One of the biggest mistakes we make in health is to mistake healthcare for public health. More tests or treatments simply can’t make up for the ways that the air you breathe, the water you drink, or the school you went to shape your health trajectory. Abdul reflects on the powerful role of place in public health. Then he sits down with Prof. Luke Schaefer, Director of Poverty Solutions at the University of Michigan’s Ford School of Public Policy and co-author of a new book, “The Injustice of Place,” about America’s internal “colonies,” and how they shape what’s possible for too many in our country.

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Dr. Abdul El-Sayed, narrating: [music break] The estate of Henrietta Lacks, the Black woman whose cells became ubiquitous in biomedical research without her knowledge or consent, has settled with a biomedical company over the use of those cells. Amazon expands its virtual health clinic across all 50 states. Ozempic and other GLP one weight loss medications face pressure to slim down. This is America Dissected. I’m your host, Dr. Abdul El-Sayed. [music break] Public health is what we as a society do collectively to assure the conditions for people to be healthy. I literally make every one of my students repeat it during the first lecture of any class I teach. Actually, while we’re at it, public health is what we as a society do collectively to assure the conditions for people to be healthy. See, that wasn’t that hard. The reason it’s so important is because it’s such a contrast to what so many people, even people in public health, sometimes think public health is, which is medicine at scale. If you’re doing enough screenings and testing and treating, then you must be doing public health. Wrong, you’re just doing a lot of medicine. See, medicine is the art and science of diagnosing and treating disease in individuals. Public health is what we as a society do collectively to assure the conditions for people to be healthy. See the difference? One is about what you do for an individual, usually after they get sick. The other is about what you do for society before they do. There are a couple of aspects here though, that I want to zero in on. First, public health is definitively about society acting collectively. It’s about collective action, people coming together to do something we could not do alone. And what is that, you ask? Creating conditions. It’s about places and spaces. Things in our context. Air, water, food most commonly, but also culture and laws and governance. The system of laws that currently reinforce racism, yeah, that shapes health. Freedom of speech. Yep. Public health too. The right to vote for your leaders. Also public health. In the space of a podcast about public health. All this may sound either obvious or esoteric, but the reason I’m raising it here today is because the thing about context is that it’s hard to identify. Most of us live in one kind of place for most of our lives. We take the nature and characteristics of that place to be fixed, to be so normal that we take it for granted. It’s only when we leave or something about that place changes that we come to appreciate how much it really can shape our lives. And when it comes to public health in America, the context that either shapes good health or deprives people of it. There isn’t just one America. There are several. See if you’re a poor Black woman in rural Appalachia, the context in which you’re attempting to live your healthiest life has already set you back. Chances are you’re among the poorest people in this country earning far less than what we call officially poor. Your school was either overcrowded, underfunded or probably both. The jobs available to you pay almost nothing and they rob you of any consistent schedule and could be pulled from underneath you in a minute. You can’t see a doctor because somehow you make too much for Medicaid because your state probably never expanded it. And even if you did have Medicaid, the nearest doctor may be miles and miles away because your nearest hospital recently shut down, but not before the pharmaceutical industry can use it as a stage to generate a generational opioid pandemic that still rages in your community. You need a car to get anywhere, but you share your car with three other people in a multi-generational home where you care for your kids and your parents at the same time. I want you to contrast that with someone living in New York’s Upper East Side, where you probably live in a dual earning household where you and your partner earn more than six figures a piece. You probably went to a great public school or a private school and even better a private college, maybe even grad school. You work a stable 9 to 5 that allows you flexibility, security and the ability to pack money away for the future. Food of all kinds is accessible within a five minute walk and you don’t need a car to get anywhere. Your nearest health care center is within a five block radius and is probably among the world’s best hospitals. You have no trouble getting in because you have excellent health insurance through your employer. See the difference? That difference well, it’s worth more than a decade in life expectancy, on average, ten years of life. Documenting the sinews of those ten years, the difference not just in time, but in the nature of what time looks like and feels like, that’s the work of our guest today, Professor Luke Schaefer. He is the director of Poverty Solutions at the University of Michigan’s Ford School of Public Policy. He’s also a colleague of mine. His work has been foundational to understanding the impacts of cash assistance for poor families and to shaping our knowledge of how public policy shapes poverty more generally. In his latest coauthored book, they traced the, quote, “Injustice of Place,” going beyond the statistics to travel across the country to document the experience of poverty as it takes shape in different pockets of the U.S.. He joined me to talk about the intersection between place and public health. The way American corporate history has shaped poverty across parts of our country and what we can do about it. Here’s my conversation with Professor Luke Schaefer. 

Dr. Abdul El-Sayed: Um. Are you ready to go in? 

Professor Luke Schaefer: Let’s do it. 

Dr. Abdul El-Sayed: All right. Can you introduce yourself for the tape? 

Professor Luke Schaefer: I’m Luke Schaefer. I’m a professor of public policy and director of Poverty Solutions at the University of Michigan. 

Dr. Abdul El-Sayed: And you’ve just recently coauthored a new book. And um I want you to talk a little bit about the premise of this book, because I think it makes a really important contribution to the way that we think about poverty and not just who poverty, but where poverty. 

