Phoenix

Finally, and probably the most inflammatory part of this post, we must have honest conversations about the systematic racial oppression in the US and the role that all systems of government have played in developing and keeping it in place. Minority groups are presented as more dangerous, more violent, more in need of police, and only responsive to force. Such portrayals are not accidental, but work specifically to detract from empathy that might otherwise be shown to them as fellow human beings. The scourge of racism is so deeply engrained in our justice systems in the US that even minority officers do not know how to discuss it, react to it, or work to dismantle it. The militarized hierarchy within police agencies causes a veil of silence among officers who fear reprimand if they are perceived as trouble makers, liberals, or sympathizers. Citizens have so little trust in the police, or the system of justice, that they are often victims without a voice. These are not characteristics of a free society, and they must be replaced with conversation, understanding, and a shared vision for what citizens want the police to do in their communities and how that will be accomplished. In the end, police officers are public servants, and their role is to protect and serve the community and every member of the community. For anyone who reads this and has an interest in taking a deeper dive into racism in the US, I would recommend three books to read: The Color of Law: A Forgotten History of How Our Government Segregated America by Richard Rothstein; Why are all the black kids sitting together in the cafeteria by Beverly Daniel Tatum; and So you want to talk about race by Ijeoma Oluo.