Jogging to the Carrot and from the Stick: The Dual Motives that Fueled the Paradigm Shift of the Exercise Industry

Michael Murakami

One fall in middle school I played for a Japanese baseball team. Although I speak little Japanese, a friend of mine recruited me when a teammate moved back to Tokyo. Practices and games mostly mirrored my other teams, except for conditioning. We worked the same routine at every practice which far exceeded a warm-up jog and stretching. I struggle to recall many of the exercises (granted, most names were in Japanese) except for two. The first began when our head coach yelled “Spi-der-man” in three, slow, drawn-out syllables. We repeatedly propped ourselves up with arms and legs extended outward and bodies held inches above the ground until we collapsed. The other consisted of shutter runs in the gym under time pressure until you either collapsed or quit. As the least fit member of the team, I felt embarrassed during conditioning since I always quit first. Even more confusing, at the end of each practice, we lined up and bowed, yelling “Arigato gozaimashita!” (thank you very much) to our coaches for leading the workout. Although perhaps atypical for youth sports, this experience illustrates a modern characteristic of exercise: we physically punish ourselves in the name of fitness out of a desire to avoid negative outcomes alongside pursuing positive outcomes…and then give thanks for the suffering. The old carrot that motivated exercise, the desire for health and wellness, recently became accompanied by a larger fear of the stick: stigmas and public shame.

The Carrot and the Stick1

Posited Virtues of Exercise

Exercise as an intentional activity (rather than indirectly resulting from manual labor) initially gained popularity for its positive physical and mental outcomes. Before analyzing the recent shift in mindset surrounding exercise, it is essential to acknowledge the benefits of and reinforce the need for a moderately strenuous exercise routine. First, exercise yields numerous positive physical outcomes. In his paper, Health Benefits of Exercise, Greg Ruegsegger explains how exercise is strongly correlated to an extended lifespan and the delayed onset of dozens of conditions and diseases, which improves peoples’ quality of life.2 Further, exercise benefits mental health. Kathleen Mikkelsen explains in Exercise and Mental Health how activity alters peoples’ moods positively and improves symptoms of anxiety, stress, and depression.3 Moreover, in the long term, exercise, especially endurance training, improves the overall mental health of those who partake.

On the one hand, this makes sense since better physical shape can make parts of life easier. Moving and performing enjoyable activities may reasonably increase one’s happiness. On the other hand, rather than being hedonically motivated, exercise may improve one’s quality of life and mental health by escaping from the negative societal implications of being viewed as “unhealthy.”

Modern culture rewards good health and, to people who fall into the “healthy” category, the positive attributes of exercise appear to be an achievable outcome. While this belief may seem reasonable and even beneficial in an isolated state (one may believe that these positive affirmations of exercise would encourage the healthy behavior of exercise), the implicit negative sentiments created about those determined to be in “poor” health are undeniably damaging. The following three sections will illustrate different sides of the same coin: negative stigmas surrounding poor health and positive reinforcement of dangerous “healthy” mindsets and activities.

Stigmas of a Lack of Exercise and Poor Health

In chapter 10 of Illness Narratives, Arthur Kleinman describes how we derive the term “stigma” from Greek, referring to “marks that publicly disgraced the person.”4 Especially in ancient societies, many stigmas plagued societies’ social structure. Societies commonly developed stigmas about race, gender, wealth/social class, and a plethora of other visible characteristics. In modern society, as we attempt to reconcile historical inequalities equitably, new stigmas have arisen in the name of a seemingly “beneficial” characteristic: health. The primary issue is that stigmas surrounding health create a false sense of causation between the size/shape of the body (a physical attribute) and the overall health of a person (a generally non-physical characteristic). The result is that stigmas against those viewed as “unhealthy” only target people who appear to be overweight, which dangerously fails to capture reality.

To disprove that physical appearance and health are necessarily causally related, I will provide two examples. First, some people eat diets that are objectively unhealthy (per standard medical dietary standards) and/or perform health-damaging activities like smoking or vaping and appear healthy since their bodies have quicker metabolisms or the effects of their actions are long-term, not yet harming the individual. Since stigmas attack physical characteristics, they would not be stigmatized as “unhealthy” since (often) the consequences of their actions are not realized in the short-term. 

The second example is the overuse of socially acceptable substances. The majority of US adults consume caffeine daily,5 and a large number drink or otherwise consume unhealthy amounts (greater than the recommended maximum of 400 mg per day). In fact, popular energy drinks like BANG and Reign contain nearly this much caffeine in each can. However, given that caffeine is a socially acceptable, productivity-boosting drug and it is difficult to measure another’s consumption throughout the day, certain substance abuse remains generally unstigmatized.

Since the results of these activities are not generally visible and/or are socially accepted, the seemingly only prevailing stigma attacks people labeled as “unhealthy” due to appearing overweight. Even worse, stigmas are not limited to adults. One notable campaign attacked children for their obesity in the early 2010s. Strong4Life created advertisements like the one below which demonizes fat children and asserts the need for lifestyle changes. It is truly unimaginable that any marketing department would consider this a promising advertisement, which could only happen after they approve it as acceptable. Neither feels right.

Strong4Life’s Advertisement6

Medicalization of Exercise

Once understanding this stance taken on people viewed as “unhealthy,” it is next important to understand how society changed as a result. In Medicine as an Institution of Social Control, Irving Zola describes how medicine and “health” became an institution of social control. This shift results from medicalization, or the integration of medicine and medical research into everyday activities that otherwise would be separated.7 Play for children and exercise for adults recently became medicalized, from programs like Play 608 to the daily tracking of activities towards goals like counting steps, measuring the distance walked, and tracking heart rate on devices like Apple Watches. Many industries took this a step further, with employers pressuring employees to exercise by rewarding tracked activity monetarily (my firm, PwC, utilizes a program named VirginPulse9) and insurers creating programs called “interactive life policies”10 which personalize rates and create discounts based on continually tracked health metrics.

While some people enjoy optimizing their exercise and routines, this data collection represents a dangerous external motivation that destroys the equilibrium activity level for others. External motivation can result from third parties who directly benefit from someone becoming more “healthy,” such as an employer or insurer, or more innocently from friends. Apps such as Apple Fitness+, Strava, and Garmin Connect, all three of which I personally use, motivate activity through comparisons to friends and direct competition against others for more calories burned, miles run, etc. Since the data is public, even those considered “healthy” by society face new stigmas if they fail to hit their move goals on any given day. Such layered stigma and motivation perpetuate and exponentiate the toxic nature of the fitness industry by creating a desire for perfection in action and perfection in results.

Apple Fitness Competitions11

Rotten Carrots: The Faux Acclaim of Physical Perfection

When someone pursues the health benefits of exercise to an extreme, the positive physical and mental health outcomes quickly disappear. A factor creating the culture of excess in exercise is blatant in fitness-related social media, specifically in the language influencers use. The industry is infested with lies and unreasonable extremism which pollute the mindset of a balanced person. First, social media highlights influencers who mislead audiences about their lifestyle, the use of performance-enhancing drugs (PEDs) to exponentiate their outcomes, and more. The average person is constantly exposed to unattainable physiques which may swing them in one of two directions: either their relative lack of progress compared to a PED user discourages them from continuing a fitness lifestyle or it creates a mindset to overtrain in pursuit of unrealistic outcomes.

The first outcome is damaging simply because it discourages the pursuit of a healthy and balanced lifestyle. Any of the aforementioned positive outcomes of fitness disappear and the person’s overall quality of life generally decreases. This is clearly undesirable.

The second outcome is potentially more dangerous. Although some of the physical benefits of exercise relative to a sedimentary life may still be realized at the highest level, many mental health benefits are quickly wiped away. This unfortunate outcome happens for a few reasons. First, as training becomes a larger part of someone’s day, other aspects of life must be minimized. The marginal benefit of additional exercise is mitigated by losing time for sleep, relationships, and other activities, all of which damage a person’s mental health. Further, the language found in the extremes of the fitness industry creates punishing mentalities that take mental and physical tolls on people. A clear example comes from David Goggins, former Navy SEAL turned fitness influencer who in his social media clips and books routinely encourages this mentality of excess and extremism with quotes like:

“We’re either getting better or we’re getting worse,”
“Don’t stop when you’re tired. Stop when you’re done.”12

David Goggins, Can’t Hurt Me

The Exercise Paradigm Shift: From Play to Work

Goggins and similar fitness influencers exemplify the overall paradigm shift found in exercise that Gabriel Winant describes succinctly; “Once associated with play, exercise is now closer to a form of labor: measured, timed, and financially incentivized by employers and insurers.”13 Here we find a dramatic shift. In our society fueled by a desire for progress and productivity, a growing proportion of our lives transform into new forms of labor. And much like other so-called jobs, forms of workaholism and gross excess appear. This flawed view of exercise that resulted from this shift quickly damaged society. 

