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She has no idea how much he hates her. And as I watch the perky blond nurse wipe drool from my father's face, I hate her too. He spits up more mucus when she adjusts the giant caterpillar of a tube that pumps oxygen into his lungs, and I wince. I don't feel sadness or fear; I'm not even grossed out. I'm just angry. That's what the old man would want. He'd want me to resent this white girl's innocence with him, if his brain were still alive.
My father came a long way to arrive at his deathbed at the age of 57. Fifteen years ago, he ranked among Indianapolis' premier physicians, treating a largely working-class black clientele in this same hospital. But the way he griped about it, you would think he spent the day sweeping floors instead of doing surgery. He'd come home tired and frustrated, complaining about the indignities he'd suffered: The white nurses who snuck behind his back to change a patient's care. The principal at my all-white elementary school who wanted to put me in special ed because of my "temper problem." The white lady next door who had made some remark about the length of our grass, or otherwise policed our property.
He developed a real attitude about the whole thing; Chris Rock had nothing on Dad's angry-black-man routine.
My father excelled in life. He was off to college at 16 and went on to get a medical degree from the nation's most prestigious black university. His legion of one-time patients and proud former schoolmates would corner me in drugstores and gas stations all over town, "Hey, little doc!" I could go nowhere without bumping into his achievements.
Yet, here we are, both rendered dependent upon this indefatigable young nurse. "How you doing today, Dr. Wright?" she beams as she pokes around the edges of his mouth with one of those loud spit vacuums that dentists use. "I bet you helped soooo many people," she softly recognizes. Everybody but himself, I snort under my breath.
As disabling diseases go, diabetes is among the most insidious. If it runs its course, as it did with my father, it will shut down most bodily functions: mobility, sight, kidney, and finally the heart. More than 2.5 million African Americans have it, which is 80 percent higher than the disease's prevalence among whites. More than 9 out of 10 black diabetics have type 2, the version that develops in adulthood. Why some people get it and others don't is still subject to considerable medical debate, but most opinions fall into two camps: genes versus lifestyle.
The genetics theory is driven by the commonsense observation that adult-onset diabetes runs in the family--if your parents had it, you are more likely to as well--and researchers are frantically searching for a guilty gene. The lifestyle, or "conditioning," argument blames obesity and inactivity, both of which happen to be more prevalent among African Americans.
This same genes-versus-lifestyle debate applies to a range of deadly illnesses that disproportionately plague black America--and middle-class black America in particular. From heart disease to AIDS, African Americans are dying from preventable illnesses in disturbing numbers. The diabetes mortality rate is 20 percent higher for black men than white men, and 40 percent higher for black women.
Progressive convention says the problem lies in poverty: too many black people uninsured, too few with access to routine care. And there's certainly clear enough evidence of a link between disease and poverty. But what no one can figure out is why the problem is getting worse even as socioeconomic conditions are improving. How does a successful, educated, and well-insured man like my father die before the age of 60 at the hands of a disease that is totally preventable?
Here's where the debate turns political. If genes are decisive, then no one is to blame for the racial imbalance in Americans' health. If it's lifestyle that divides the sick from the well, then the problem is a matter of personal choice.
But there's a third way to look at the disparity, one that is both more complex and more disturbing. This theory holds that black folks carry a legacy of disease that isn't genetic but that nonetheless is transferred from one generation to the next--and eventually catches up even with those who clamber up the socioeconomic ladder. Dad died, according to this theory, from the side effects of racism.
I was 13 when I learned what it meant that Dad had "sugar trouble." We were watching The Simpsons, and during a commercial he told us that he needed an operation. He pointed to his pinkie toe; it was jet black and had dried up like a date. It was dead, he told us, and would have to be cut off--a common problem for diabetics, because poor blood flow allows routine skin injuries to turn infectious. I soon learned that once they start chopping things off, they rarely stop with a toe. By his mid-40s, Dad had lost everything below the kneecap on his right leg.
My father was around 6 feet tall and on the far side of the 300-pound mark for most of his 40s and 50s. He never figured out how to balance his large frame on the prosthesis, and that gave him a wobbly gait. I was alternately embarrassed and horrified when he came to my football games, awkwardly propelling himself across the grass. Jesus, I'd think, what if he falls? The same thought was written on his face. But at least he was still working back then, still showing up for the games in a suit and tie, with his meticulously groomed mustache and tidy modified Afro, looking every bit like a ridiculously out-of-shape Apollo Creed. Only the unsteady stride set him apart from the other parents--that, and the fact that everyone else was white.
Throughout his adult life, the closest Dad ever got to exercise was stalking the halls of the downtown Indianapolis hospital he worked and died in. Obesity had been the norm in his family. Both of his siblings were overweight, and both developed diabetes and heart disease before middle age.