Professor Luke Schaefer: A number of years ago, uh Kathy Edin and I wrote a book called $2 a Day, which was about really, really poor families in the United States who were um living on almost no cash at all. And uh in that book, we uh went to Chicago, which was a field site that was very familiar. In that book, we use big data, but also qualitative ethnographic work following families who are in extreme poverty. Um. Cleveland. And then we went to Johnson City and um then down to the Mississippi Delta. Um. In uh that was my first time in a rural Mississippi study in poverty. And I remember at the time thinking, um I mean, poverty, extreme poverty in Chicago is really, really bad. Um. But it seemed to me like maybe the Mississippi Delta was a whole another level. And so that got us started, really just interested in in space and place in what it means to be disconnected from services or opportunities. And uh we got sort of out of the blue a call from the um Robert Wood Johnson Foundation, and they were thinking along the same lines. They had read our book and wondered, could we do a study on place? So you might know that this book um The Truly Disadvantaged by William Julius Wilson came out in the eighties. It really focused on neighborhoods um the urban neighborhoods and said nothing sort of about community more broadly. Um. But uh we knew that there was um some data emerging uh that really suggested that not all communities are created equal in the United States in terms of life expectancy. So you know we know the zip codes in very small geographic areas can vary by more than a decade. Um poverty rates obviously vary quite a bit, and uh rates of social mobility really vary depending on where you are. So, uh you know, in some places, uh the American dream that if you grow poor uh you can rise to the middle class is alive and well and in other places, if you grow up poor you’re just as likely to be poor as an adult. So we wanted to study place and so we started thinking of the factors that we thought really encapsulated poverty on a on a more holistic level. So government poverty statistics just look at income. But I think when Americans think about poverty, they think about social mobility. You know, can I do better than my parents? And they think about health. So uh we tried to bring all those factors together and we put every county in the United States into our data set and every large city, the 500 largest cities into our data set. That gets you down to cities that are like 50,000. So we could do an apples to apples comparison on income and health and social mobility, and we ranked them uh using a machine learning technique. And the thing that really surprised us at the start was how much at the very bottom, the most disadvantaged places that had, you know, really, really high poverty rates and really, really poor life expectancy and um really poor social mobility. How much of those were rural places um in Central Appalachia, down in the cotton belt, uh in the Deep South and then down in south Texas. And you know that was honestly, it took us a little by surprise as researchers who had had a little bit of exposure to the to the Delta, but had spent most of our careers in urban, urban places. And so that really started the work of the book of trying to go to these places and understand them and see what lessons we could draw about uh space and place more broadly. 

Dr. Abdul El-Sayed: Before we get to the findings of the book, in your own experience, literally touring the country’s poorest places, I want to ask you, you dedicated your entire career to poverty. What what drew you to the topic? 

Professor Luke Schaefer: Yeah. So I grew up without a lot of money. Uh. My dad had a career change when I was in middle school, and we had been sort of clinging on to the bottom rungs of the middle class before that. And then after that we had to move very abruptly. Um. We only were able to find a place because um someone we knew sort of took pity on us uh and rented to us for a very low amount. Um, you know, I didn’t have any health insurance. Uh. We we were uh I remember government food. But on the other hand, uh when we were really in trouble, we could go to grandma and grandpa. They had money. And so, you know, I remember sort of thinking to myself, I wasn’t I wasn’t really poor, or at least I wasn’t extremely poor, but I certainly wasn’t middle class. And that sort of led me to want to somehow be a connection for society to try to help people who didn’t understand what it wasn’t, was like to not have a lot of money, um help them understand that. And so early in my career, I thought I was going to go into nonprofit management. I was a caseworker for a while. I thought maybe I’d work at a housing corporation, but when I was a caseworker, I was helping families who were behind on their rent or they were going to have their utilities shut off. That’s when I noticed this cycle. A lot of people talk about this cycle of poverty, and they when they say that they mean poverty, that, you know, families who uh are in some sort of cycle. But the real cycle that I saw was a structural one, a societal one, where, um you know, every month, whether it was the same families or not, some families couldn’t pay their rent or they were falling behind on their utilities. And it was the same landlords who were doing some of the same things. And uh and so that’s what led me to think, you know, uh there’s got to be some some bigger picture solutions here. So I have tried to dedicate my career to to finding ways to make our public policies work better for for families who are struggling to make ends meet ever since. 

Dr. Abdul El-Sayed: We really appreciate your uh work and, you know, I’ve gotten the opportunity to work alongside you for a short bit of time uh at the school of public policy and then certainly to to read your work. As I’ve thought about public policy in my appointed roles in government. And one of the the things that I think you establish in this book is that poverty is as much about places as it is about people. And I think for a lot of folks, that’s really hard to wrap your mind around because when you think about poverty, it literally means the lack of money and a place doesn’t really seem to have money, except for if you go to different places, it’s really quite clear that people have invested different levels of money in those places. So walk me through what it means to be a poor place um and the impact that that has on poor people. 

