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An Ethnography of Pregnancy as a Site of Racialization
By Khiara M. Bridges
UNIVERSITY OF CALIFORNIA PRESSCopyright © 2011 The Regents of the University of California
All rights reserved.
Alpha Hospital: Unique, But Not Singular
ALPHA HOSPITAL: A UNIQUE INSTITUTION ...
George Washington was only a toddler when Alpha Hospital first opened its doors in the early eighteenth century (Opdycke 1999). Since then, Alpha has become arguably the best public hospital in the country. It is one of the few places in the nation where poor people have access to first-rate, outstanding health care. Indeed, the hospital is one of the most widely recognized medical institutions in the United States. The programs it provides top several lists: emergency medicine, neurology/neurosurgery, cardiovascular medicine, nursing, and, most notoriously, psychiatry. Alpha's reputation as a psychiatric hospital par excellence may be due to its counting many famous figures as former clients, including Edie Sedgwick, Norman Mailer, Charles Mingus, Allen Ginsburg, John Lennon's killer Mark David Chapman, and, more recently, Courtney Love, who was taken to Alpha after she was seen confusedly ambling around her Manhattan neighborhood. She was later photographed handcuffed to a gurney in the hospital—what may be standard procedure for those who resist treatment (People 2004). Yet one does not have to be a celebrity to be granted entry to Alpha's psychiatric ward. "If you're in Manhattan and you happen to be unfortunate enough to decompensate in a manner that involves an imminent threat to yourself or those around you," you are most likely going to Alpha—that "single word that, for more than a century, has told the rest of New York City that there is now one less person on the streets about whom it has to worry" (Harris 2008).
Alpha's status as a psychiatric hospital is so recognized that it has become embedded as such in the cultural imagination of the nation. This partially explains how Alpha has become a pop culture referent. Alpha was the site to which Barney Miller shipped everyone he considered mentally unstable when he encountered them during his travails in the Twelfth Precinct. In Miracle on 34th Street, Alpha Hospital was the temporary home for Kris Kringle as he awaited a court hearing to determine whether Santa Claus really existed. In one, not uncommon, heated exchange between Alice and Ralph in The Honeymooners, she tells him, "I'll go fix my lipstick. I won't be gone long, Killer. I call you Killer 'cause you slay me." Ralph, a jibe always on the tip of his tongue, replies, "And I'm calling Alpha 'cause you're nuts!" However, "spokesmen for the hospital will remind you, with the dogged patience of those who have had to say it again and again, that Alpha is much more than a psychiatric center" (Harris 2008). By most accounts, it is an excellent hospital that provides superb, wide-ranging care.
Alpha is unique for two distinct reasons: first, the quality of the medical care it offers in many respects is the world's best. Alpha's program for the reattachment of limbs has global renown (New York City Health and Hospitals Corporation 2009). Should the president of the United States or any manner of foreign dignitary require medical care while visiting New York City, he or she most assuredly will be whisked to Alpha Hospital (New York City Health and Hospitals Corporation 2009). When police officers or firefighters are injured in the line of duty, Alpha's record of offering the best in trauma care assures that they will be rushed to Alpha's emergency room (Dvorchak 1990); indeed, Alpha's record of excellence in providing trauma medicine explains why its ER was inundated with patients after the explosion in the basement of the World Trade Center in 1993 (Zuger 2001) and why its ER would have been similarly inundated in 2001 had there been more survivors following the collapse of the Twin Towers. Moreover, Alpha's history has included pioneering innovations and Nobel-Prize–winning research (Opdycke 1999, 12). The history continues to the present, as Alpha is the site of a number of studies that may very well shape the future landscape of medicine and technology. Accordingly, Alpha is frequently cited in medical journals as the hospital at which research was conducted and important (read: publishable) results were found. Furthermore, it is a referral center for "high-risk" pregnancies, providing cutting edge maternal-fetal medicine to those who require it (NYC.gov 2010). It also offers women enjoying "low-risk" pregnancies the option of a midwife-assisted, natural childbirth in a picturesque, Jacuzzi-fitted birthing center. Wrote one journalist, "The lavish birthing room hardly squares with the image of Alpha.... Luxury and Alpha might never have appeared in the same sentence, but the new birthing center is gleaming, beautiful, and luxurious" (Fein 1998). Between the birthing center and the traditional labor and delivery ward, close to two thousand babies were born at Alpha in 2007 (NYC.gov 2010).
The second reason for Alpha's uniqueness is that because of the generosity with which New York City's public hospitals have been funded, it is able to offer the world-class medical care described above to more people who otherwise would have no access to health care at all, let alone state-of-the-art health care. "[N]owhere else in the United Stated does there exist a public hospital of such scope and generosity" (Opdycke 1999, 12). Indeed, when the federal government began subsidizing health care for the poor via the Medicare and Medicaid programs, millions of persons across the United States gained access to health care that they had been unable to afford in the past. However, this increased access to health care enabled by Medicare/Medicaid was not as dramatic in New York City, in which universal access to health care was already close to being realized—due in part to the city's expansive network of public hospitals and clinics. (Opdycke 1999, 139). "New York City has provided hospital care in its public hospitals as a mandatory service, not a discretionary service" (U.S. News & World Report 1975). Alpha Hospital is a significant part of this story, as it has always been the oldest and largest of all the public hospitals and clinics in New York City, the flagship institution providing care to more of those in need than any other public hospital in the area.