In the end, balance is important. There is no question that there are various benefits to physical activity that ought to be neither overlooked nor ignored, but taken to an extreme, the fruits of our labor quickly become rotten carrots that we endlessly continue to pursue. Although difficult in a productivity-focused world, it is imperative that our culture accept and normalize a moderate, healthy amount of exercise without slipping into unnecessary extremes or abandoning fitness altogether. In my opinion, this is most important for children. Rather than the rigid minds of adults who may already habitually follow an extreme, children should be shielded from exposure to an unhealthy form of labor. Such a shift would allow future children to not fear Sunday morning baseball practice as I did, but to look forward to time with friends playing a game they love. At a minimum, society ought to let kids be kids again by encouraging them to play in any condition, rain or shine, rather than mandate exercise and conditioning.

My teammate, Ray, and I after a game.

Works Cited

  1. Taylor, Justin, “Donkeys, Carrots, Sticks—and the Gospel.” The Gospel Coalition, 5 Dec. 2011, 
  2.  Ruegsegger, Gregory N., and Frank W. Booth. “Health benefits of exercise.” Cold Spring Harbor perspectives in medicine 8.7 (2018): a029694.
  3.  Mikkelsen, Kathleen, et al. “Exercise and mental health.” Maturitas 106 (2017): 48-56.
  4.  Kleinman, Arthur. Illness Narratives: Suffering, Healing, and the Human Condition. BASIC Books, 2020. 
  5. “National Coffee Association.” NCA, 
  6. Lohr, Kathy. “Controversy Swirls around Harsh Anti-Obesity Ads.” KERA News, 24 Aug. 2020, 
  7. Zola, Irving Kenneth. “Medicine as an Institution of Social Control.” Ekistics, vol. 41, no. 245, 1976, pp. 210–14. JSTOR, Accessed 20 Mar. 2023.
  8. “Official Site of the National Football League.”, 
  9. “Changing Lives for Good.” Virgin Pulse, 2 Dec. 2022, 
  10. Barlyn, Suzanne. “Strap on the Fitbit: John Hancock to Sell Only Interactive Life Insurance.” Reuters, Thomson Reuters, 19 Sept. 2018, 
  11. “How to Start an Activity Competition with a Friend in Watchos 5.” MacRumors, 
  12. Goggins, David. Can’t Hurt Me: Master Your Mind and Defy the Odds. Lioncrest Publishing, 2020. 
  13. Winant, Gabriel. “A Radical Critique of Wellness Culture.” The New Republic, 23 Mar. 2023,

Medicalization in Female Reproductive Care

Female reproductive care is both familiar and extremely foreign to many women. Talking about menstruation and other biologically female processes that concern the female reproductive system is often considered taboo. While this stigma may seem harmless, it can greatly restrict patient comfort and autonomy by allowing increased medicalization of the female body when women seek treatment for reproductive issues. In many instances, medicalization causes dismissal of female pain and exclusion of the woman from her own treatment plan. Under-medicalization refuses recognition of her pain and thus denies medical remedies, placing the blame on the woman. However, over-medicalization can also reject a woman’s autonomy over her own body, giving doctors jurisdiction because of the taboo subject area (Zola, 2012). Medical control over a woman’s reproductive organs normalizes the dismissal of female-reported pain and a lack of patient-doctor communication due to the taboo nature of the subject.

Image from Pexels.

A Personal Story

(Note: I changed the name of the woman here because the story is personal and I wanted to preserve her privacy.)

Last year, Stacy experienced the impacts of medicalization when she sought care here in South Bend. At midnight, Stacy went to the ER experiencing extreme pain in her lower abdomen. The ER was empty, and she was the only person in the waiting room. Her pain was so extreme that she could not walk. However, Stacy waited over an hour before a healthcare professional was able to see her. Once she was able to be seen by the doctor on call, she was shamed for her potential promiscuity.

“Doctors asked me over and over again if I was pregnant. When I said no, they would ask, ‘Are you sure?'”

Stacy on her experiences seeking treatment for lower abdominal pain at Beacon Memorial Hospital in South Bend

She rated her pain an 8 on a scale of 1 to 10 and yet doctors continually dismissed her pain. As a college-age woman of color, her self-reported pain was not deemed significant enough to warrant urgency. She was left alone in her hospital room for six hours, and doctors ran no tests besides bloodwork, despite her intense physical pain. When they ran urine tests, Stacy asked for water and was denied with no explanation. She eventually was given two ultrasounds and sent back to the room to wait.

At roughly 6:30 AM, several doctors and healthcare professionals came rushing into the hospital room to give her an IV with morphine. They told Stacy that her pain was coming from ovarian torsion and that she might lose an ovary. They said that she may need surgery, and that the doctor would be in at around 4 PM to perform it. When the doctor finally arrived, she told Stacy that surgery was not needed, and doctors discharged her.  The medical situation was never explained to Stacy, who went back to campus; she was simply sent home with 8 oxycodone pills and a bill for $6400 in hospital fees, although she never received care.

Image from Pexels.

Reading Stacy’s story in conjunction with texts from this module of the course reveals three major themes for women as they experience healthcare: the dismissal of female pain, moral judgements surrounding healthcare, and the refusal of female agency. These themes represent an over-stepping of the medical field and provide concrete examples of medicalization in the real world.

Dismissal of Female Pain

When Stacy first arrived at the hospital, her pain was dismissed by doctors, possibly due to her age, race, or gender. This is not an uncommon experience for women, especially women of color like Stacy.

One in five women say they have felt that a health care provider has ignored or dismissed their symptoms.

Emily Paulsen, Duke University Healthcare

The refusal to accept and treat female pain can be viewed as an under-medicalization. One of the four ways that Zola reports medicalization occurring is “through the retention of absolute control over certain technical spheres” (Zola, 2012). Through this logic, isn’t the refusal to take control by treating pain an example of under-medicalization? When doctors deny that a woman’s pain exists, they are not only denying her treatment—they also characterize her as an unreliable narrator, stripping her of the psychological agency to report her own pain.

Moral Blame

Because doctors and medical professionals deny women the psychological credibility to be perceived as rational actors over their own bodies, women are often refused agency in their treatment plans. As seen in Stacy’s story, the doctors who treated her assumed that the pain she reported reflected some sort of mistake on her part. Had she practiced unprotected sex? Was she having sex? This moral judgement relates to the discussion in Zola where our society’s perception of illness inherently places blame on the patient (Zola, 2012).

Denial of Agency

Ranging from period taboo to difficulties with fertility, many women are shamed for talking about reproductive health. This relegates female reproductive health to the medical sphere, placing it solely within the doctors’ jurisdiction. When female bodies become the property of the physician rather than the woman herself, an inevitable loss of autonomy occurs. In Stacy’s story, her own pain was not explained to her. Doctors abandoned her to suffer in confusion rather than walk her through treatment options. Even when her diagnosis was finally made, it was not explained. There was never any option for an active involvement in her own treatment. As a young woman of color, Stacy was not given the option to communicate with the doctor as she devised Stacy’s treatment plan. Depersonalization transformed Stacy from an agent to a body in the eyes of the medical field. Dehumanization does not just work in the medical field—systematic racism impacts everything from housing to food access through policies like segregation and redlined (Bailey et al 2021). Women of color lose agency in the medical field because of power hierarchies that have been in place for hundreds of years and still function today.

Image from Pexels.

Cost of Care

In Stacy’s story, she was charged $6400 and ended up paying approximately $1800 out of pocket, although she ultimately received no treatment but pain medicine (which was not regulated). In fact, she was denied water when she asked for it. How can doctors justify that charge? Profit-driven hospitals use medicalization to decrease quality of care and increase margins of profit (Rosenthal 2013). Stacy experienced how medicalization can create high charges and worse care firsthand.


Bailey, Z. D., Feldman, J. M., & Bassett, M. T. (2021). How structural racism works — racist policies as a root cause of U.S. racial health inequities. New England Journal of Medicine, 384(8), 768–773.

Paulsen, E., & Paulsen, E. (n.d.). Recognizing, addressing unintended gender bias in patient care. Duke Health Referring Physicians. Retrieved February 24, 2023, from

Rosenthal, E. (2014, April 18). Paying till it hurts. The New York Times. Retrieved February 24, 2023, from

Zola, I. K. (1972). Medicine as an institution of Social Control. The Sociological Review, 20(4), 487–504.

Medicalization of Women’s Health


Obstetric medicine has always been fascinating to me. However, while trends and data can be noted by anyone, the processes discussed can only truly be experienced by women. As such, it can be complicated and sometimes disingenuous to speak about, as a man. Because of this, I will largely rely on articles and experiences shared by loved ones (each of whom consented to share their story).

