Health Care Off the Books: Poverty, Illness, and Strategies for Survival in Urban America

Health Care Off the Books:  Poverty, Illness, and Strategies for Survival in Urban America, by Danielle T. Raudenbush, (Oakland: University of California Press).

Review by Thomas Hansen

Teachers of social studies—and all teachers interested in social justice—can make good use of this text as either a good reference for their personal library or a good research source for students in secondary school courses to read and consult.  There is a great deal of good information here about healthcare and healthcare policies in the US.  The book is written in accessible language and does not appear to have any offensive passages.

Danielle T. Raudenbush explains the ways in which poor urban dwellers in a project navigate the challenging world of health care, some with insurance, some without.  Raudenbush shows us there are three different levels of approaches to getting the needed pills, bandages, and even medical equipment whether patients follow the formal approach to getting their healthcare—or not.

The author makes it clear there is a consistent and reliable informal network of helpers for poor persons to get pretty much whatever they need on the streets.  Raudenbush acknowledges this particular qualitative study, done over time, focuses very much on healthcare issues and does not address food, money, rides, or other items very much. 

The author shows us there are those three different approaches, first formal: going to doctor appointments, buying medication and/or using insurance to do so, and then taking all of the medication/following all the doctor’s orders, and convalescing as directed.  There is also informal—and this is the one that seems to be of most interest to the author.

A second approach is “informal” and it involves using local resources and persons in the process of purchasing or trading for the pills, bartering for the pills, lending other needed medical supplies and goods, or purchasing these items from a helper in the project.  It is very interesting how the author is able to get so much information, and she has established very good rapport, it seems, with the residents of the project.  Like her subjects in the study, the author is African-American, and this connection helps her to get the trust of the people she interviews.  She also conducts focus groups with the residents.

A third approach—she calls it the “hybrid” one, shows local and formal together.  The author reveals how much the residents of the project bend rules, make important connections, share resources, and make use of the people who serve as “helpers” in that community.  Doctors and other medical personnel are also involved in the hybrid approach in various ways—and in the informal approach too.

Helpers provide the backbone for the poor to get access to so many services, and to food, and to medication, and even to walkers and wheelchairs.  Often heard among the homeless, also, are these kinds of questions:

  • Who is giving away winter coats?
  • Who has free dinner tonight?
  • Is there any place with decent sack lunches by my spot where I stay now?
  • Where can I get some gloves and underwear on a Sunday?
  • How do I find that lady who has the phone chargers for sale?

In addition to these questions, helpers often have to deal with others—such as ones dealing with social security application rules, where to get free aspirin, how to get disability checks, how to find a good dentist who takes XY or Z insurance, and other needed information.  As in this book, one will find out the streets have helpers who are constantly assisting those in need—and who are well-known among the street networks. 

Informal networks and devoted helpers are an integral part for many residents of that project.  The author does a great job of show how complex the relationships can be.

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