However, Alpha's status as a (if not "the") premier institution of public health in the nation and perhaps the "best shot" the poor have for obtaining quality health care raises the stakes of the critique that is to come. In the following chapters, I will argue that the institution (and the services it provides) demeans its patients and perpetuates racial and social inequalities. In the process of supposedly equalizing the poor and their non-poor counterparts, Alpha nonetheless pathologizes and stigmatizes the former. Indeed, because the program of universal prenatal care offered within Alpha Hospital may be the best version available, and Alpha may be the closest the nation has come to universal health care, the critique of U.S. political economy and racial politics I offer becomes all the more critical.
... BUT NOT A SINGULAR ONE
Though the uniqueness and extraordinariness of Alpha Hospital should be recognized, the hospital ought not to be understood as singular. Which is to say, to the extent that Alpha is a site where poor, pregnant women's bodies are excessively problematized and racial inequities are reiterated, this is a product not of some peculiar quality of Alpha, but rather a product of an institution that depends upon public dollars to deliver health care to uninsured, marginalized persons in the United States. Consequently, the critique is not of Alpha as such, but rather of the nationally circulating discourses, politics, policies, and practices that also affect Alpha and the people who populate it.
Alpha is a site of racialization—a racialized and racializing institution—because it is a hospital that is firmly located on the second tier of the U.S. two-tier health care system, a second tier disproportionately populated by poor people and people of color. "For years, New York City's public hospitals have been known as health care outposts of last resort. If the Health and Hospitals Corporation, which runs them, had advertised their medical services, it would have been considered akin to Albania hawking its tourist attractions: they may exist, but who would want to go there?" (Steinhauer 2000). While we may see within Alpha "the contrast between public care and private at its purest" (Opdycke 1999, 12), this is a contrast that is present throughout the nation. Alpha is unique in that it does an exceptional job of providing medical services to a large group of persons who must rely upon public health care, but the hospital is far from singular: numerous institutions throughout the United States replicate the job that Alpha endeavors to do for the poor. In every major city in the United States, one will find a relative of Alpha, a distant cousin perhaps—a public hospital existing alongside its private counterpart, providing the care the latter either cannot or will not provide. And so, the ethnography I offer might have been written about any of these other laudable institutions of public health.
Further, although Alpha is world renowned for its research and innovations, such achievements do not exempt it from its status as a public hospital; Alpha must still depend on government dollars, which seem to always be in short supply. The result is that Alpha is plagued by problems affecting many public institutions: it is underfunded and understaffed. Moreover, the equipment that the staff and physicians use may be in short supply, or may have been superseded by newer, better versions—versions that remain out of the hospital's fiscal reach due to budget constraints. A chief resident, Gloria Vance—a soft-spoken, pleasant white woman who was looking forward to finishing her residency and beginning a new position as a general OB/GYN at a large private hospital in Boston—explained it to me in the following way:
Anywhere from the actual machine for a CAT scan to the X-ray machine is better at Omega [the private hospital with which Alpha is affiliated] than it is here. It has a higher resolution. So, for example, if we're ruling out a pulmonary embolism—which we do a lot, because in pregnancy, people are at an increased risk for getting blood clots—they will often call it a poor study here, whereas, at Omega, they never do. One time, I asked the radiologist why that was so, and he just said that the actual scanner [at Omega] is a better quality machine. So, there is just the equipment level. And then there's the number of scanners and the number of staff—so that makes it easier to scan, or MRI, or whatever, over at Omega than to do it here. And it's not always true that one is going to be better than the other. It's just that, in terms of the overall, it's easier to get a scan there. And it's better quality....
[Alpha] is a teaching hospital. And for somebody who has no insurance, it's a tough world. And they feel like this is a place where they can come. But, if you compare what is here versus what is at Omega, there are just more restraints here—because it's all based on budgets. Another procedure, for example, that we could do at Omega is a procedure called endometrial oblation. There are all different types of techniques to do it. And we don't have all that technology [at Alpha] to do that.
These challenges, which may affect the quality of health care that Alpha can deliver to a patient on any given day, are mirrored in the experiences of other public hospitals throughout the nation.