The only organ any of them ever really took care of was their brain. Like most upwardly mobile black boomers, my dad had a belief in education that bordered on reverence. "Mind like a steel trap!" he'd belt out after reciting some arcane piece of data. His intellectual cockiness was boundless, and whether he was instructing my attorney brother on the finer points of law or lecturing me on the value of a hip-hop song he'd never heard, I had to give it to the old man--he always had the marrow of it right. "Boy, I read," he'd laugh, mocking our challenges to whether he knew as much as he thought he did. "The problem with your generation is that you actually celebrate ignorance."
Education had been the key to his end run around Jim Crow, his defiant response to people like the grade-school teacher who told him that black boys from the East Side don't grow up to be doctors. But in the midst of all that learning and achieving he never got around to the walks in the park or turns on the treadmill that will keep you alive despite diabetes or heart disease.
By 50, a series of strokes had turned Dad's precision hands into clubs. The diabetes next started chipping away at his sight. It eventually all but immobilized him, and it sparked the kidney failure that landed him in the hospital for the last time.
Toward the end, when his illness gave him all the time in the world to sit and think, my father was keenly aware of the irony of his situation: He had spent his career counseling black folks about how to stay healthy. I'd ask him why he never followed his own advice, and he'd twist his face into that same disbelieving stare, shocked I couldn't do the math on my own. "When would I have the time to go to Fall Creek and take a walk, Kai?"
True, but the answer was never quite sufficient. In his medical practice, he witnessed every day the hidden tragedy of the late-20th-century tale of racial progress. Since the civil rights movement, African Americans have improved their lot in life by almost every measure: Black and white incomes are more equal, the racial gap in school dropout rates has been cut by a third, the glass ceilings of many professions have at least cracked. But in that same period, black America has made no progress on what may be the most important measure of all: living to see old age.
According to a paper coauthored by former Surgeon General David Satcher that appeared in Health Affairs last year, the gap between black and white mortality rates exploded among middle-aged men during my father's lifetime--rising by just over 20 percent between 1960 and 2000--while the overall black-white death gap hasn't budged from an alarming 40 percent since Dad was a grade-schooler. In an accompanying article, University of Michigan sociology and epidemiology professor David Williams highlighted specific trends. Black and white death rates from heart disease were equal in 1950; by 2002 blacks died 30 percent more often. Blacks had a 10 percent lower cancer death rate than whites in 1950; now it's 25 percent higher. The infant mortality gap doubled between 1950 and 2002.
As you move up the economic ladder, black health drastically improves, but the disparities between blacks and whites do not. One dramatic study showed that infants of college-educated black women are twice as likely to die as their white counterparts, largely owing to low birth weight. If genetics isn't the explanation for those sorts of counterintuitive facts, what is?
The answer, a growing number of researchers say, is that the vaunted black middle class simply ain't all it's cracked up to be. Black strivers have a much harder time turning their paychecks into the status, opportunity, and security that white yuppies take for granted. "Maybe one of the sources of the anger of the black middle class," suggests Brandeis University sociologist Thomas Shapiro, a leading proponent of the theory of differential realities for bourgeois blacks and whites, "is that they look in the mirror and they know how hard they've had to work. But they understand that they've not 'made it' in the same way as their white office mates."
The resulting dissonance--harder work and longer hours to reach success, stress from discrimination that you can neither mistake nor prove--eventually manifests itself in the bodies of people like my dad. They don't have time to take care of themselves, and even when they do, wellness is just not a priority. So as the white middle class has grown more healthy in recent decades, the tenuousness of black middle-class life has left many stumbling through a vicious circle. It's harder for "bourgie" blacks to leverage the advantages of our nominal status, so we are more likely to be plagued by health problems associated with poverty, which in turn undermines our ability to sustain what class mobility we've eked out.
Despite all of the material success he achieved in life, my father died deeply in debt, largely from unpaid taxes on the symbols of middle-class life he had once accumulated--a nice house, a nice car, his own business. By the time he got hold of his dream, he could no longer stay healthy enough to keep it.
The white poster board that always hung in my parents' bathroom, with its numbers neatly printed in colored marker, looked like something from one of my overachieving brother's science-fair projects--a chronicle of his boxcar's velocity, perhaps. It was supposed to be charting my dad's weight loss, but it just marked his steady fattening. Its very presence pissed him off. This was exactly the sort of nagging my schoolteacher mom was good for.