Medicalization of Childbirth

Reproduction and childbirth are aspects so ingrained in the human experience. Many of us have already faced questions such as; do you want children? how many children do you want? etc. For an aspect of human life that seems so joyful and exciting, it can also be one of the scariest. This is especially true when it comes to women encountering childbirth. A 2018 study, researching the prevalence of tokophobia (the fear of childbirth) among pregnant women, found that 75% of respondents were classified in the low to moderate range while up to 25% of respondents were classified in the high to very high range of tokophobia [1]. As obstetric medicine has advanced, the context and setting of childbirth have continually evolved. What was once set in homes or birthing centers has moved to hospitals and operating rooms. The rise in the medicalization of childbirth arose concurrently with this change. The California Health Care Foundation cite the following statistics; 68% of women with vaginal births were given an epidural, 31% of women had a c-section, 85% of women with previous c-sections had a repeat c-section, and 14% of women had labor induced for non-evidence based reasons [2]. These numbers show the prevalence of medical intervention in the process of childbirth. 

“Fear of childbirth, also known as tokophobia or maieusiophobia, has been defined as a psychological disorder which ranges from insignificant to extreme fear of childbirth”

Demšar et al. [1]

According to a 2002 article in the British Medical Journal, the medicalization of childbirth has grown into interventions that are often unnecessary or not evidence-based [3]. This increased medicalization of childbirth paired with the predominance of hospital births likely affects the aforementioned high levels of tokophobia. While it may seem natural to fear a major event such as childbirth, it must be noted that increased fear of childbirth may correlate to increased levels of c-sections [4]. Furthermore, maternal anxiety can increase the likelihood of delivery complications (such as placental abruption) and congenital anomalies as seen with prenatal stress disorder.

While it may seem that these interventions are a negative and a medical overreach, it is necessary to understand the importance that these interventions can have. The example I often turn to when explaining my interest in obstetric care is the story of my birth. Just before my birth, my older brother found my mother (pregnant with me) semi-conscious laying on her bed, her sheets soaked in blood. She was rushed to the hospital where she underwent a premature emergency c-section. Throughout the night we were both in critical condition. Thankfully we both survived, and she was later told that she suffered from a uterine hemorrhage. Without the remarkable advancements in obstetric medical techniques and equipment, it is likely that neither of us would have survived. 

In the same way that a series of statistics cannot completely explain the state of medicalized childbirth, neither can one success story. This is a complicated issue that is not black or white. It is important to recognize and utilize the tools that have allowed us to decrease infant and maternal mortality. However, it must be noted when these tools are used inappropriately. Whether it comes in the form of ignoring preconceived birthing plans or improper informed consent processes, the increased medicalization of childbirth has whittled away at women’s decision-making capacities. Medical interventions need to be balanced and contained to allow for the highest level of care and comfort in the process of childbirth. 

PCOS and Simplistic Medicine

Another over medicalized area of women’s health is menstruation. One area of this that has been particularly impactful to me is polycystic ovary syndrome (PCOS). This is a hormonal disorder in which the ovary accumulates cysts and becomes enlarged. Some symptoms include; irregular periods, excess body hair, weight gain and retention, and infertility [5]. According to the CDC, up to 5 million women experience PCOS [6]. 

“PCOS is one of the most common causes of female infertility, affecting 6% to 12% (as many as 5 million) of US women of reproductive age.”

Centers for Disease Control and Prevention [6]

The reason PCOS is important to me is because of how it has impacted my family. My sister was recently diagnosed with PCOS. However, her path to diagnosis was anything but direct. After experiencing constant menstruation for over a month, she went to her doctor. She described the meeting as short and dismissive. She was given two options; start an oral contraceptive or lose weight. Several months and multiple doctors later, she was being given the same answers. She believed she had PCOS and feared birth control would mask the irregular menstruation symptom, impeding any further diagnosis. Furthermore, the only other option was to lose weight; misconstruing a symptom for a cause. 

She eventually received the PCOS diagnosis, but this was not before several months of discomfort, embarrassment, and dismissal from her doctors. The Martin article discussed how the language around menstruation is often that of dysfunction or degradation [7]. However, in a typical menstruation cycle, those negative connotations can at least be partially ameliorated by connotations of regrowth, but not for my sister. She lived in that state, so often negatively connoted, for months without cessation. Her experience was one of lack of access, treatment, and dialogue, and of increased simplistic medicalization. Her two options were to accept blame for her state and “lose weight” or to accept the medicalized option of oral contraceptives.


While these are two snapshots of the medicalized state of women’s health, they are far from comprehensive. A more holistic view must examine the cause of these issues and where they overlap. Though a disorder like PCOS and medicalized childbirth may seem very different at the surface level, they share a lack of communication and a reduction in the voice of those affected. Just as pregnant mothers have fewer options so too do women suffering from disorders like PCOS have their choices minimalized; both favoring the simplest medicalized paths.


[1] Demšar, Karin, et al. “Tokophobia (Fear of Childbirth): Prevalence and Risk Factors.” Journal of Perinatal Medicine, vol. 46, no. 2, 2018, pp. 151–154.,

[2] “Infographic: The Overmedicalization of Childbirth.” California Health Care Foundation, California Health Care Foundation, 21 Aug. 2019,

[3] Johanson, R. “Has the Medicalisation of Childbirth Gone Too Far?” BMJ, vol. 324, no. 7342, 2002, pp. 892–895.,

[4] Ryding, Elsa Lena, et al. “Fear of Childbirth during Pregnancy May Increase the Risk of Emergency Cesarean Section.” Acta Obstetricia Et Gynecologica Scandinavica, vol. 77, no. 5, 1998, pp. 542–547.,

[5] “Polycystic Ovary Syndrome (PCOS).” Polycystic Ovary Syndrome (PCOS) | Johns Hopkins Medicine, Johns Hopkins Medicine, 28 Feb. 2022,

[6] “PCOS (Polycystic Ovary Syndrome) and Diabetes.” Centers for Disease Control and Prevention, Centers for Disease Control and Prevention, 30 Dec. 2022,,US%20women%20of%20reproductive%20age.

[7] Martin, Emily. “Medical Metaphors of Women’s Bodies: Menstruation and Menopause.” International Journal of Health Services, vol. 18, no. 2, 1988, pp. 237–254.,

Social Determinants of Health for Migrant Farm Workers

Migrant Workers picking strawberries Source: Unsplash1

The healthcare system in the United States boasts some of the most cutting-edge technology and research, but this high quality of care is not evenly distributed. For minorities, such as Latinos living in rural areas, their health is controlled by social, economic, and political determinants. We have studied these social determinants of health in class, and learned that determinants are:

“The conditions in the environments where people are born, live, learn, work, play, worship, and age that affect a wide range of health, functioning, and quality of life outcomes and risks.”

Healthy People 20302

While I agree that the facts and statistics about the number of people affected are important to know, I would like to share a couple of stories that show the people hidden between all those numbers. I was reminded of them after having read the Nature article by Amy Maxmen which discussed how farm worker disparities are due to their social determinants of health.3

Working at a berry farm for three years was a wonderful opportunity because I got to learn about agriculture and work alongside 200+ workers from Mexico in order to harvest over 400 acres of strawberries, blueberries, blackberries, peaches, and muscadines. The work was not for the faint of heart because it required seven days work weeks in blistering humid Arkansas heat and resulted in millions of pounds of produce each season. This became even more challenging when the company limited workers’ contact with the outside world in an attempt to reduce the chances of the Corona virus running rampant in the small rooms that housed anywhere from six to fifteen people. It was amidst all the craziness that comes with harvesting crops, that I got to know some of the workers such as Rosita and Jose and realized just how many adversities they must overcome in order to receive medical care.

Overview look of lake and blackberry field Source: Lucero Chena4

Rosita, The Spokeswoman

If you ever need someone to control a group of over 200 rowdy adults with one word, Rosita is the one you call. She was the unofficial spokeswoman for all the workers and was the first to voice everyone’s concerns about the COVID vaccine when it was offered at the farm. All they were told was that if any worker wished they to receive the vaccine they could do so for free. This news though exciting for some was also troublesome for others because they wanted some more information before making a decision. A week before the vaccine was to be administered, I was tasked with asking everyone whether or not they wished to receive the vaccine but was warned by my supervisor to not offer my opinion or answer questions because I was not a medical professional and could be held liable if something were to happen. Rosita was the first to bombard me with questions, but at that time, all I was able to share was that physicians are required to inform a patient of any possible side effects and must sign an informed consent form.5 The only problem with that is that the doctor had sent said forms, but they were in English. It took a lot of research and persuasion before the company agreed to prepare a meeting in which a doctor would address the workers’ concerns and hand out a Spanish version of the possible side effects.