Professor Luke Schaefer: Yeah, I think a lot of us are thinking about um a [?] like poverty as being much more relational. Uh. So historically, we’ve really thought about it as the problem of families who don’t have enough. Um. And uh you know sometimes the solutions, when you think of it that way, are to try to help families cope. Um. And and those could be really good things, you know, mentoring programs that are can can have very positive impacts. Um. Sometimes they sort of offer people things that maybe they don’t really need. Like there’s honestly not that much research or any research to support like financial literacy classes um because it you know, in my view, it may um while being well-intended may sort of miss the bigger problem. Right. Of of the structures that that don’t work uh for families. So you know we can talk about the places I study but you can look at a place like uh Detroit. Right? And uh you know, one thing, when Poverty Solutions, the initiative that I run. When we started working in the city of Detroit, we came with all of our ideas of of what um what was going to be the big issues of poverty. And uh you know what people really maybe brought up to us the most in those first couple of years was the high cost of auto insurance. Um. You know, a policy that in Cleveland cost you like 1200 dollars, cost like five, $6,000 in the city of Detroit. And so what do you do uh when your auto insurance is 20% of your annual income? You’re sort of foist, forced into a set of choices of um do you drive uninsured so you can get to your job? Or do you call in and say you can’t get to your job because of your auto insurance? So we’re sort of forcing people to make decisions. And then if um the person drives uninsured, they can’t afford the premium. They drive uninsured. They get pulled over for an out tail light. And it turns out Michigan for a long time has jacked up the prices of all the fines and fees uh that you face. And and so you get a much bigger ticket than you once got. And if you don’t pay it, it gets much bigger. So, you know, to to sort of put all of the onus on the person, I think misses right. It’s kind of like you’re looking at a you’re looking at a beautiful piece of art or a terrible piece of art. I’m not sure what, but you’re only looking at the corner of the Mona Lisa. You’re missing the bigger picture, which is all the systems in which people um are embedded. So we might take the example of government corruption. So I did not, Abdul, expect to write a chapter in the book about government corruption. But one of the things that really interests us interested us is that when uh we went to communities, so we went uh were in communities in Central Appalachia, in the tobacco belt in South Carolina and the cotton belt down in Mississippi and then in South Texas. If you ask community leaders um what are the biggest challenges that they face, pretty much invariably it will get to sort of the poor. They don’t work hard enough you know. They make bad choices. They’re sort of bringing us down. Um. And, you know, maybe they’re um cheating welfare and and getting a you know thousand extra dollars a year or 2000 extra dollars a year than they would have otherwise. But in every single place, uh there was a fairly recent example of significant government corruption. So um down in uh Crystal City, South Texas, you know, um in the 2010s, like the FBI descended on city hall of this town of just a few thousand and arrested like every member of the city government except one city council person, and took all of the records. Um. And uh this one wasn’t about illegal gambling. I think this one was about like kickbacks for contracts. Um. You uh you know, we had examples of um people who are in positions of power, had sort of helped factories get sweetheart deals to come in and maybe build a factory there. They would they would get benefits. And then the factory never the jobs never materialized um as a result. And then in uh eastern Kentucky. You just have these examples actually where um uh city, uh you know, a mayor or a city manager would would be in league with uh drug dealers. Central Appalachia was sort of the hotbed of the start of the opioid crisis and still is, I think, like um the hottest part of that in the entire country. Um. So, uh you know, a lot of our our place based initiatives flow through elites. They throw they flow through people who are running communities. And I think we’ve made the mistake of because we don’t know a lot about a lot of these places thinking that they’re monoliths, right? That like they’re all everybody there is sort of together. But really the histories of these places are histories of um you know a small number of people who are who are often in charge of the community, um who, um you know, uh have in some cases sought benefits at the expense of a very large group of people who are who are laborers. So that gets you into the role of history and starting to think about um you know I can go back in time and I can look at things like the level of segregation 100 years ago and predict the poverty rate of a a county or a city today with like incredible precision. And and that then, I think, really leads you to a place where you think we we can’t think about poverty as just the problem of an individual of one person. We really absolutely have to think about it in the context of present decisions that have been made, um but also decisions that maybe were made a decade or two ago, like auto insurance in in Michigan and and decades ago or even a century ago. 

Dr. Abdul El-Sayed: Yeah, I really appreciate that point because one of the conceits of our cultural individualism, is that we attribute all outcomes to individual choices as if everybody has perfect agency. And, you know, one analogy to think of is the quality of soil and a seed. We don’t blame a seed if it doesn’t grow in certain soil. We blame the soil. And when it comes to individuals and the circumstances that they face, we we fail to appreciate. And I think policymakers do this all the time, even even policymakers with the best intentions. We fail to appreciate that the set of choices that people make are not the same as the ones we would make because they we face different constraints. And so when you think about auto insurance, you might look at somebody and be like, Wow, I can’t believe they didn’t buy auto insurance. And they’re, quote, “driving dirty.” And you’re like, Well, yeah, if your auto insurance is artificially higher because there’s a legalized policy of redlining. 

Professor Luke Schaefer: Right. 

Dr. Abdul El-Sayed: And it’s now a fifth of your annual income, you’d probably make a similar choice too. But you assume that away because that’s not your circumstance. And I think the hard part is when you attribute agency, you implicitly also attribute the same choice that that you have and that choice that is almost always a function of context. And one of the things for me that was so eye opening about that was I was a professor in New York before uh I came home to the metro Detroit area to lead Detroit’s Health Department. And I got a lot of really well-meaning advice from folks who were doing work in the Bronx. And they said, Abdul, here’s some research from what we’ve been doing, and you can take some of these ideas and apply them. And it was really quite fascinating because they were speaking to statistical similarities between the Bronx and Detroit. But the thing single thing that they failed to address was the fact that these places are just fundamentally different. Detroit is a really fascinating example because it’s almost a rural space in an urban area. A lot of folks, when they go to Detroit, they don’t appreciate how small the downtown is and how vast uh the neighborhoods where people actually live on uh in are. And that that [?] a failure of concentration is not something we normally attribute to urban spaces, except for that’s exactly how the experience is in Detroit. And so if you can’t concentrate your collective welfare or your collective wealth, you can’t attract some of the civic uh uh energy uh that often exists in a place like the Bronx. And so these places end up being fundamentally different. And so this this notion of the the fact that some of the poorest places you identified are rural actually makes a lot of sense, even by analysis of the urban communities that I’ve lived and worked in. And one of the things that I think you guys do really well is to establish this idea that there are colonies within the United States. Can you explain what you mean by that in terms of the kinds of shared histories that pull places together and explain some of the differences in the nature of despair today? 

