Mama Might Be Better Off Dead: The Failure of Health Care in Urban America

“From her perspective, the eight-lane highway is an escape route for the employees of the various hospitals and social service institutions, for people who do not carry poverty home with them in a plastic bag.”

Abraham frequently takes on the perspectives of the Banes family, paraphrasing their ideas, as she does with Jackie here. The comparison of the highway to an escape route is a politically pointed one that hints at the profound distrust and Misunderstandings Between Medical Workers and Marginalized Patients that will be revealed throughout the rest of the book.

“Robert tries to curry Jackie’s favor with small gestures such as pretending not to smoke and buying her a box of candy when she gets mad. What Jackie wants most, though, is for him to stay away from cocaine, and that he has a harder time doing. He sometimes goes weeks, even a month or two, without using cocaine but then binges and spends every cent he can find on drugs. That leaves Jackie straining to meet her household budget, and it cannot be good for Robert’s health. Robert refuses to discuss drugs with anyone but Jackie and then only if she pushes the issue.”

The internal dynamics of the Banes family, including the building tension in Robert and Jackie’s marriage, are small-scale conflicts that Abraham ties directly to the difficulties they face navigating the healthcare system. Robert’s drug use is an issue that clearly weighs heavily on the family, both emotionally and financially. However, here are the first inklings of boundaries between Abraham and her subjects. This distance between the narrator and the story highlights the fact that Abraham’s insights are inherently limited in some key ways as an outsider.

“Something about the sign, perhaps the bright orange kindergarten-capital letters in which WORKING was printed, was condescending. Its cheery simplicity rang hollow to anyone who knows how rare jobs are among dialysis patients. Not only do the poor get sicker, but the sick get poorer.”

Abraham specializes in observational writing that reveals her story in the most minute details; in this case, a handmade sign posted at the dialysis clinic. Describing the writing as “kindergarten” reinforces the sense of condescension in the messaging, since it implies that the sign-writer viewed the patients as akin to kindergarteners. The use of chiasmus in the last sentence reinforces the inevitability of the cycle between poverty and illness, and the futility of the sign.

“There really is not much for the social worker to do, she continued, except to make arrangements for patients to receive dialysis when they travel to Europe or Hawaii.”

Dark humor is utilized throughout the book to simultaneously provide relief from and emphasize the heavy subject matter. Here, a comparison between social workers for wealthy dialysis patients and social workers for poor dialysis patients renders the absurd revelation that the former work as de facto travel agents. As is frequently true in Mama Might Be Better Off Dead, bewildering comparisons between the experiences of the rich and the poor are utilized to highlight the injustice of healthcare inequity.

“If this all sounds incredibly confusing, that’s because it is. Because the United States does not provide a basic level of health care to all its citizens, the country is left with a patchwork of state and federal programs among which inconsistencies are inevitable. People are divided into groups and subgroups, and then divided again.”

In a rare moment, Abraham acknowledges the experience of her readers, highlighting and reaffirming the confusing nature of the subjects that she is discussing. The subtext of this acknowledgment is that the system is, naturally, confusing to the point of being unnavigable for the Banes family, and what’s more, that this confusion is by design. By designating inconsistencies in care “inevitable,” Abraham implies that the system was irredeemable in its state at the time of writing.

“‘I have two appearances, my inside appearance and my outside appearance,’ Jackie says. ‘My family tells me they like the way I look when I’m walking out the door.’”

The pressures placed on Jackie by both society as a whole and her own family are evident in the guard she puts up whenever she leaves the house. At the same time, her curated appearance is portrayed as a suit of armor that helps her maintain her dignity in a world full of systems that demean and dehumanize her on a daily basis.

“These facts paint a picture of a Norman Rockwellian doctor of the kind that health planners say are in desperately short supply in the inner city: a family practitioner who over two decades provided basic primary care for three generations of poor people. What Mrs. Jackson and her family had no way of knowing was that Dr. Marino had failed a peer review by the Department of Public Aid’s Medical Quality Review Committee.”