Rosita’s story is just one of millions that highlight how language, education access, and socioeconomic status play a role in a person’s health. There are many Non-English speaking migrants that are not comfortable going to the doctor out of fear that the appointment or medication may be too expensive or based on previous frustrations from trying to communicate with the doctor. Many Latinos who do not speak English are less likely to receive medical care6 or are less informed of the medical situation due to the language barrier.7

Lake scene from farm where I worked Source: Lucero Chena8

Jose, The Veteran

By my second year, I had become the farm medic and would treat any minor injuries or acquire medication during the first year when the farm was on lockdown. I would often help the workers before or after their shift, so it wasn’t surprising that Don Jose, a man who has been working at the farm for over twenty years, was there to greet me at six thirty in the morning as I opened up the store for the day. Cuts, scrapes, and bruises are common occurrences at a farm, but when Jose began to limp into the store to ask for pain medication, I knew that the situation was more serious than he was letting on. It took a lot of convincing and promises that he would not have to miss work before he finally explained that he had hit his leg had hit a nail on the edge of a trailer when he was loading boxes of fruit, and when he finally showed me his shin, I informed my manager of the situation. During his lunch break, he was taken to a clinic an hour away where the doctor informed the other farm interpreter that the wound on his shin had become infected and would need to be cleaned daily for two weeks before asking he schedule a follow up appointment. He was told to rest his leg for three days and keep it elevated to reduce the swelling, but Jose went back to work the next day after I disinfected his wound. He continued to work with his injured leg until the end of that harvesting season where he returned to Mexico to treat his wound.

Aside from the vulnerability due to language barriers and lack of access to education, farm workers also face physical, political, and economical barriers that prevent them from seeking adequate care. Many might wonder why Jose didn’t just inform someone of his injury immediately after it occurred. The reason for that is out of fear that his injury would put him out of work and cost him a lot of money to get it looked at. In the agriculture business, migrant workers are supposed to be paid a flat hourly rate and a piece rate pay, but there are many owners who violate these wage laws or decide to return the worker to their country if they are not picking quick enough.9 Farm owners are also not required to provide healthcare insurance for their workers because they are seasonal employees. All of these circumstances drive many workers like Jose to work through injuries instead of seeking medical care.10


Although I focused on the social determinants of health of two people and how their categories affected their healthcare outcomes, these determinants apply to everyone’s life. Research continues to show us the relation between the social determinants and the disparities in healthcare for minority groups such as Latinos. These disparities were especially brought under scrutiny during the COVID pandemic, but now having acknowledged that they exist, it is time to start work to eliminate these disparities and make healthcare more accessible for everyone. I know that when those changes do come, they will be because of people like Rosita and Jose, not because of some statistics we read somewhere.

Works Cited

1Mossholder, Tim. “Strawberry Picking.” Unsplash, 21 July 2021,

2“Healthy People 2030,” U.S. Department of Health and Human Services, Office of Disease Prevention and Health Promotion,

3Maxmen, Amy. “Inequality’s Deadly Toll.” Nature News, Nature Publishing Group, 28 Apr. 2021,

4 Chena, Lucero. “Lake and Blackberry Field View.” 6 June 2020.

5 Commissioner. “Pfizer-BioNTech Covid-19 Vaccines.” U.S. Food and Drug Administration, FDA,

6Taira, D A. “Improving the Health and Health Care of Non-English-Speaking Patients.” Journal of General Internal Medicine, U.S. National Library of Medicine, May 1999,,care%20than%20English%2Dspeaking%20patients.

7Al Shamsi, Hilal, et al. “Implications of Language Barriers for Healthcare: A Systematic Review.” Oman Medical Journal, U.S. National Library of Medicine, 30 Apr. 2020,,a%20problem%20understanding%20their%20healthcare.

8 Chena, Lucero. “Gazebo Over Lake.” 6 June 2020.

9 Robinson, Erin, et al. “Wages, Wage Violations, and Pesticide Safety Experienced by Migrant Farmworkers in North Carolina.” New Solutions: a Journal of Environmental and Occupational Health Policy : NS, U.S. National Library of Medicine, 2011,

10Bail, Kari M., et al. “The Impact of Invisibility on the Health of Migrant Farmworkers in the Southeastern United States: A Case Study from Georgia.” Nursing Research and Practice, Hindawi, 1 July 2012,

A Different Crisis at the Border

The deteriorating health of the Rio Grande Valley

I was born and raised in McAllen, Texas—a region nestled along the border between the United States and Mexico. I love that I have been able to grow up in such a unique community filled with joy and grit.

Because we are a border community, we are 94.2% Hispanic or LatinX as of 2021. This area is a predominantly LatinX community, and gleams with pride in numerous colorful outdoor markets, delicious taco stands, and electric fiestas. As a borderland, you get the best of both worlds: reaping the benefits of living in one of the most modernized countries in the world, while also immersed in a vibrant Mexican culture. Do they, though?

This wasn’t until my grandfather was diagnosed with Stage 3 Hodgkins-Lymphoma disease and my family had to make the difficult decision to move to Houston, Texas—about 7 hours away from the Rio Grande Valley—just so that my grandfather would have the best opportunity to beat his cancer. There were hospitals in the Rio Grande Valley, but I did not realize they were unable to provide the accurate care my grandfather needed. I started to question why this was.

2 years later, my 9th grade English teacher suffered from a massive stroke during class. Thankfully, after a couple of months, she made a miraculous full recovery and was back in the classroom. During this time, however, I was researching “What causes a stroke?” “What is high blood pressure?” “What is diabetes?” “What causes obesity?” I was asking so many questions and I was making connections between these phenomenons happening before my eyes. After the premature research I was able to conduct, I came to the realization that my hometown was in a crisis. A severe public health crisis.

Rio Grande Valley border bridge
Source: ValleyCentral

Social Determinants of Health

This region also boasts high rates of poverty, where 29.5% of residents live in poverty. With that, 34.1% of the population lack health insurance coverage. Not to mention, the Rio Grande Valley has a population of approximately 1.3 million people, and 200 to 250 thousand are undocumented individuals. It is also known that undocumented immigrants have significantly lower rates of health coverage. These demographics are an unfortunate medley that allow for social determinants of health to take over and deteriorate the health of my hometown. It it as if the already-broken health care system’s flaws are further amplified in the Rio Grande Valley, as the region suffers from high levels of obesity and diabetes. Not to mention, because of the higher immigrant population, there are higher barriers to the access of health care as well. Not only do individuals visit the doctor to address their intoxication from pesticides from their crop-picking job, but they will also attend that doctor’s visit with the fears of potentially being deported. Fragmented care also plays a major role in the declining health care within the Rio Grande Valley as individuals are forced to switch in and out of primary care physicians as an attempt to deflect any immigration-related accusations. Undoubtedly, there is a constant fear within immigrant communities of deportation, and because the Rio Grande Valley’s close proximity to the U.S-Mexico border, this fear is heightened since there is a stronger presence of United States border patrol agents. Not to mention, the Affordable Care Act (ACA) explicitly excluded undocumented immigrants from accessing health care—further pushing undocumented immigrants from obtaining the care they so desperately need.

But we’re not just about the border wall or the river…We’re about being fat, we’re about being poor, we’re about being illiterate.

Rose Timmer, long-time resident of Brownsville, TX

Food Insecurity to COVID-19

Another important and crucial crisis within the Rio Grande Valley’s health is food insecurity. Although this region lacks food access, it also has one of the highest rates of obesity in the United States. This is primarily due to this being a food desert, where fresh food options are scarce, but fast food options are excessive. It seems as if everywhere you go, you will not be more than a mile away from a McDonald’s, Whataburger, or a local taco stand. You will, however, struggle to find a grocery store near you that carries fresh fruits and vegetables that are not deep-fried. Even if individuals are lucky enough to access fresh fruits and vegetables, many will be unable to afford them as poverty levels remain high. The low socioeconomic status that impedes individuals from accessing the appropriate ingredients to supply a healthy and nutritious meal are rare, yet fast food is everywhere.

Taco stand in Brownsville, Texas
Source: Pinterest

The food insecurity and food deserts within the community are slowly attacking my community and worsening the obesity and diabetes epidemic within the Valley. Because of this, the COVID-19 pandemic was also detrimental to the region, as COVID-19 blazed through the Rio Grande Valley. Because of the social determinants of health that have put the Valley in such a vulnerable position, the COVID-19 pandemic had a disproportionate impact on the Rio Grande Valley compared to other regions of Texas. The Rio Grande Valley is 3% of Texas’ population and was 9% of total COVID-19 deaths.

They are more at risk because of where they work and where they live, and because of limited access to health care

Carlos Rodríguez-Díaz, professor at George Washington University’s Milken Institute School of Public Health

The higher rates of obesity and diabetes put the community at a higher risk and was evident as Rio Grande Valley hospitals were at maximum capacity. Even when hospitals were overflowing with COVID-19 patients, Texas governor, Greg Abbott only lifted social distancing and opened Texas back up.

Hospital in Edinburg, Texas during COVID-19
Source: Texas Tribune

The Future of the Rio Grande Valley

In 2016, the Rio Grande Valley welcomed its inaugural University of Texas-Rio Grande Valley School of Medicine class, and graduated its first doctors in 2020 with the hopes of bringing a new generation of doctors who are properly equipped to serve a community who is in dire need of empathetic doctors who understand that their situation is a systemic issue, not a personal issue.