Professor Luke Schaefer: So uh we first sort of uh mapped uh all these counties and cities so we could see them on the map and you could see these really hotspots of deep deep disadvantage, as I mentioned, in um Central Appalachia and down in the tobacco belt, in the cotton belt, and then down um in South Texas. Um. And you can see hotspots in the West, but they’re not really clusters. They’re sort of a few places those tend to be, uh Native American reservations or counties that have tribal lands. Um. So you know we started our research project process by picking places um in all of the in the clusters and embedding researchers there. And they talked to community leaders and they talked to um sort of lower income citizens. Uh. They went to fairs, uh you know, just got to know the places. Um. When COVID hit, uh we had to take a pause on all of that. And that’s when we really turned to the history. Right. And we started looking at what had happened in these places over the years. We’d been doing a little bit of that. But, you know, we do this deep dive. And what really struck us was uh that uh we started reading these histories and um in place after place we could see uh that they were all places that had been dominated by a single industry for long periods of time, a single um extractive industries, something that really sort of pulled from the land, really. So um in the Mississippi Delta, it’s cotton. And in the tobacco belt it was tobacco after it was cotton. Um. In Appalachia, it’s uh first salt and timber, and then it becomes coal, which I think everybody’s more familiar with. And then down in south Texas in the early 1900s, when they figure out that irrigation, it became table top vegetables like spinach and onions. Um. So these were all things that uh were uh sort of came from the land that required very, very large, um low wage labor forces and that they were controlled by a very, very small elite. And uh the elite in these places controlled not only sort of the economic means of production, but also the um political apparatus. So they they ran the town as well. And so um they use that power, uh both economic and political, to enforce uh sort of the low wage labor that they needed for long periods. So I think the story that we’ve spent the most time uh sort of trying to understand, not remotely enough, but the one that we’re sort of most familiar with is slavery turning into Jim Crow and tenant farming. Right? So in the early 1900s, we replicate um in the cotton belt, we replicate slavery. And I think some would argue that even. I mean, there’s a there is another and different layer of viciousness uh that comes because um there isn’t a total control of the law. Um. So, you know, Jim Crow and and I think that um lynchings really sort of spike after 1880 through um the first few decades of um the 1900s. Um. In South Texas. Actually, it’s some of the same elite. So some of the plantation owners from the cotton belt in the 1910s and the 1920s. As um you know, the soil starts to be played out. They actually move to South Texas and then in South Texas, it’s a slightly different setup. But they’re also taking sort of the lessons that they’ve learned um from the cotton belt and and replicating them in a way with uh migratory uh immigrant labor patterns. So uh these are are towns where you have sort of a steady stream of folks coming across the border, um but they sort of create sort of these um growing seasons that mean that to survive, people have to stay in South Texas and then some move up through the uh the West and the upper Midwest for sugar beets and then cherries actually here in Michigan and then come back down again into south Texas during the growing season. And all of the political apparatus of elections, decisions about schools, those are all done when um uh migrant laborers are away. And so they’re able to sort of replicate sort of that powerlessness in a way. And it’s and it’s it’s some of the same families. And then um up in Appalachia, you have uh sort of coal companies that they come in and they actually own everything, right? So they control not just the mines, not just your jobs, but they own the houses that people are living in and really whole towns. And after they disappear, you have this just huge gutting of communities where communities are just sort of um all of the things going on in communities that are almost wiped off the face of the earth in a very short amount of time. And then we would argue, actually the opioid epidemic is another example of an extractive industry that’s sort of preying on the the bodies um targeting um folks in Central Appalachia. So that’s why we sort of saw this. I think what we the argument that we’re making is that each of these stories are unique, um but in some ways uh they follow this similar pattern and they’re places where the large um majority of people are not granted full citizenship. And that’s why we started to do the parallels for the experience of people in these places uh where there’s an extractive industry that requires low wage labor and people’s sort of citizenship is sort of subjugated um to ensure that through the experience of colonies all around the world. And and I think that the the comparison really, really holds up. 

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Dr. Abdul El-Sayed: In some ways, profound poverty presently is the ghost of racial capitalism uh in so many parts of our country. And it shows up in in some profoundly different ways. One of the parts to me that was just so much more devastating was that like the sealer of fates was uh substance use. And it’s almost like when everything else is gone. It’s like the termites that come down to finish things off. And um you have a whole chapter in the book uh about the role of the opioid crisis in so many of these American colonies. Can you speak to just how devastating uh opioids have been and um the ways in which uh the frankly, the medical industry uh and the failure of public health have enabled it to happen? 