Moreover, if I had not had the good fortune of stumbling upon Alpha in New York but instead ended up patrolling the halls of the obstetric clinics at Chicago's Cook County Hospital, Los Angeles' County General, or Atlanta's Grady Memorial Hospital, I would have still been able to write some version of the ethnography of pregnancy as a site of the racialization contained within. That is, because public hospitals serve those marginalized elements of society private hospitals can refuse, public hospitals have in turn become marginalized (Opdycke 1999, 194). It is the Alpha Hospitals of the nation that have served those groups that the vicissitudes of history have marked with stigma: individuals dying from tuberculosis, babies born with crack cocaine metabolites in their bodies, gay men and intravenous drug users suffering from AIDS, and so on. During the mid-1980s, when ignorance of HIV and AIDS caused "the fear of contagion" to grip the United States, Alpha treated more people suffering from AIDS than any other hospital in the country; this was not because the providers and staff at Alpha were exceptionally heroic or courageous, but that "the city's municipal hospitals, and Alpha in particular because of its location in Manhattan, must accept any AIDS patient, many of who are referred by private hospitals" (Sullivan 1985). At the time, many were aware of the stigma that AIDS patients brought to the institution that cared for them. "Faculty members expressed concern that treating a disproportionately large number of AIDS patients could stigmatize Alpha and upset an overall patient mix that traditionally has offered Omega-Alpha residents a classic postgraduate training in medicine in a major big city hospital." (Sullivan 1985). Yet, there was nothing Alpha could do to avoid its patients and the stigma they brought; as the hospital of "last resort," it admitted them and cared for them in the best way it could. That public hospitals serve the stigmatized in part explains their continued existence; Alpha and like institutions survive because they meet "social needs that private providers have been unable or unwilling to address" (Opdycke 1999, 10).
THE ROLE OF MEDICAID
Medicaid and Medicare threatened to undermine the segmentation, and simultaneous racialization, of the U.S. health care system by allowing for the integration of the two tiers. When Medicaid and Medicare were first introduced in 1965, many commentators believed public hospitals would find themselves invigorated as they would no longer have to absorb the health care cost of the previously uninsured who now had Medicaid/Medicare. Other commentators believed public hospitals would find themselves deserted in the advent of Medicaid/Medicare, as the formerly uninsured who depended on them would take their Medicaid/Medicare insurance to more prestigious private hospitals. (Opdycke 1999, 140). Many of them did. However, public hospitals—and Alpha Hospital specifically—did not find themselves deserted wastelands as every indigent former patient flocked to the more privileged private hospital down the block. This was because there still remained a large number of persons who did not qualify for Medicaid or Medicare and, uninsured, would continue to depend on public hospitals for their health care. One can still find stories of uninsured patients who were turned away from private hospitals only to end up at Alpha Hospital and have their lives saved there. The New York Times reported the story of a French woman who had sought care for abdominal pain from one of the more prestigious private hospitals in Manhattan.
Pelvic cancer was suspected, and she was admitted to the obstetrics and gynecology floor, where the diagnosis was confirmed. A private doctor, along with the house staff, attended to her. The doctor concluded that she needed surgery within several weeks followed by chemotherapy. The woman had no insurance. The senior physician discharged her, and left a note on the woman's chart saying that she had instructed her to obtain health insurance or go to a public hospital.
Investigators determined that when the woman left the hospital, on Manhattan's West Side, she had barely been able to walk. That same day, she went to Alpha Hospital, a city facility, where surgeons operated immediately. (Kleinfield 1999)
Moreover, private hospitals are still able to choose which services they will provide and which they will deny. Accordingly, "the exodus to the private sector did not represent a cross-section of the municipal caseload—more white patients than black found a welcome in the private system, more Medicare than Medicaid, more acutely ill than chronic, more expectant mothers than drug addicts, more sober employed than homeless derelicts." (Opdycke 1999, 146). Instead of undermining the segmentation that characterizes the U.S. two-tiered health care system, Medicare/Medicaid actually functioned to exacerbate the polarization. "[T]he arrival of Medicare and Medicaid had further narrowed the circle of New Yorkers who had to depend on public care, leaving behind, once again, the people with the least choices and least resources." (Opdycke 1999, 146). These people are, for the most part, Alpha's patients.
Excerpted from Reproducing Race by Khiara M. Bridges. Copyright © 2011 The Regents of the University of California. Excerpted by permission of UNIVERSITY OF CALIFORNIA PRESS.
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Table of Contents
PART ONE CLASS,
1 / Alpha Hospital: Unique, But Not Singular, 21,
2 / Pregnancy, Medicaid, State Regulation, and Legal Subjection, 41,
3 / The Production of Unruly Bodies, 74,
PART TWO RACE,
4 / The "Primitive Pelvis," Racial Folklore, and Atavism in Contemporary Forms of Medical Disenfranchisement, 103,
5 / The Curious Case of the "Alpha Patient Population", 144,
6 / Wily Patients, Welfare Queens, and the Reiteration of Race, 201,
What People are Saying About This
"Powerful. . . . Bridges builds a thoughtful and important argument. . . . An enormously challenging and valuable book."Anthropological Quarterly
"The richness of this book's ethnographic accounts is truly extraordinary, as is a detailed discussion of federal and state programs. . . . Highly recommended."Choice
"Her work should be read by everyone involved in delivering healthcare to those without class privilege."Anthropological Quarterly
"A beautifully written and well researched ethnographic study of the delivery of prenatal and birth health care at one of our nation's most preeminent public hospitals."American Journal of Sociology
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