Tightrope

The authors begin Chapter 9 with a description of modern advances in health care. Now, even the poorest American will not die of the kind of infected wound that killed the richest man in the world, Nathan Mayer Rothschild, in the 19th century. However, starting in 2015, life expectancy in the United States, which had peaked at 78.9 years, began to fall. This decline was due to the falling lifespan of working-class white people, linked to what Princeton economists call “deaths of despair” attributable to “drugs, alcohol and suicide” (113).

The authors explore how these factors played out in the lives of those Kristof grew up with, such as the Knapp family. While the Knapp children, despite their abusive father, grew up with the love and support of their mother, they were nonetheless marginalized and driven to self-destructive behaviors by their poor circumstances. Research suggests that for some people living in poverty, people’s despair over not believing they can escape means “they are more likely to surrender and engage in self-destructive behaviors that make the despair self-fulfilling” (117). This was true for the Knapp children, four of five of whom died in a five-year period due to alcohol and drug addiction. The authors then look to the broader factors that created the Knapp family’s despair, including the loss of well-paying unionized jobs; the huge increase in the availability of drugs, from meth to opioids; the war on drugs, which criminalized drug users, making it harder for them to get and retain jobs; and mass incarceration for drug offences, which separated families and left children without positive male role models.

In Chapter 10, the authors turn to a program designed to counter some of these problems: Women in Recovery, a Tulsa, Oklahoma, initiative to divert nonviolent female drug offenders from prison. One of the alumnae of the program is a woman named Rebecca Hale, who grew up in poverty and with her parents in prison and experienced sexual abuse as a child. In her twenties, she ended up in prison, where her background was similar to that of many other female inmates, most of whom have experienced sexual or physical violence. While in prison, Hale changed her outlook, and she joined Women in Recovery to stay sober and repair the bond with her children. The 18-month residential program—the length of which is important, as shorter programs are less effective—is founded on intensive psychosocial counselling and peer support and costs $28,000 per person, which is far less than the cost of a prison term. It also has a much lower recidivism rate, at 4.5%. Hale’s enrollment in the program helped her examine her own history of trauma, abuse, and neglect and also learn the discipline to achieve her goals, which led her to acquiring a job at an air-conditioning company. While there are still struggles, including over money and the trauma both Hale and her children have experienced, she expresses confidence that the cycle will stop with her, a confidence made possible by the existence of programs like Women in Recovery.

The authors also profile Tanitoluwa Adewumi, a young refugee from Nigeria who, along with his family, was homeless upon his arrival in New York but nonetheless managed to win a state chess championship in 2019. Adewumi’s family had little in the way of financial resources, so Adewumi’s victory—over other players with expensive chess tutors—was especially impressive. Still, the authors note, Adewumi’s success was the result of several extraordinary circumstances: His family was highly committed to his chess playing, the chess club waived all fees for him, and his public school happened to employ a passionate part-time chess teacher who visited Adewumi’s class each week. Such a confluence of circumstances rarely exists for homeless youth like himself.

Kristof and WuDunn shared Adewumi’s story in The New York Times, provoking an outpouring of support from readers offering everything from a place to live to a car to $250,000 in crowdfunded donations. The problems, say the authors, is that when people read such a story, they are inspired to help the specific child they read about—the exceptional one, who won a chess tournament—rather than all those who share the same struggles. The Adewumis, recognizing this greater need, put 90% of the crowdfunded sum into a newly created foundation to help other struggling immigrants.

At the opening of Chapter 11, the authors describe a healthcare fair in Wise, Virginia, where people camp overnight to access free medical care. The fair was the initiative of a British man named Stan Brock, who was inspired to offer free medical clinics to people living in poverty in Guyana after he was treated for injuries by local tribespeople in the country, and he subsequently expanded the initiative to Haiti, Uganda, and finally, the United States. Now, Remote Area Medical holds 70 healthcare fairs across the country, offering dental and health care to people who lack insurance. As the authors tour the fair in Wise, they observe that many of the people seeking care have long neglected their health because of a lack of insurance coverage, exacerbating their own health problems—such as in the case of Daniel Smith, a young man who’d only been to the dentist once in his life before the fair and had to have 18 teeth extracted.

One way to address this problem, the authors write, is to offer universal healthcare, in line with what many wealthy countries already offer. As the authors point out, a version of universal healthcare already exists in the United States in the form of Medicare, which is available to those over 65—who are also the most expensive demographic when it comes to medical care. The system is irrational in other ways, too, they note, in ways that cause drugs and medical procedures to be far more expensive in America than in other countries; for instance, an appendectomy costs $15,930 in the United States, and in Spain, $2,003. This means the United States spends more per capita on healthcare than any other country, even as many people can’t access treatment.

This access problem has particular consequences for maternal health. American women are twice as likely to die in childbirth as their British counterparts; the authors note, “today one of the most dangerous places in the advanced world is the American South, where women die in childbirth at far higher rates than, say, Spain or Sweden” (152). This statistic is related to the fact that many pregnant women are young and don’t have access to primary care. American teenagers also don’t have access to contraception and education on family planning, which means the rates of teen pregnancy are three times as high in the United States as in Europe, despite the fact that teenagers have sex at the same rates. In closing the chapter, the authors note that there’s still little recognition of the importance of pregnancy prevention, as, for instance, the Trump administration tried to halt funding for teen pregnancy prevention initiatives.

In Chapter 12, the authors describe an encounter with a homeless man in McMinnville, the county seat of Yamhill County, who turns out to be Kristof’s childhood neighbor, Mike Stepp. Stepp struggled with drug and alcohol abuse through much of his adulthood. He ended up on the street, like half a million other Americans, a number that has increased “even as America has become much wealthier, because of a confluence of factors” (160). One of these factors is a lack of housing for people with mental and physical disabilities. Another is the ethos of personal responsibility that took hold in the 1980s, leading the federal housing budget to shrink. Even those who are housed are often in precarious situations, as many American renters pay more than the recommended proportion of 30% of their income on rent. For solutions, the authors look to changing zoning that sets aside areas for single-family dwellings, which decreases the availability of affordable housing, housing voucher programs that allow families to move into better neighborhoods, and financial literacy programs to help renters budget better. While these programs can be expensive, the authors note that they’re ultimately less expensive than the public health, economic, and moral costs of homelessness, as well as the amount of money the government spends on subsidies for wealthy homeowners in the form of mortgage interest deductions.