Professor Luke Schaefer: Well. So when we got into um uh, we were in Clay County, Kentucky, which is in Central Appalachia, and it was really an area that was targeted by especially by there’s this very clear record um from Purdue Pharma of targeting uh that region for the expansion of of opioids because um there are a lot of people who there’s a lot of pain. We don’t totally understand the uptick in pain, but there is a lot of evidence that sort of the history of a place, you know uh, where uh people were coal laborers. Um. There was this like backbreaking work and incredibly unhealthy work that there’s been a legacy of that. Um. More people on sort of disability insurance and then a high constellation of family um practitioners who uh they thought the pharmaceuticals saw were maybe a little more susceptible to nudging towards um uh prescribing. Uh. All of those things mean that uh they sort of converge on the community and make this the um region of like the first explosion. And you know it’s really uh just something that’s touched the lives of every single family. So if you were to talk to any family in um Manchester or Clay County, they would have a pretty close experience of people who um had become addicted to opioids, had maybe moved from prescriptions to um um sort of non prescription opioids. They moved to heroin um and that it had devastated the lives of their their sister or their brother, um their child, uh their parents. And um it had really you know has this effect of leading everybody to be fearful and to hunker down right as soon as it’s just out there. It leads people to sort of cut off those social interactions. But we also think that there is an effect of um sort of the loss of the social interactions driving um addictions. So when we got into um the fieldwork we kept on hearing from people over and over again, you know, kids get into drugs because there’s nothing else to do. And we honestly sort of thought that was, when we first heard it, we sort of discounted it as like, oh, that’s not serious. Um. It’s just something people say. But when you hear it over and over again, you start to, you know, in our view, you got to really look at it. And the research is, um I think uh, pretty compelling on this front. Uh. So, you know, we’ve seen studies that um changes in the density of sort of community based organizations are related to um changes in uh opioid overdoses. Uh. There’s interesting uh research among um rats that you know if rats are offered drugs uh versus food, they will get incredibly addicted to the drugs if they’re isolated. But if they’re with other um rats and they have cool stuff to do, then they’ll almost ignore the drugs completely. Uh. We did our own um you know research of looking at um the loss of things like the local movie theater, the bowling alley, arcades, actually. Right. So you think about the transition from going to the arcade. Usually something you did with somebody. Maybe you saw your friends to being at home, um you know, playing on your own box. Right. Though what’s lost is that social connection. And again, it seems um almost silly to start out with, but I’ve just been incredibly um convinced. And then just the final point is that drugs uh there’s a lot of evidence that sort of the experience of drugs almost mimics what social interaction does for us. So it really it becomes a substitute for the type of social connection that we’re really um craving. Um. But once you’re into them, it causes you to get further and further isolated. So it becomes this uh truly vicious cycle. 

Dr. Abdul El-Sayed: Hmm. So you’re laying out this space where these communities, because of the consequences of backbreaking extractive labor, become a target for pain medication. And once you end up with uh addiction taking hold, they start to decimate a lot of the social networks in those spaces. And then once people get socially isolated, like you said, there’s nothing to do but drugs. And uh and so it becomes a self-fulfilling um– 

Professor Luke Schaefer: –prophecy. 

Dr. Abdul El-Sayed: –doom loop almost uh between uh the collapse of social networks and um and addiction. And you know, that tracks in terms of thinking about the individual predictors of um of of of drug use. And uh and, you know, a lot of even the protective factors against um uh– 

Professor Luke Schaefer: Yeah. 

Dr. Abdul El-Sayed: –addiction, even after someone uh is already uh suffering substance use. I want to step back because one of the one of the important um addicts from the book and your study is about the kind of intervention that we we need. And there’s there’s been a real push for unconditional cash transfer. You hear it in the– 

Professor Luke Schaefer: Yup. 

Professor Luke Schaefer: –universal basic income argument that the best way to address poverty is to give people money. And that’s a pretty compelling argument. But one of the things that you’re pointing to here is that there is a there is the effect of place above and beyond individual uh income and that it’s not just enough to give an individual or a family money, but that you actually have to think about the system’s impact in a particular locale. So what are the solutions here? Uh. How do we go about trying to address the poverty of places and not just individuals and families? 

Professor Luke Schaefer: As you as you know, I um I’m a proponent of cash transfers, especially for um child benefits. I think the evidence on um tackling child poverty with cash transfers is incredibly um uh compelling. We’ve seen it happen over and over again across countries. We saw it happen here with the expanded child tax credit. And and one of the things it does is it does sort of wipe away um sort of differences in state or county or municipal administration. Um. [cough] If you’re getting a money directly to people, you uh, it becomes more equal across space. Um. But as you say, uh that is not going to wipe away the differences across space. Right. It’s a way to make sure that with cash transfers we’re getting everybody the same amount. But it doesn’t it doesn’t directly tackle sort of the compounded disadvantage of a lot of the places that we talk about in our book um relative to um other places. So uh this is a book you know, my last book was really about cash matters uh for for families and kids. And it was a part of driving the expanded child tax credit. Um. This book is there’s not a one solution, I think, that we offer, but we hope by delving into a lot of the mechanisms um that uh we offer readers and policymakers a lot of different ways that we think may be more effective to tackle the problems we have. So it takes social infrastructure. Um. We would argue that uh to really fight the opioid epidemic, you know we clearly need to have more um treatment beds. 

Dr. Abdul El-Sayed: Arcades. 

Professor Luke Schaefer: Right? But we need arcades! Yeah, we need arcades. 

Dr. Abdul El-Sayed: Yeah. 