Inaugural UTRGV School of Medicine Class
Source: Texas Monthly

The Rio Grande Valley needs home-grown physicians who will understand the social determinants of health that have led them into their offices and will advocate for them. The future of the Rio Grande Valley is bright, but this brightness will be dulled unless we take legislative action to provide adequate health care for all—regardless of immigration status.

Works Cited:

Blackburn, Christine Crudo, and Lidia Azurdia Sierra. “Anti-immigrant rhetoric, deteriorating health access, and COVID-19 in the Rio Grande Valley, Texas.” Health security 19.S1 (2021): S-50.

Champagne, Sarah R., and manuel fergus. “South Texas hospitals are running out of beds.” The Texas Tribune, 4 July 2020, Accessed 18 February 2023.

Dickman, Samuel L., David U. Himmelstein, and Steffie Woolhandler. “Inequality and the health-care system in the USA.” The Lancet 389.10077 (2017): 1431-1441.

Galvin, Gaby, and Cecelia Smith. “A Battle for Community Health in Texas’ Rio Grande Valley.”, 16 May 2018, Accessed 18 February 2023.

Hampton, Tylisa. “RGV could suffer if undocumented immigrants aren’t counted in the 2020 Census.”, 16 September 2020, Accessed 19 February 2023.

“Health Coverage and Care of Immigrants.” KFF, 20 December 2022, Accessed 18 February 2023.

Narea, Nicole. “How coronavirus devastated Texas’s vulnerable Rio Grande Valley.” Vox, 8 August 2020, Accessed 18 February 2023.

“Obesity and Diabetes Reports in Rio Grande Valley to Texas 2004-2018 8.5×11 Final Version.” RGV Health Connect, Accessed 18 February 2023.

“Rio Grande City city, Texas.” Census Bureau, Accessed 18 February 2023.

Shmerling, Robert H. “Is our healthcare system broken?” Harvard Health, 13 July 2021, Accessed 18 February 2023.

“Social Determinants of Health – Healthy People 2030 |” Office of Disease Prevention and Health Promotion, Accessed 19 February 2023.

Wilson, Sarah. “The University of Texas Rio Grande Valley hits the ground running as UT system’s newest institution.” Texas Monthly, Accessed 19 February 2023.

Advancing Medicine and Medical Treatment: Our Salvation or Downfall?

Better Medical Resources ≠ Better Medical Care

Over the past century, humans have made incredible progress in our understanding of medical ailments and how to properly provide treatment to those affected by them. Major advancements in the development of technology and different medications have played a significant role in this growth of the medical field. With instruments that allow us to better study human pathogens, screen for various diseases, provide extremely precise care, and much more, we are living in a world in which people of the past never would have thought could exist. Within about 120 years, we have progressed from a nation where an average of one in every 40 Americans die annually to a significantly lower rate of about one in every 120 Americans and, although this average rate is affected by numerous factors, discoveries and advancements in the medical field have played a tremendous role in its steady improvement (Penn Wharton, 1). One cannot deny the benefits technology has provided us in our quality and duration of life, however, technology has also been a driving force of widening disparity within our healthcare system. Despite continuous breakthroughs in medical care through the use of technology, many of these new forms of care remain inaccessible to a majority of the population and distort our views of the medical world. The diabetic population clearly illustrates this growing disparity within the healthcare system and demonstrates our need to improve current policies to better utilize the incredible achievements we have made as a species.

 “Living with diabetes means people usually don’t realize or understand what you’re living with”

Nick Jonas

What is Diabetes and How Does Technology/Medication Play a Role?

Type 1 diabetes is an autoimmune disease in which the immune system irreversibly destroys the insulin-producing beta cells of the pancreas. Insulin is the hormone released by our body in response to the consumption of food as it allows glucose within the bloodstream to be taken up by cells for the production of ATP. For a diabetic that has lost the ability to produce insulin, that glucose will remain in the bloodstream and prevent cells from producing energy for the body while leading to many negative effects, such as the blood becoming acidic, loss of vision, damaged nerves, kidney failure, amputation of limbs, and much more. Type 1 diabetes is a chronic condition, meaning once a person is diagnosed, they will live with the disease for the rest of their life. Furthermore, it is a condition that requires 24/7 monitoring and care, often leading to drastic changes within a person’s everyday life and causing their whole world to revolve around this medical condition. Just over 100 years ago, a diagnosis of diabetes was a death sentence in which a child, as type 1 diabetes is primarily diagnosed in early childhood, would not be expected to live more than 3 years (Distiller, 3). However, medical discoveries and major advancements in technology have provided patients with the ability to live full and high quality lives as we now have access to synthetic insulin, insulin pumps, continuous glucose monitors (CGMs), improved education, and more. It is impossible to deny the tremendous amount of good these technological and medical achievements have made in the lives of people living with such a life-altering condition, however, this also begs the question of how there can be such large disparities in the quality of life for a disease we now know so much about and have incredible resources for managing. 

“We have the greatest hospitals, doctors, and medical technology in the world – we need to make them accessible to every American.”

Barbara Boxer

Barriers to Medical Care and our Misconceptions of Diabetes Management 

In today’s world, we have access to insulin pumps that will automatically deliver precise amounts of insulin, CGMs that allow a person to know their exact blood sugar at any given moment without the need for finger pricks, inhalable glucagon that saves lives when used during hypoglycemic emergencies, and so much more. So why is diabetes still such a hard disease to manage? Aside from the fact that diabetes is an irregular disorder that may still have complications regardless of near-perfect management, the primary barrier to effective diabetes management remains access to supplies. A majority of diabetics struggle to access the life-saving medical supplies we have available that transform a burdensome and debilitating condition into one that is manageable. This disparity in access is due to a number of factors, however, the main barrier remains the cost of insulin and diabetes technology. While various technologies such as insulin pumps and CGMs greatly improve a person’s ability to manage diabetes and can have life-changing results, it is still possible to manage one’s condition without these technologies through the use of traditional insulin syringes and finger pricks. Insulin, however, is required for a person with diabetes as they cannot survive without it. As previously mentioned in this discussion, insulin is needed to take up glucose from the blood for energy production and when insulin is not present, the body will turn to other sources for energy. The method for providing energy that the body primarily turns to is a process in which fat is converted into energy, however, unlike the regular process involving glucose, this secondary process produces ketones as a byproduct. This results in the buildup of ketones within the blood, turning it acidic and leading to a life threatening condition called diabetic ketoacidosis (DKA). Aside from this dangerous condition, sustained levels of elevated blood sugar can also lead to the many debilitating long term consequences that were mentioned earlier, such as loss of vision, kidney function, feeling in extremities, and limbs. This is why insulin is essential for not only living a high quality life, but for survival itself. With over 1 million diabetics having to ration their life saving insulin everyday, our healthcare system needs a dramatic change (Norton, 1). 

Bottle of insulin injection with a syringe on black table and stainless steel background.

Why is Insulin so Expensive?

According to Ashley Driesbach’s research, a study conducted in 2018 found that on average it costs about $2.28-$3.42 to produce a single vial of human insulin and a year’s worth of insulin only costs $48-$71 per diabetic patient (Driesbach, 8). So how can so many people still be struggling to afford their life saving medication? The answer comes down to the lack of regulations surrounding the major insulin-producing companies. Insulin is manufactured by just three major companies: Eli Lilly, Novo Nordisk, and Sanofi (Martínez, 1). These companies face very few regulations in how they manufacture and sell their product, which is what allows them to increase the selling price of insulin to about $25-$100 per vial for older insulins and $174-$300 per vial for newer insulins merely for the sake of profits. Although insurance may help with some of the cost, many people with insurance are still forced to pay a hefty amount out of pocket and those without insurance are often left helpless (SingleCare, 6). A study from 2019 and 2020 found that insured diabetics were still forced to pay an average of $35 for a 30-day supply of insulin while many others are forced to pay more (Lovelace, 11). Recent studies have also shown that this inflation crisis is only getting worse as insulin prices have increased by about 600% over the last 20 years (Inskeep, 1). The cost of insulin has proven to be a major barrier to diabetics living a full and healthy life and as this crisis continues to worsen, leading to the deaths of people around the globe that could have been prevented with access to insulin, many are wondering what can we do as a society to solve this problem.

“Universal coverage, not medical technology, is the foundation of any caring health care system.”