Abraham’s invocation of Norman Rockwell—who painted idealistic pictures of American life—immediately conjures a romanticized image of American society that does not match up at all with the Banes family’s experiences. Dr. Marino is juxtaposed with this hypothetical “Rockwellian” doctor to emphasize just how far away his standard of care is from the ideal.

“Dr. Ahluwalia guessed that some of Mrs. Jackson’s repeat hospitalizations might well have been prevented had her depression been aggressively treated. ‘There is a direct correlation between her physical illness and her depression,’ he said.”

The connections that Abraham draws between Cora’s mental and physical health place the two medical disciplines on equal footing in terms of necessity. This is a rare stance to take, especially for an author in the ‘90s, and is not reflected at all in the handling of Cora’s healthcare (her physical health is almost exclusively prioritized over her mental health). Dr. Ahluwalia’s admission that such prioritization may have, in fact, been counterproductive, has a somewhat hollow tone to it, since by the time of the interview, the damage has already been done.

“The emergency room is where the inequities and distortions of a health-care nonsystem—one driven more by patients’ ability to pay than by their medical need—are most obvious.”

Abraham places immense significance on the emergency room; it is the only department of the hospital that gets its own profile within the book independent of the Banes family’s story. By investing the emergency room and its workers with such intense symbolism, Abraham distills her critiques into one setting.

“Some commentators say such morbid humor demeans and dehumanizes patients. But others acknowledge that, while the language may be cruel, it relieves the pressure of making split-second decisions that can determine whether someone lives or dies. It also allows doctors and nurses to put some distance between themselves and the anguish they see each night.”

Mama Might Be Better Off Dead is filled with questions regarding medical ethics, including this examination of medical workers’ use of dark humor. The debate about whether such humor is acceptable falls into the broader theme of Miscommunications Between Medical Workers and Marginalized Patients, since it can come across as distinctly insensitive to patients but functions as a necessary form of relief that allows the workers to do their jobs. Even Abraham herself utilizes dark humor at moments in the text where the subject matter feels too heavy to speak about fully seriously. The same ethical debate, then, can be applied to Abraham’s writing style.

“‘Are you a diabetic?’ she asked loudly. ‘No,’ he screamed back. ‘I’m a Baptist.’”

This is another moment of dark humor that cuts through the serious tone of the rest of the book. Coming just after Abraham’s commentary on doctors’ use of dark humor as a coping mechanism, there are resonances between the author and the healthcare workers that she follows. Both are outsiders to the Lawndale community and need the humor at times to carry out their jobs.

“Hospital leaders explained that a perception might exist that black patients were being discriminated against because Jewish patients were indeed the institution’s first priority. ‘No Jewish person will be turned away if at all possible,’ one Mount Sinai representative said. ‘Jewish patients will be catered to and wherever there is a problem we will favor the Jewish patient.’”

Jewish hospital administrators’ discrimination against Black patients is one of the book’s central conflicts, especially since those administrators insist that it arises as a result of the commitment to prioritizing Jewish needs in an otherwise antisemitic healthcare system. The interactions between these two communities are a good example of the intersectionality of Abraham’s subject matter, and it requires an understanding of multiple layers of systemic oppression to analyze the state of healthcare access in North Lawndale.

“A Chicago newspaper once compared Mount Sinai to a ‘medieval monastery […] for half a century, a center of healing and teaching for the community.’”

The metaphor of Mt. Sinai as a medieval monastery, made by the Chicago Sun Times in 1972, is simultaneously complimentary and critical. On the one hand, it emphasizes the hospital’s essential role as an institution committed to healing the community, but on the other, it places it firmly in the past. For a hospital trying to remain in business in the 20th century, comparisons to the world of medieval medicine are an indication that Mt. Sinai’s care is not as state-of-the-art as they might hope.

“In the end, the emphasis on ‘individual responsibility’ may be more dangerous than a diversion. It has the potential to undermine any attempt at all to reform the health care system to benefit the poor. Because, after all, if these poor folks make themselves sick, why should we waste our efforts helping them out?”

Here, Abraham takes a firm political stance against the rhetoric and healthcare policies of the George H. W. Bush administration. Her use of sarcasm in the last sentence is meant to underscore just how ludicrous she finds the Republican emphasis on “individual responsibility” to be.