Professor Luke Schaefer: We need uh public libraries. We need uh local movie theaters. We need things that can bind people together in fun sort of cheap ways. And the and the government invests very little on these, right? And you know, maybe they would say we need hospitals more than arcades, but we need arcades um or whatever it is that the community you know communities want. Um. I think we need to do more to um ferret out uh government corruption at the local level. I think we need to uh sort of just be more cognizant that that um that corruption is more common than I think we like to think in this country, and um I happen to think that uh and maybe, you know, this is a point that uh I’d be interested in your take on. But I think we need to do a lot more to actually train people who want to uh do right in their communities and try to lead train them not just to get elected, but how do you actually run a community? Right. How do you run a town of 8 to 10000? Uh. Because we have these uh just interesting case studies where uh people uh might try to they want to overthrow, you know, the people who’ve been running the town uh who um are not doing right by it. Um. Most cases are corrupt. Uh. But when they get into office, they don’t they don’t know what to do at best. And in fact, the only models that they ever have, maybe were the corrupt ones. And so they may sort of fall into that, those kinds of traps. And and so I think we need to do more. Um, you know, there’s this uh the Agricultural Extension service is incredibly popular among farmers because it concretely helps them figure out how to do the work of farming, you know, much more popular than universities or university agricultural extensions. Uh. Maybe we need to do more to to really help um train uh municipal and county leaders all across the the country. Um. And then uh we actually uh came out uh with uh one policy recommendation which we didn’t expect, which was around free trade. So in a lot of these communities, uh you know, the sixties and the seventies were brutal to them as the sort of automation, um really uh [coudh] sort of stopped the way farming was done and and the coal industry went into decline um some of them, the nineties and 2000s were pretty terrible too, as uh globalization meant that, you know, any factories or any sort of um industrial uh enterprise uh shifted overseas. And and we actually came to appreciate that that transformation you know where um we were sort of, I think have had done it under the idea that like free trade is better for everyone in the long term and we can compensate the losers. Um. Well, I don’t think we’ve adequately compensated the losers. And a lot of them, you know, are right here in Michigan, but a lot of them are across the south. And and some of the most recent research suggests that has had profound political implications where a lot of the communities in the South that were most at risk of NAFTA and um free trade expansion into China in the 2000s, they’re uh the ones that have shifted the most from being strong Democrat to strong Republican. And that’s that’s really shifted our politics in a very serious way. 

Dr. Abdul El-Sayed: Yeah, I really appreciate um a couple of the points that you made. Uh. The social infrastructure point. Absolutely. Um. Any space that can create a moment for people to come together and appreciate that the single most important and uh joyful thing that people have on this world is other people. Um. I think is is uh is critical. But on the governance point, I think there are two pieces here that that interact in a in a really profound way. You kind of think about any economy as a garden, and any time you just grow a single crop, you’re going to corrupt your soil. And one of the challenges that you’ve identified is that you end up having a situation where each of these communities was a place where you had one single mega sector that dominated the entire economy, which left the rest of the economy really brittle. And I think one of the challenges that we have right now is that it’s so easy for an administration to try and score another hit off of this sort of, you know, 100, 150, 400, 500 hundred jobs scenario, rather than doing the work of actually growing a well-rounded, diversified economy. And the hard part is that because our economy is so corporatized, it’s kind of easy to do this. And so you end up, in effect, trading the entire farm. You’ll see uh uh, you know, a local mayor offer these absurd subsidies to some very, very large corporation to come bring 400 jobs. They never deliver those jobs. They get the subsidies anyway. And then you just destroyed your tax base that you would have used to actually invest in 100, 500 small businesses that actually provide diversified jobs so that if one of them goes down, you don’t lose your entire income base. Um. The other part of that, though, that’s really important is when you have one mega sector, what tends to happen is that sector tends to wrap its tentacles around the politicians in the area. And one of the things that’s even more important is that small towns don’t tend to be run by their mayor and commission. They tend to be run by city administrators who their mayor and commission will appoint. But what happens is, if you have a long standing administrator, that person, just like any other politician, can instantiate themselves in power. And they tend to do that right by getting buddy buddy with whoever the most powerful source of money actually is, which tends to be that dominant sector. And so you tend to see these things sort of go hand in glove and then you get a new mayor in place. But they don’t really know how to actually cut through right the thicket of relationships that have preexisted them. So they end up being there and then they can’t really make a change. One thing that I’d love to see right would be sort of a public policy extension school. You could imagine a University of Michigan Ford school, for example, doing um, you know, a a program for mayors and commissioners, but not just mayors and commissioners or uh city council people, but the people who, you know, are appointed and are leading, you know, departments in these local communities, whether it’s the Department of Public Works or uh the the city administrator. Um. And I think part of it is uh an appreciation for some of the change in the way that governance ought to be cutting through, not just we elect our public officials who show up and cut ribbons and go to the parade, but also the folks who actually run the machinery of government in these small towns. Um. And I think all of those things tend to tend to sort of fit together. The last point, though, that, you know, really comes to mind in what you shared to me is the way uh in which um, you know, obviously this is a health care podcast, but is the way in which um health care tends to be the last and final major industry that operates in a place. And one of the biggest challenges that we have as a national government is because we rely on Medicaid, which reimburses poorly to substantiate these rural hospitals. So many of them end up closing down. And what happens is you go without the health care that the people in the community need. But also when that happens, the biggest employer in the community goes down, too. And um we tend not to appreciate how our federal policy and Medicaid reimbursement, which is, you know, at that point, state policy, can kill these local economies in ways that um uh that really are profoundly devastating. And uh and, you know, the other part of that is when you have a rural health care center, it tends to bring with it um a little bit less brain drain, which means that you end up having doctors who have to move in. One of the fascinating things if you go to any small town, the only some of the only diversity in those towns uh tends to come from the doctors who work in the hospital. 

Professor Luke Schaefer: Yup. 