Richard Lamm

What needs to be done

Reducing the growing disparity diabetic patients face in accessing their medical supplies and technology is something that needs to happen, but there is no clear and simple solution for achieving this. From reading the current research and hearing the life experiences of diabetics around the world, I believe our best chance at reducing this disparity is reducing the cost of diabetes supplies. Although there may be other factors that make accessing medical supplies difficult for a diabetic, cost of insulin and other diabetes supplies remains the most significant barrier as insulin pumps themselves cost an average of $4,500-$6,500 (Vaida, 16). To help alleviate some of the financial burden faced by millions of Americans living with diabetes, we must form new policies that regulate these costs, whether that be introducing policies to provide greater healthcare coverage for uninsured patients, policies that require insurance companies to cover more of the costs for things like insulin and insulin pumps, or policies that regulate the major insulin-producing companies and how much they can sell their product for. It is difficult to say when policies such as these may become possible or if they will ever become possible, as the US is still a long way away from adopting universal healthcare and pharmaceutical companies and insurance companies have remained relatively free to make decisions that directly benefit them at the expense of their “customers” for decades. Whether or not policies such as these are achieved in the US someday, we must continue to raise awareness of the issue as healthcare costs continue to be a widespread epidemic that plagues non only diabetics, but millions of Americans affected by other conditions as well.

Works Cited

Catastrophic spending on insulin in the United States, 2017–18. (n.d.). Retrieved February 21, 2023, from

Centers for Disease Control and Prevention. (2022, December 30). Types of insulin. Centers for Disease Control and Prevention. Retrieved February 20, 2023, from

Distiller L. A. (2014). Why do some patients with type 1 diabetes live so long?. World journal of diabetes5(3), 282–287.

Drugmakers that dominate the world’s insulin market must scale up access efforts globally. Access to Medicine Foundation. (n.d.). Retrieved February 20, 2023, from,%2Dincome%20countries%20(LMICs).

Facts. JDRF. (n.d.). Retrieved February 20, 2023, from,to%20have%20T1D%20by%202040.

Inskeep, S., & Aubrey, A. (2022, September 12). Insulin costs increased 600% over the last 20 years. states aim to curb the price. NPR. Retrieved February 20, 2023, from,patients%20ration%20this%20lifesaving%20drug.

NBCUniversal News Group. (2022, July 24). Why is insulin still so expensive for diabetes patients in the U.S.? Retrieved February 20, 2023, from

NBCUniversal News Group. (n.d.). Insulin costs will be capped in 2023, but most people with diabetes won’t benefit. Retrieved February 20, 2023, from

Over a million Americans are rationing insulin due to high cost. (n.d.). Retrieved February 21, 2023, from

PPI, W. (2018, December 19). Mortality in the United States: Past, present, and future. Penn Wharton Budget Model. Retrieved February 20, 2023, from,of%20more%20than%20two%20thirds.

Team, S. C. (2023, February 8). How much does insulin cost? The Checkup. Retrieved February 20, 2023, from,133%20per%20patient%20per%20year.

Vaida, B. (n.d.). What diabetic supplies do I need, and what are the costs? – goodrx. Retrieved February 21, 2023, from

Xplore. (n.d.). Medical Technology quotes. BrainyQuote. Retrieved February 20, 2023, from

Disparities in Rural Healthcare as seen on the Pine Ridge Native American Reservation

Through the Contemporary Concerns in Medicine course, we have learned about flaws in the United States healthcare system and have determined that current policies do not provide high quality care for all people.  One particular group that receives inadequate healthcare is Americans living in rural regions of the country.  Among the worst off are Native Americans living on reservations.  

In high school, I traveled to Pine Ridge, South Dakota, one of the largest of the 326 Native American reservations on US territory (Indian Affairs (IA)).  This was an immersive trip and part of my high school’s effort to educate students on disadvantaged communities within the United States.  In learning about the conditions on the reservation, I was most surprised to learn about the poor healthcare available on the reservation and the diminished healthcare outcomes for Native Americans living on the reservation.  Taking both the knowledge I learned from my travels to Pine Ridge, and our discussions on disparities in the U.S. healthcare system in this class, it is clear that the Pine Ridge reservation is an example of how the US healthcare system does not support all people living in this country.  

The Pine Ridge Reservation was established in 1889, encompasses 2.1 million acres of southwest South Dakota, and is located near Rapid City, South Dakota and Badlands National Park (Strickland).  Roughly 18,000 people live on the reservation with the majority of residents identifying as part of the Oglala Lakota Native American tribe who consider the Black Hills of South Dakota their ancestral lands (Pine Ridge Indian Reservation Facts | Re-Member).  People living on Pine Ridge have some of the worst health and are among America’s poorest with a per capita income of $8,768.  Life expectancy on the reservation is the lowest in the entire U.S. with women having a life expectancy of 52 years and men having a life expectancy of 48 years (Shift).  89% of people on the reservation are unemployed, and a reported 53.75% live in poverty, and some estimate the poverty rate to exceed 80% (Pine Ridge Indian Reservation Facts | Re-Member).  Additionally, Native Americans on Pine Ridge see an excess of tuberculosis, infant mortality, suicide, alcoholism, cervical cancer, diabetes, car crashes, and unintended injuries (Shift).  Further, very few hospitals exist on the reservation and within the surrounding area, meaning residents have to travel great distances for care.  Only one true hospital exists on the entire 2.1 million acre reservation which is the Pine Ridge Hospital.  Despite being responsible for a population of 18,000 people, this hospital has only 45 beds and 16 physicians (Pine Ridge Service Unit | Healthcare Facilities).  The available care is still significantly worse than care received at other hospitals.  In 2017, the Centers for Medicare and Medicaid Services ended the provider agreement with Pine Ridge Hospital, preventing the hospital from being able to bill Medicare for services.  This decision was made due to reports of misdiagnoses and inadequate care that put patients at risk for “imminent injury, serious harm, death or impairment” (Abourezk).  The combined effects of extreme poverty and limited access to adequate care causes Native Americans on Pine Ridge experience extremely poor health.

Disparities in healthcare are caused and exacerbated by a variety of factors, including a lack of access to insurance, inability to afford medical care due to cost-sharing, geographic barriers, illness-based disparities, and institutional racism (Dickman et al).  All of these issues can be seen on the Pine Ridge reservation and contribute to the decreased health outcomes for Native Americans.  At present, the US has no national health care plan, and healthcare is primarily tied to employment  (Shmerling).  For the people in Pine Ridge, 89% of people are unemployed, meaning most do not have reliable health insurance or must rely on Medicaid for insurance.  Even for those who are insured or qualify for Medicaid, cost-sharing and out of pocket costs for specialty services can be expensive and not feasible for the many residents of Pine Ridge who live in poverty. As is common with healthcare in many rural regions, Pine Ridge has extremely few healthcare facilities, and aside from the Pine Ridge hospital, there are only two other facilities on the reservation with limited providers and services (Pine Ridge Service Unit | Healthcare Facilities).  

Roland left the reservation for the first time in his life in April, when he was airlifted to a hospital in Rapid City for an emergency surgery after he slipped in the snow and shattered his hip while chopping firewood. Only able to move with the help of a walker, Roland, who wears a dirt-covered jacket and repeatedly pulls up his oversized jeans as they sag from his waist, says he will never be able to pay the $2,000 in medical bills through the small amounts of cash he gets doing odd jobs for neighbors and ranchers.


Additionally, several of the illnesses plaguing Pine Ridge residents such as substance abuse and mental health conditions are not adequately treated for and exhibit illness-based disparities.  With limited health centers and practicing physicians, treatment for psychiatric care is limited in Pine Ridge despite the widespread incidence of mental health conditions and substance abuse among residents.  Psychiatric care is oftentimes an out of pocket cost not covered by insurance plans, meaning low income families may not be able to afford these services (Dickman et al).  Systemic racism also affects Native Americans on reservations.  During the U.S. westward expansion, Native Americans were forcibly removed from their ancestral land and placed on reservations.  Beyond this, Native American communities have experienced massive injustice, including massacres such as the 1889 Wounded Knee massacre at Pine Ridge and placement in conversion schools.   For decades, the U.S. government did not provide healthcare to Native Americans despite stipulations in reservation treaties dictating the government must provide for these needs.  This history of oppression has placed them at an economic disadvantage, and to this day federal programs and infrastructure on reservations are underfunded and underdeveloped.  These systemic issues have direct effects on the health of Native American people (Ferguson and Solomon et al).

The present-day poverty gripping many indigenous communities – on and off reservations – is firmly rooted in the historical laundry list of massacres, ethnic cleansing, land theft and broken treaties endured by indigenous people in North America.


Native Americans experience significant problems in accessing healthcare and experience worse health outcomes than the majority of people living in the United States.  This is a serious injustice that contributes to massive suffering among Native American communities and must be addressed.   Many initiatives from well-known organizations are in progress to address the social determinants of health that apply to rural communities such as efforts by the Association of American Medical Colleges to educate new physicians on healthcare in rural regions and how to treat patients in rural areas.  Additionally, the US Department of Health and Human Services included rurality as a social factor that affects health in its report to Congress to inform Medicare purchasing programs (Social Determinants of Health for Rural People Overview – Rural Health Information Hub).  However, in discussing the issue of health disparities in rural communities, the significant disadvantages that Native Americans face are lumped together with the larger issue of inadequate rural healthcare.  There is a lack of awareness and understanding of the considerations specific to Native American reservations, especially with respect to healthcare.  