“‘That’s the way it should have been,’ Jackie sighed, ‘just me and Latrice.’”

The revelation that Jackie longs for a time before she was married to Robert and her second two children were born reveals the extreme strain that her caretaking responsibilities have placed on her. In particular, the implication that she wishes DeMarest and Brianna had not been born is meant to evoke shock.

“For a long time, I was thinking Medicaid and Medicare were the same thing.”

Jackie summarizes how fundamentally confusing federal insurance programs are. This confusion draws attention to the similarity of the names given to both programs and is intended to evoke sympathy.

“To say that Jackie and other poor mothers ‘fail’ to immunize their children is not the end, only the beginning, of the story. If government child-health programs are to work, they must reach out to poor parents, or at the very least ensure that getting care is relatively straightforward. They do neither, and the blame stretches from the city, to the state, to Washington, D.C.”

Once again, Abraham redirects the blame for the Banes family’s predicaments away from them and onto the federal government. This criticism suggests that the national government is failing to fulfill some of its most basic obligations and blaming citizens for it. As such, statements such as this one support the author’s political stance against the Bush administration’s “individual responsibility” position.

“A poster behind the check-in desk at Jackie’s Public Aid office epitomized the problem. It advertised ‘Healthy Kids,’ Illinois’ name for its EPSDT program, and showed an illustration of a doctor examining a child over the words ‘Call for More Information.’ There was a white box for the phone number underneath those words; it was blank.”

Abraham once again focuses on the signage in doctors’ offices to demonstrate the problems that she is critiquing. The poster’s lack of a phone number is a seemingly small failure of communication that can have immense negative effects, failing to help mothers immunize their children. The empty box represents the wider lack of support for poorer families in the area.

“As Barber skimmed Robert’s medical history, she mentioned offhand that focal glomerulosclerosis had caused his kidney failure. His eyes widened in surprise. For the past ten years he had assumed he lost his kidneys to high blood pressure, when, in fact, hypertension had been a symptom, not the cause, of his renal failure.”

Doctors’ failure to communicate to Robert the basic premise of his illness is one of the book’s many structural ironies; oftentimes the Banes family is advocating for itself in the medical system, despite not understanding the nature of their illnesses. This is a key example of serious Misunderstandings Between Medical Workers and Marginalized Patients.

“Even Robert, who surely appreciates the benefits of transplant, balked at the idea of donating his organs after his death. ‘I don’t know about letting my heart go out of my body when I die. I might jump back up.’”

The mistrust between Robert and medical authorities leads to another moment of acute irony: his unwillingness to become an organ donor. Abraham treats minute ironic moments like this one as symptomatic of larger problems within the system—in this case, Black patients’ hesitance to donate organs due to the history of medical abuse and racism that has traumatized their community.

“A general distrust of the white establishment inevitably seeped into her dealings with doctors, few of whom are black. A pragmatic woman, she sometimes used me as her intermediary with doctors, figuring that my color and education would give me an edge.”

This is another moment in which Abraham herself becomes more visible in the text, since Jackie’s perception of her has come to the forefront. Abraham’s whiteness is an issue that often goes unaddressed in her writing, but here she deems the racial difference important for demonstrating Jackie’s perception of how the medical establishment treats Black people versus white people.

“The perception and the reality of second-class care—including unwanted, experimental care—inescapably stain and strain relationships between medical professionals and poor blacks.”

By affirming there are realities of medical neglect for Black patients, Abraham refutes medical professionals who refuse to understand why mistrust within the Black community exists or dismiss such feelings as illogical or superstitious. In moments like these, the book functions both as an exposé of medical racism and a political critique of the people who perpetuate it.

“Watching Dr. Stone care for his Jewish patients was a joy; the sadness was that Mrs. Jackson did not get that from Dr. Stone or any other health care professional.”

The stark contrast between the “joy” of watching Dr. Stone in one setting and the “sadness” in another illustrates that doctors who fail to adequately treat patients like the members of the Banes family can be good doctors with patients who come from their own cultural backgrounds. Once again, a contrast is drawn between the Jewish community and the Black community, despite Dr. Stone’s attempts to care for both.