These two books, each in its own way, provide much-needed resources for thinking about how public policies should change to address the latest developments associated with the enduring problem of unequal access to basic resources in U.S. society, including housing and health care. In recent years, unequal access to affordable and decent housing and uneven access to affordable and decent health care both have taken on new features posing new challenges for participants in the public policymaking process. The Geography of Opportunity, edited by Xavier de Souza Briggs, brings together a set of richly detailed essays that look at the housing disparity problem from the increasingly popular perspective of regionalism; and The Social Medicine Reader, edited by Jonathan Oberlander and colleagues, offers an equally informative group of essays that range more widely to address a variety of issues concerning the changed landscape of health care in the United States today. Both books are likely to prove to be critical resources for energizing renewed efforts to make policy less exclusionary in each area.
As William Julius Wilson highlights in his Foreword to The Geography of Opportunity, the persistent trends toward uneven development in metropolitan areas serve only to exacerbate racial and ethnic inequalities now that with the dawn of the twenty-first century, non-Hispanic whites for the first time are not a majority of the population of the largest 100 cities in the United States. Wilson agrees with the contributors to the book that a regional perspective now takes on a renewed sense of urgency, especially since the federal government has become decreasingly interested in funding housing development. Briggs's introduction underscores how far, in fact, federal as well as state and local housing policy has fallen away from the goal of promoting more inclusionary development in the metropolis. Briggs is not overstating the case, it seems, when he bluntly notes that racial and ethnic segregation has been removed from the policy agenda. It is no longer even an actively monitored issue that most policymakers feel the need to address. Things have changed radically. He notes that the volume is designed to help put that issue back on the agenda. And the chapters in this book provide a mass of information to help make that case.
The essays in the book are presented in four parts. The first set examines the role of discrimination in housing choice as affected by the actions of buyers, sellers, lenders, realtors, and just about anyone else who has anything to do with how residents come to live in one place or another in the metropolis. A really interesting issue is raised when Camille Zabrinsky Charles introduces the concept of “racial comfort zone,” which implies that a significant number of residents choose location on highly racialized grounds that are not necessarily tied to explicitly racist attitudes as much as a preference for protecting the privileges associated with being white. Yet this distinction does not amount to much for Charles because it still ends up reinforcing racial segregation and all the problems associated with it. Race and place are still highly imbricated with each other, even if public policy has given up on doing much about it or its deleterious consequences. In other words, the problem is not so much necessarily whether there are still the same levels of explicit racism operating in white society, though there are reasons to think that attitudinal surveys showing declines on this score need to be treated with at least a bit of skepticism. Instead, the issue is that racial segregation is still a significant preference point for many residents in the metropolis even if they do not hold explicitly racist attitudes. And therefore, correspondingly, the negative consequences of racial segregation, as in uneven access to basic resources like schools and jobs, are also still very much a major problem regardless of whether there is less racism in post–Civil Rights America.
The second set of essays reviews findings on the limited initiatives in place to help promote economic and racial integration in housing. John Goering's piece on the multisite, experimental, demonstration project Moving to Opportunity (MTO) underscores both its importance, given the failure of public policy to promote development in poor inner-city neighborhoods, and its lack of positive results according to the extant research. While the research indicates that MTO can lead to improved social and economic well-being for the participants who get to move from racially segregated, low-income, inner neighborhoods, suburbs have often proven reluctant to participate, and not enough research is being done to understand which communities would be more receptive and how less-receptive communities could become more so. The third set of essays addresses the issues of coalition politics, especially when trying to devise regional solutions to racial segregation. The Twin Cities comes in for intensive analysis in the essay by Edward Goetz, Karen Chapple, and Barbara Lukermann, as well as the essay by Mara Sidney. The first highlights how the Twin Cities Metropolitan Housing Council in the 1970s was innovative but eventually failed to fight effectively segregationist housing patterns because it lacked both enough funding and enforcement power. The Sidney essay highlights how more recent developments in the Twin Cities to promote more affordable housing in the suburbs has floundered on the shoals of the racial issue because it failed to take that on explicitly. The two concluding essays drive home the point that racial segregation is highly institutionalized in housing policy and practices in the United States today, and that requires a broad coalition of diverse actors if effective change is to come about. Whether the result of a deep reservoir of persistent racism or an artifact of how racial disparities result from a failure to revise institutional practices, the deleterious consequences of racial and ethnic segregation continue to create some of the most significant social problems of our society.
The Social Medicine Reader is based on readings assigned in the interdisciplinary seminar Medicine and Society required of all first-year medical students at the University of North Carolina at Chapel Hill. The course has been taught since 1978 and this volume under review is the second edition of the third volume of the reader. This volume emphasizes the controversies in health policy. It is great to know that future doctors are reading this book. It ought to be required of all medical students. If it were, it is likely that a majority of doctors would have been pushing for national health insurance a long time ago. While the readings cover many issues, from rationing to managed care, to queuing for donated organs for transplants, to the intergenerational conflicts over health-care financing, an underlying theme is that while our highly privatized system of entrepreneurial medicine may lead to great innovations and wonderful care for those who can afford it, it also increasingly fails to ensure equitable access to quality health care and does so in ways that pose increasing risks for the well-being of our society overall. In her excellent chapter on managed care, Deborah Stone writes: “If we want compassionate medical care, we have to structure both medical care and health insurance both to inspire compassion. We must find a way, as other countries have, to insure everybody on relatively equal terms, and thus divorce clinical decisions from the patient's pocketbook and the doctor's personal profit…. There is no perfect way to reconcile cost containment with clinical autonomy, but surely, converting the doctor into an entrepreneur is the most perverse strategy yet attempted” (p. 17).
Although the book poses a variety of issues on how the health-care system in the United States operates in less than equitable ways, it is basically silent on the racial implications of uneven access. For instance, there is growing appreciation that even the issue of organ donor disparities is racialized in part due to a failure to reach out to and serve nonwhite communities, making donor matches based on blood type harder for some groups. This and other issues of racial disparities in health care need to be discussed in a volume like this, or future doctors will be at risk of not learning about the role of race in creating and perpetuating many of the most important issues of inequitable access and treatment in health care.
Taking these books together, we can see how race and class are seriously entwined in the United States in ways that political scientists have yet to fully comprehend. Through its examination of the persistence of housing segregation, The Geography of Opportunity highlights how many whites participate in housing markets in ways that underscore their fear of losing the class benefits associated with being white; and The Social Medicine Reader by implication can be used to show how many nonwhites are disadvantaged in accessing health care because of their low class position in our society. And what is true for housing and health care is also probably true for education and jobs and other critical resources. The challenge is to talk about the intersections of race and class and how they help create systematic inequities in access to the major social goods people need to thrive in the United States today.