The problem of healthcare on reservations is vastly complicated, involves the interplay of economic and social factors, and is rooted in historic mistreatment of the Native American community.  In my opinion, a critical first step in rectifying healthcare disparities is increasing the number of practicing physicians on reservations.  This could be accomplished by incentivizing physicians to work in Pine Ridge or by encouraging and providing access for community members to gain an education to become a physician.  Additional work could be done in expanding insurance coverage and in tackling extreme poverty occurring on the reservation.  

Severe mistreatment of Native Americans is a part of U.S. history that is not always acknowledged, but still impacts their community today.  Healthcare is a basic human right, and the fact that Native Americans experience barriers in accessing health care due to their initial displacement in the 1800s is disheartening and adequately addressed.  It is important to continue educating people about this issue to reach any progress and improve conditions for these communities who called U.S. territory home well before the majority of Americans.

Strickland, Patrick. “Life on the Pine Ridge Native American Reservation.” Human Rights | Al Jazeera, 2 Nov. 2016,

The Reality of Nursing Home Aides

20 February 2023

This summer I worked my first job as a Certified Nursing Assistant at a state nursing home in a predominantly white suburb of Philadelphia. This would be my first patient contact experience in healthcare, but I learned more about society and the healthcare system from the people I worked with than the residents I took care of.

As an aide I would be responsible for bathing, transferring, toileting, and feeding my assigned residents on the dementia floor of this nursing home in my 7am-3pm shift. Everyday I worked alongside a team of nurses and aides, of which the majority were from the African country of Sierra Leone. Other than the activities director, I was the only non-black worker on the floor last summer.

One common occurrence last summer was the way coworkers rotating on the same floor as me would assume that I was the nurse. I wore a surgical mask, scrubs and dirty shoes like every other aide, no makeup, and no jewelry, so this was probably based on my phenotypic differences from the other workers. The difference in my appearance other than my size and age were my straight hair and my biracial tan skin tone.

…coworkers rotating on the same floor as me would assume that I was the nurse.

Still, at least twice a week, a coworker would begin asking me a medical question, and I would quickly cut them off and direct them to the nurse on the floor.

Image from

 This was a firsthand experience seeing how racial differences are associated with higher status even to people of color and in health care. While this assumption was not an insult to me, it was showing her internal bias that a black person such as herself would have a job that requires less education and a non-black person would have a job requiring a higher degree.

From the beginning, I struggled at the physical demands of this job. I would need to ask for help, adding to my workload of my coworkers who would reluctantly assist me.  At the end of the first week they made it clear they did not think I would be able to do this job.  Little by little I gained the trust of my coworkers that I would be able to handle a full workload as they do, turning obese residents and working efficiently enough to care for thirteen plus residents at a time.

I remember one day a coworker, an African aide, asking me about my ethnicity. I told her my dad was born in the Philippines and my mother was white. I remember her saying, “Oh that is why you are so beautiful, your mother is white.”  Later in the conversation she confided to me how stressful this job is for her, and further how she believes this job is ‘meant for black people.’

“Oh that is why you are so beautiful, your mother is white.” 

I remember not knowing how to respond, but I later understood why my abilities were underestimated when I first started. I think my coworkers could not grapple with someone from a non-black race sharing their same workload.

Both of these occurrences remind me of the Desmond and Emirbayer article that describes this “internalized racism” in which “people of color often internalize prejudice at their own racial group, unintentionally contributing to the reproduction of racial domination” (Desmond and Emirbayer, 2009: 346). The racial based comments my coworkers made were never offensive, showing how society gives my half-whiteness a higher, respectable status.

As seen in the US Health Care System Profile, “There is no universal coverage for long term care services” for Medicare or private insurance users. Public spending in the United States for long term care facilities, such as the state nursing home where I worked, represents “approximately 70 percent of total spending on long-term care services, with Medicaid accounting for the majority” (Tikkanen et al., 2020). The lack of funding for workers at this nursing home would be one of its biggest problems.

Image from

Three to five aides would be on a floor and have to provide for fifty-five residents of which the majority needed total assistance, making this job nearly impossible to give each person the care and attention they deserved. The lack of funding to nursing homes like this shows in the lack of supplies available to our residents, hurting their quality of care. Lack of funding also contributes to the low wages for both aides and nurses that would often work doubles, 7am-11pm multiple times a week. While I enjoyed the sense of accomplishment I got from my job, I did not have the stamina to do what they did.

Three to five aides would be on a floor and have to provide for fifty-five residents of which the majority needed total assistance, making this job nearly impossible

The stress and burnout of this job that I noticed in my coworkers manifested itself in habits and physical appearances.  One thing I noticed about my coworkers was how common it was for the aides to use their fifteen minute break to smoke cigarettes, as well as how many of the aides and nurses I worked with were experiencing obesity.  As seen in the Remote Area Medical movie, smoking is a way to cope with stress, and the nature of the job and the long hours worked certainly contributed to the need for this coping mechanism.

I came to view these habits not as the culmination of ignorance to health risks, but rather a coping strategy to work related stresses. The Zola article described the over medicalization of conditions in society deemed pathological (Zola, 1976).  While I do not deny the biological basis for conditions such as obesity, the over medicalization of obesity puts the fault on the individual and overlooks the underlying societal factors in one’s environment that contribute to these health conditions.

I came to view these habits not as the culmination of ignorance to health risks, but rather a coping strategy to work related stresses.

In this work environment I saw how my coworkers experienced stress, a lack of sleep and a lack of time and ability to care for their physical needs due to their financial need to work overtime. Society would first question an obese person’s eating habits, rather than how lack of sleep (Beccuti et al., 2011) and stress (Van der Valk et al., 2018) can contribute to one’s experience of obesity. 

The summer I was able to experience firsthand how systemic factors contribute to people’s health and bolster the effects of internal racism and over medicalization. To me, improving long term care conditions for both providers and residents, and solving the cycle of internal racism is multifaceted. The combination of lack of funding and coverage from Medicaid and Medicare (respectively), the lack of enforced legal restrictions on how many residents an aide can provide for at a time, and the lack of coverage for a high proportion of black women working in healthcare (Dickman et al. 2017) are all systemic factors that contribute to the health of black women in healthcare.

Works Cited 

Beccuti, G. and Pannain, S. (2011). Sleep and Obesity. National Center for Biotechnology 


Desmond M. and Emirbayer M. (2009). What is Racial Domination? 

Dickman, S., Himmelstein, D., Woolhandler, S. (2017). Inequality and health-care systems in the USA.  The Lancet.

Reichert, J. and Zaman, F. (2013). Remote Area Medical. IMDb.

Tikkanen, R., Osborn, R., Mossialos, E., Djordjevic, A., Wharton, G. (2020). International Health Care System Profiles: United States. The Commonwealth Fund

Van der Valk, E., Savas, M., van Rossum, E., (2018). Stress and Obesity: Are There More Susceptible Individuals? National Center for Biotechnology.,to%20abdominal%20obesity%20%5B4%5D

Zola, I., (1976). Medicine as an Institution of Social Control.

The Intersectionality of Privilege

I think that privilege can be one of the most difficult things to explain to someone who either a) doesn’t understand it, b) has it, or c) fails to acknowledge that it exists. Often when I hear the word privilege, like many people, I usually assume that the context around it is from a racial standpoint. However, privilege exists in so many different dimensions. Privilege exists not only racially, but also based on gender, ability, socioeconomic status, age, sexual orientation, religion, citizenship, education level, and most associated with this class–health

Source: UK Research Integrity Office

Understanding different forms of privilege is important to understanding how systems of inequality are perpetuated because privilege is one of the key mechanisms that perpetuates these systems. When certain individuals or groups have privilege based on certain identities that they possess, they have greater access to opportunities and resources that others (without those identities) do not. For example, studies have shown that prospective job employees with more ethnic-sounding names face hiring discrimination in comparison with their competitors with white-sounding names. This kind of discrimination leads to unequal variations in status, opportunity, and resources–that end up being key factors in the perpetuation of systemic inequality. However, learning about these inequalities and addressing them can help dismantle them to create a more equitable, just society.

Many of the inequalities that we have discussed in this class highlight an underlying trend of individuals with privilege–or lack thereof, and how this affects their lives. In the first week of class, we discussed the many pros and cons of the American healthcare system using readings from The Commonwealth Fund. Although there are pros–such as advanced care, technological innovation, and vast research–there are also many cons in the system that have detrimental effects to those that may not have some of the privileges that I listed above. Some of these cons include, but are not limited to, expensive costs of care, uneven investment in resources, lack of access, corruption, and disparities affecting marginalized groups. 