Dr. Abdul El-Sayed: Um. And uh and so they’ll they’ll come they’ll work in those hospitals because they get loan forgiveness programs. Um. And then, you know, it’s like ends up being the, you know, the only Brown or Black family who’s who’s, you know, in an all white town or, you know um uh, you know, many of these rural um southern towns in particular, and you touch on this in the book are we think about rural poverty as being a white phenomenon. 

Professor Luke Schaefer: Right. 

Dr. Abdul El-Sayed: But actually in so much of the South, it’s actually a Black phenomenon and we miss out on that. Um. I want to just you know, I of course, this is um this is the question I would ask. But one of the counties that shows up as as um one of the poorest counties in America is the county in which I’m the health director, Wayne County. Um. And much of that is, of course, is driven by the city of Detroit. But um, you know, it’s not lost on me that we have towns in our county that are not Detroit that are actually poorer than Detroit. You think about Highland Park, for example. Um. What would be the advice that you give to me? Because one of the metrics, two of the metrics that you use to even calculate your index are low birth weight uh and um the proportion of babies born, low birth weight and life expectancy. As a health director, um thinking about the injustice of place, which is the title of your book, what can I do to address the injustice of place? And what can our listeners do who work in this field or thinking about this field? What should they be thinking about as they think about doing their work and trying to tackle and disrupt this injustice of place? 

Professor Luke Schaefer: Yeah. I think as you were talking about um the diversification of the of the um economy and industry and the importance of not being tied to one industry, uh you really could have been talking about uh Wayne County, right, uh that it all applies. And in fact, Detroit, um as you say, went, Wayne County’s uh [?] and Detroit and Flint are among the most disadvantaged cities in the entire country. So they’re they’re they’re in that most disadvantaged hundred counties and cities in the entire uh nation. And, you know, my hope is that the book, which focuses a lot more on uh rural areas, as we’ve talked about and our both, you know, predominantly white, predominantly Black and predominantly uh Mexican-American uh in South Texas. Uh. My hope is that it offers an approach that people can bring to their own uh communities to see where some of the mechanisms really are um the same and uh the mechanisms are different. So I think that the social infrastructure um argument, uh my guess is that it will hold um both in Detroit as well as uh Highland Park and any of the other uh communities in Wayne County that we’re talking about. Clearly the diversification of the um of the economy is a critical piece, right? We can see that Michigan um has not fared well over the last couple of recessions, you know, all pre-COVID, uh because, you know, we had too many of our eggs in one basket. And so some of our peer states that were a bit more diversified were able to weather those better. And so there’s a big picture there. Um. One thing we haven’t touched on that I think is a really big piece of the puzzle is violence. So uh we were actually um a little bit taken aback to find that some of the rural communities that we were in uh were among the most violent in the nation. So the county that we’re in in um in Kentucky and in Mississippi is a rival um sort of the level of violence that we see in Cook County where Chicago is um is based. So I know uh that’s a challenge uh in Detroit, too. And there are big structural issues at play. I don’t think any of us know uh how to deal with uh violence yet. I do think um, you know, we make a case that um we have to fight violence with opportunity as well as other evidence based strategies. Um. And also um we have a lot of guns around. And so you can see that places that uh where there’s greater access to guns, there’s there’s more violence. Um. So, uh you know, I think um how uh how confident uh city and municipal government is is clearly important. Uh. So when places uh have functioning uh municipal or county governments, uh they tend to do better. So I think we can we can see that focus, too, um in other places, besides the places where we’re where we’re at. And then there’s one more theme that I think is really uh useful in Wayne County. So we have a chapter called Revolt and Retribution, and uh in pretty much every town at some point, sort of the laboring class that has been exploited they rise up uh and they protest and it takes different forms in in the different places um and a lot of those cases, there are examples where they were successful. Um. But uh there’s always sort of the longer term retribution that uh even if a revolt is successful in the short term um the folks who are in power um sort of come back at some point and uh and and make uh make the community pay for it uh so uh you know the that might take the form of violence in some places it takes a form of of people just moving out and then um in in in south Texas in Crystal City one of the sites we’re in um there was sort of an electoral revolt after actually a really amazing school walkout where high school and middle school kids, like 1700 kids, walked out of the schools demanding sort of more Mexican-American history in the schools and more um bilingual uh teachers and career counselors that would actually tell Mexican-American students about, you know, more than just the handful of occupations that um, you know, the Anglos thought uh that they should do. So um that uh revolt by children actually spurred an electoral revolt that just completely shifted the power dynamics in the in the community and the um the response of Anglos actually was to move out of the community. They just moved out in mass. So the community went from maybe 80% Mexican-American to like 95%. And then you can see these very clear examples where every other level of government was trying to um do what it could to make sure the community failed. So um the governor of Texas calls Crystal City Little Cuba and refuses to let any sort of um federal dollars flow into the community. Hmm. And the county does what it can to sort of cut off resources to the community. And as the result, that community struggled and you know the people who uh went on to run the community, they uh also made mistakes, uh but they didn’t have any roadmap and uh they had sort of every other level of government uh across the region sort of wanting to see them fail almost as a way to show uh that, you know, they got what they asked for. Right. And I think that there are some parallels there to um Detroit and Wayne County as well. Right. Where we’ve been very divided and um over decades, um the region, you know, some forces in the region uh uh were sort of happy to try to disconnect the city and to do what it could to to watch it fail. . 

Dr. Abdul El-Sayed: Hmm. The story you shared about Crystal City echoes very much the history of um state government takeover uh in the city of Detroit and so many other majority-Black cities in the state. Uh. Luke, we really appreciate you joining us to share your insights uh from what is an excellent book called The Injustice of Place, written with coauthors. Uh. Our guest today was Luke Schaefer. He is the current professor of social justice and social policy at the Gerald R. Ford School of Public Policy at the University of Michigan. Uh. And um and we really, really appreciate you joining us today. Thank you so much. 

