Poverty, by America

Book Title: Poverty, by America

Author: Matthew Desmond

Publication Details: Crown, 2023, 284 pp., $28.00, hardcover

Family physicians have a tall order. Not only do they treat acute and chronic diseases in patients from in utero to death, but they also are tasked with understanding and addressing social determinants of health. Multiple articles urge family medicine physicians to be informed about the impact of poverty on health. ^{1, 2} Poverty increases the risk factors for disease and death; it limits opportunities for health and healing. Physicians are charged with addressing poverty and advocating for patients. ² Matthew Desmond’s book Poverty, by America is a guide for doing just that—what he calls becoming a “poverty abolitionist.”

Desmond is a professor of sociology at Princeton University and the author of Evicted: Poverty and Profit in the American City,³ which won many prizes including a Pulitzer. The author grew up in a family with significant financial challenges (eventually losing their home), was shocked by the discrepancy in wealth he saw while in college, and has been studying the puzzle of American inequality ever since. He comes at the problem with both passion and academic rigor.

After laying out the problem of poverty with stories, statistics, and public policies, Desmond delves into three main issues in the first half of the book: (1) workers having less power and less economic security over the past several decades, (2) the exploitation of the poor through the housing and financial banking markets, (3) and the disproportionate amount of public aid going to wealthy families ($35,363 per year to top 20% compared to $25,733 per year to bottom 20% [p. 99]).

The second half of the book is a call to abolish poverty. Addressing poverty means decreasing exploitation of the poor. It means increasing choices and opportunities. Desmond shows how poverty could be eradicated if society had a will to do so. He reviews policies that have successfully addressed inequality and those that have increased it. He acknowledges that rebalancing society will require some to take less; and he is steadfast in examples of how the government chooses to subsidize affluence over alleviating poverty. He points to tax loopholes as an obvious way to help close the gap, but also shows how many of us benefit from keeping others poor. Empowering the poor involves giving them choices of where they live, work, and bank, and when to start a family. Neighborhood options are particularly powerful in mitigating the effects of poverty. Living in high opportunity neighborhoods versus concentrated areas of poverty is a game changer. He calls for replacing exclusionary zoning policies with ones that require all neighborhoods to have affordable housing, an idea first proposed by Republican Senator George Romney in 1970 (p. 168).

Desmond wants to “make equality of opportunity a reality” (p. 179). This requires prioritizing public aid for the poor, reducing exploitation, and tearing down the walls of class and ethnic segregation. Although challenging, he believes this is achievable. He backs up his claims with 76 pages of notes and references.

This book can be difficult to read at times, in part due to how clearly the information is communicated. The stories of people impacted by poverty are heartbreaking. Our complicity in maintaining poverty is disturbing. Programs that have succeeded or failed provide compelling lessons. The overall lack of progress by one of the wealthiest countries in the world is inherently frustrating and is the reason for the book.

Yet, not learning more about how poverty is sustained, not considering the impact of private enterprise and public policy on our patients seems neglectful. The strength of this book is putting poverty at the forefront of a social agenda and directing change at root causes. The book offers ideas about how citizens can help push antipoverty policies. These go far beyond the traditional role of the physician and may bring up negative thoughts and feelings in those who went to medical school in order to practice medicine.

The helplessness physicians feel when providing medical care to the poor has been recognized. ^4- 6 Poverty, by America does not address health care specifically, and physicians may prefer to read more targeted investigations and recommendations related to health care. ^{4, 2, 6, 7} However, if inroads are to be made regarding poverty, there is no escaping the need for advocacy for change at the societal level. It is a tall order for physicians, but ameliorating poverty may have a more significant impact on health outcomes than health care. ⁴