Source: Unsplash

The film that we watched in class, Remote Area Medical, was a powerful visualization of what some of the healthcare inequalities look like in this country. The film followed the nonprofit group that stages free clinics in Bristol, Tennessee that lacks access to basic health care. The film explained that Bristol has a bad drug problem and many of its citizens have done/do drugs, leading to various conditions such as lung cancer, bronchitis, lung disease. Many of the people living in Bristol are also blue collar workers that have no jobs or have low paying jobs with no insurance coverage.

Source: National Institute for Healthcare Management

I think one of the biggest eye-opening moments for me from the film really was the way that privilege, in many different areas, was displayed. Because so many people in rural areas like Bristol do not have the resources or education to obtain college degrees, they are often forced to work in jobs with dangerous health implications such as jobs in the painting industry, automotive industry, and mining industry. Many of these jobs do not have medical benefits, which highlights one of the flaws in the American healthcare system, that there is no universal coverage.“Compared with the insured, uninsured individuals have a higher prevalence of chronic medical illness, greater physical morbidity, and higher mortality” (Washington, 2001). This would be an example of individuals lacking privilege from a socioeconomic standpoint that then affects their lives in other areas, such as health and education. While all of the patients in the film were white and do obtain privilege in their lives from their whiteness, and some may have privilege as it pertains to their physical ability or sexual orientation, they are all disadvantaged socioeconomically in one way or another. This demonstrates a key idea around privilege–that it is not one-dimensional. 

For example, a white woman in America can experience sexism and not racism, while a Black woman can experience both. The white patients that were being treated in the film were disadvantaged academically and economically, but they were not discriminated against based on their race.

The socioeconomic statuses of the patients being treated by RAM significantly impacted their way of life and their access to quality medical care. Bristol, TN is over 90% white, so this racial makeup makes sense, however I could not help but wonder how the availability and accessibility of this free medical care could be different if Bristol was 90% Black. Would the clinic even exist? Would RAM try to make sure that the physicians that were volunteering represented the demographics of the people that they were serving? Would there have been racial bias within the diagnosis and treatment of certain conditions that are often racialized?

Understanding the intersectionality of privilege is critically important because it helps us to conceptualize that individual experiences that people have are constantly being shaped by their numerous identities, whether that be based on their race, gender, sexual orientation, socioeconomic status, or ability. These compounding identities intersect with one another that can either exacerbate or mitigate one’s privilege or lack thereof.


Blacksher, E. White Privilege, White Poverty: Reckoning with Class and Race in America. Moral and Social Challenges of Civic Learning. 25 February 2021.

University Libraries at Rider University. Privilege and Intersectionality.

United States Census Bureau. United States Census Bureau. 2022.

Bridges, K. Implicit Bias and Racial Disparities in Healthcare. American Bar Association. 2023.

UK Research Integrity Office. Academic Wheel of Privilege. 2023.

Washington, D. Charting the path from lack of insurance to poor health outcomes. West J Med. July 2001.,it%20has%20significant%20health%20consequences.&text=Compared%20with%20the%20insured%2C%20uninsured,physical%20morbidity%2C%20and%20higher%20mortality.

Day, J. Rates of Uninsured Fall in Rural Counties, Remain Higher Than Urban Counties. United States Census Bureau. 9 April 2019.

Roberts, N. Urbanization Leaves Rural America In A Health Care Crisis. Forbes. 25 October 2019.

Carlsson, M. Is It Your Foreign Name or Foreign Qualifications? An Experimental Study of Ethnic Discrimination in Hiring. ECONSTOR. November 2008.

Costs of Confusion: When What You Don’t Know Definitely Hurts

Monopoly on Knowledge

If I gave you two minutes to explain the basic details of your health insurance plan, could you do it? If not, you are far from alone. A recent survey has concluded that a majority of Americans feel “hopelessly confused” by health insurance (Bend, 2021). Coupled with the fact that Americans spend more on healthcare than any other country in the world while producing outcomes that are far from the best, the current state of affairs is aptly summarized as rife with market failures (Tikkanen, et al 2020). Wherefore art thou invisible hand?

Source: Adapted from T. Rice, et al., “United States of America: Health System Review,” Health Systems in Transition, vol. 15, no. 3, 2013, p. 27.

Imagine I was something akin to Billy on the Street, and I brought with me a large poster of the image to the right. How likely is it that an interviewee would be able to provide a brief summary of our healthcare system? Even if I were incentivized with a $1, I may consider it not to be worth the mental effort. Overly complicated systems engender feelings of helplessness, and you don’t have to look far for another example. The US tax code has become so complicated that an entire industry has arisen to profit from the average American’s lack of understanding.

The healthcare industry naturally profits from consumer naïveté. A study from the American Economic Association suggests nearly 9 out of 10 Americans purchase the wrong prescription drug coverage plan for their needs, costing them 30% more than the ideal plan on average (Abaluck & Gruber, 2016). It begs the question, who is responsible for educating Americans on navigating our healthcare system? By the time Americans need to purchase health insurance for the first time, they are likely 26 years old. Many years removed from the education system, we are relying on Americans to figure it out for themselves, and it clearly isn’t working.

“Because people are so bad at choosing plans, the market often sends weird signals to insurance companies, encouraging them to offer more of the wrong plans instead of the right ones.”

Margot Sanger-Katz, “It’s Not Just You: Picking a Health Insurance Plan is Really Hard”
Inexplicable Inconsistencies

This past fall break, I road tripped to a close friend’s house outside of Charlotte, North Carolina. As usual, I forgot to pack an item, but unfortunately this time it was my thyroid medication—something I am supposed to take daily. Luckily, I was able to have the prescription filled at a Costco in Charlotte, where I was only charged $7. This was in stark contrast to the $27 I typically pay at the Costco in Mishawaka, Indiana. In the American health system, this isn’t remotely unusual! The varying costs of identical surgical procedures from hospital to hospital and city to city are well documented (Rosenthal, 2013).

Yet again, a lack of transparency and awareness leads to wasteful spending. In an ideal market, consumers and competitors would take advantage of mispricings and force the most efficient outcome. In a country that prides itself on free market capitalism, how is this allowed to persist? I believe two central issues perpetuate this broken system.

The first is the influence of the healthcare industry on regulation via political lobbying. Three of the top five largest political donors this past year were the Pharmaceutical Research and Manufacturers of America, the American Hospital Association, and Blue Cross Blue Shield—all donating in excess of $25 million (OpenSecrets, 2023). Uneven pricing allows some to inflate their margins. The desire to protect their profits is a rational, self-interested act.

The second is once again a lack of knowledge on behalf of the consumer. Once more, if you asked random individuals on the street to estimate the price of a common medical procedure, more likely than not you would get wildly different responses. Ask the same people the price of a gallon of milk and nearly every answer would be between $2-$4, depending on location. This is by no means the fault of the everyday American. Even at the same hospital with the same doctor, individuals may have wildly different out-of-pocket costs depending on their insurance plan. It is, however, a failure of broader American society.

A Simple Step Towards Better Healthcare

“There is rarely a single, immediate remedy […] Success would be incremental.”

Dr. Elizabeth Loder, The Heroism of Incremental Care

Much of the debate in U.S. politics over the healthcare industry surrounds controversial topics. Deadlock prevents radical change, and thus leaves us stuck with the issues of the present. In our obsessive debate over universal coverage or the sustainability of current public health programs, we forget about the uncontroversial. One of the few matters in existence not to exhibit diminishing marginal returns is that of useful knowledge. It is not controversial to suggest that Americans should have a better grasp of our healthcare system. The government has a long-held desire for an educated populace. More quickly than we can cut through red tape, more quickly than we can restrain the influence of lobbyists, more quickly than we can reign in pharmaceutical drug costs, politicians can help the everyday American by enacting programs that will help them to navigate the costs of care. The citizenry so often criticize the wasteful spending of government; how ironic it is that government now has the opportunity to eliminate the wasteful spending of its citizenry. Unsurprisingly, education can make our country stronger.


Abaluck, J., & Gruber, J. (2016, August 8). Evolving Choice Inconsistencies in Choice of Prescription Drug Insurance. American Economic Review. Retrieved February 20, 2023, from 

Bend. (2021, February 3). More than Half of Americans Confused by Health Insurance, including HSAs. Bend News. Retrieved February 20, 2023, from  

OpenSecrets. (2023). Top Spenders. OpenSecrets: Following the Money in Politics. Retrieved February 20, 2023, from 

Rosenthal, E. (2013, June 1). The $2.7 Trillion Medical Bill. The New York Times. Retrieved February 20, 2023, from 

Sanger-Katz, M. (2020, December 11). It’s Not Just You: Picking a Health Insurance Plan is Really Hard. The New York Times. Retrieved February 20, 2023, from 

Tikkanen, R., Osborn, R., Mossialos, E., Djordjevic, A., & Wharton, G. (2020, June 5). United States. International Healthcare System Profiles . Retrieved February 20, 2023, from