Professor Luke Schaefer: It was my pleasure. 

Dr. Abdul El-Sayed, narrating: As usual. Here’s what I’m watching right now. 

[clip of unspecifed news reporter] Henrietta Lacks is one of the most important figures in modern medicine you may have never heard of. Before she died of cancer back in 1951, doctors took her cells without her consent, and then they were used in countless medical breakthroughs. But her family was never compensated until now. 

Dr. Abdul El-Sayed: Let me take you back through history and remind you who Henrietta Lacks was. In 1951, the then 31 year old mother of five sought care at the Johns Hopkins Hospital in Baltimore for vaginal bleeding. Her diagnostic workup found a very aggressive cervical cancer, so aggressive, in fact, that scientists who took samples of her cancer without her knowledge or consent found that when they cultured the cells, they would double just about every 24 hours. Tragically, Henrietta Lacks died of cervical cancer later that year, but her legacy lives on in those cells. Today, more than seven decades later, her cell line is known as HeLa for Henrietta Lacks, and her cells are still cultured for research on everything from the polio vaccine to COVID dynamics to cancer genetics. They are definitively both the best studied and most important cell line in world history. But none of that changes the glaring fact that this woman, poor and Black, had her cells taken for research without her knowledge or consent. And her state has been trying to hold the folks, basically the entire biomedical industry who’ve benefited from her cells accountable. And just this week, they finally came to a breakthrough. They settled with biomedical giant Thermo Fisher Scientific, though the terms of the settlement remain confidential, the family has expressed a sense of relief and justice. Tuesday, the day of the announcement, would have been her 103rd birthday. Next year’s Prime Day deal may just include a discount on a doctor’s visit? That’s right. Amazon has fully expanded its virtual clinic service to all 50 states, building on its supremacy in, well, everything. I’ll be honest with you, I have really mixed feelings about this one. Look, before you call me a Bezos buddy, let me explain. I do not like Amazon at all. I worry a lot about the way their business model is both vertical and horizontal. They both eat whole new industries and eat more and more of the supply chain of the industries they’re already in. And that’s not even talking about the way they basically own the infrastructure of the modern Internet as we know it through Amazon Web Services. It’s that ability to consolidate whole industries toward monopoly that scares me. And at the same time, that’s exactly what’s wrong with health care right now. You’ve got major hospital chains eating up other hospitals and clinics growing unperturbed. What’s worse is that when they buy a hospital, they feel they can’t make profitable, they just shut it down. And guess who that hits hardest? Poor folks, usually rural or Black, as we talked about with Luke today. Amazon is challenging a lot of those hospital chains. And while I hate the fact that that’s Amazon who’s doing it, they’re providing a virtual option to folks who have no option at all. And at the same time, I don’t trust that they’re doing this for any reason but their bottom line. And I believe they follow the exact same incentives their brick and mortar competitors have. You know what would really help? Providing great health insurance to everyone, you know, like um hmm Medicare for All? And finally, back to a story we’ve been covering here for a while. Ozempic and other GLP one agonists, drugs that act like hormones that tell your body that you’re full and are effective to an astonishing effect are hitting a number of challenges. Novo Nordisk and Eli Lilly, manufacturers of Ozempic and Mounjaro, are facing a lawsuit over claims that the drug is causing stomach paralysis in some patients. A disturbing side effect where the stomach basically stops stomaching, but that’s not the only pressure they’re facing. Patients are literally knocking down the doors to get access to the drug, and the insurance companies are balking at the price tag, which is upwards of $900 a month. Insurers around the country are cracking down on off label or unindicated uses while rethinking coverage for this class of medications altogether. But remember, this is in a time when upwards of 42% of adults in this country would be eligible for these medications that well, it sets up a showdown over costs. The insurers real play here is trying to get the manufacturers to drop their prices to make these meds more affordable on their bottom lines. Meanwhile, new GLP one agonists are hitting the market and more data is coming out showing that the benefits may surpass simple weight loss. One trial found significant cardiovascular benefits for Wegovy the formulation of Ozempic meant for weight loss. Unlike Ozempic, which is meant for diabetes. We’ll keep watching this space. That’s it for today. On your way out. Don’t forget to rate and review. It really does go a long way. Like please. Rate and review now. Thank you. Also, if you love the show and want to rep us, I hope you’ll drop by the Crooked store for some America Dissected merch. [music break] America Dissected is a product of Crooked Media. Our producer is Austin Fisher, our associate producers are Tara Terpstra and Emma Illick-Frank. Vasilis Fotopoulos mixes and masters the show. Production support from Ari Schwartz. Our theme song is by Taka Yasuzawa and Alex Sugiura. Our executive producers are Leo Duran, Sarah Geismer, Michael Martinez, and me. Dr. Abdul El-Sayed, your host. Also, a special shout out to Sarah Wick, who celebrated her last day with us last week. Thank you for all you’ve done for the show, Sarah. We’ll miss you. Thanks for listening. [music break] This show is for general information and entertainment purposes only. It’s not intended to provide specific health care or medical advice and should not be construed as providing health care or medical advice. Please consult your physician with any questions related to your own health. The views expressed in this podcast reflect those of the host and his guests and do not necessarily represent the view and opinion of Wayne County, Michigan, or its Department of Health, Human and Veterans Services.