That was back when we were upwardly mobile black folks. We had a modest house with a big yard and a pool, the only African Americans in our neighborhood. For that matter, my brother and I were the only black kids not bused to our grade school. It was the mid-1980s, but integration remained a novel concept in Indiana. Race politics in Indianapolis have always been typified by what Notre Dame historian Richard Pierce has dubbed "polite protest." At its founding, Indy was the nation's only state capital situated on a non-navigable river; it was chosen for its central location rather than the existence of any real economy. It's never been a place for frenetic movement--people in Indy get hold of something and keep it. Blacks were here from the city's humble inception, so we appreciate stasis as much as everyone else. Black and white worlds have learned to tolerate each other, largely by whites ceding certain parts of the city's life and by blacks staying content with their allotment.
As late as the 1980s, blacks lived in a handful of clearly demarcated neighborhoods and sent their kids to unambiguously black schools. The old man's robust medical practice broke our family out of this mold. He sent us to a Jesuit high school and pushed around Indianapolis in his early-model sports car, the backseat piled with discarded McDonald's bags. He worked a lot of hours to get that house and car, and it meant lunch and dinner on the run, gobbling fries from salty sacks snatched up at drive-through windows. My mom's poster board never accounted for that fact.
When he did sit down to a dinner, Dad was partial to the salt-laden, fatty soul food that he grew up with--recipes passed down over generations, from a time when black folks had to tease flavor out of meals cobbled together from scraps. Psychologically and emotionally, Dad never strayed far from that hardscrabble history. He never really got along with other middle-class people--including both my mom and his second wife. Both marriages ended in divorce, at least in part because of fights about his unwillingness to take care of himself.
I've always wondered how many of those disputes, and how much of his inaction in the face of growing health problems, were proxies for his reluctance to embrace the status he'd worked so hard to reach. He had a pool he never used, a suburban house where he rarely entertained. Even his choice of sports car, the ultimate marker of male success, lacked some of the requisite flash--a light blue Datsun 280Z. We all knew not to bother him with anything that smacked of showing off. Come the holidays, you might as well give him a dead fish as an alma-mater sweatshirt. As my mom always succinctly reminded us, "You know your daddy don't like all that stuff."
Dad came from a long line of class climbers. The furthest back his family's collective memory goes is to Dan Gurly, who took his last name from the Alabama town that his slave owners lorded over at the end of the Civil War. Dan lived past 100, and right up to his death he farmed cotton on the land he had slowly bought through sharecropping. "My momma and them had his age as 103," remembers my grandmother, "but some of the whites there say he was the same age as they granddaddy, and say he was older than 103."
My grandmother spent her childhood summers with Dan. She recalls not only his relative prosperity but also his sense of an earned status to go with it. "He was very proper. You know how we take fish and pick it with our fingers? His fingers never touched food. But just to talk about slavery--he didn't ever talk about it to me."
He and his wife had eight kids, all of whom rose to their era's equivalent of white-collar jobs--preachers, mailmen, morticians. Leveraging income from Dan's farm, his kids and their families got plots of their own in Gurley, and the homes lined up one next to the other. Dan's youngest, Isabella, went north with her husband, Harrison; they ultimately joined a massive black migration to western Kentucky's coal mines. Coal mining was a lot like the sharecropping Dan Gurly had climbed out of: The company held all the cards. Rent, groceries, doctors' bills--they took it all out of your paycheck. But Harrison and Isabella made it to what felt like middle class. They had money in their pockets, kept some savings, and Harrison stayed dressed to the nines when he wasn't in the mine.
He also began a tradition of heart disease that has continued with every male, and most females, on my dad's side of the family. His work was physical enough that, despite a soul-food diet, he never got obese as later generations of his family would. But he smoked Lucky Strikes until the day he died, and that combined with "black lung," earned while working in the coal mines, finally brought heart trouble in his 60s. Isabella died at 62 of diabetes, and Harrison's heart gave out at 72. That's 25 years longer than his son-in-law's heart lasted, and 15 years longer than the grandson he barely met--my father.
Dad's class ascendance was arguably the most impressive in our family since Dan Gurly's. He was the first to go to college, let alone graduate school. And his annual income reached $100,000 at its peak. He was typical of the slice of black baby boomers who reaped the early benefits of the civil rights movement. In 1960, fewer than a million African Americans had what sociologists define as middle-class occupations. By 1995, nearly 7 million blacks held such jobs.
But Brandeis' Shapiro, author of the book The Hidden Cost of Being African American, says these numbers don't tell the whole story of black bourgeois life. According to one study Shapiro cites, middle-income black families worked the equivalent of 12 more weeks in 2000 than did whites with matching incomes. "That puts more stress on the family--less leisure time, less downtime," says Shapiro. "There's a reason why people go to fast food: Wifey can't stay home and cook anymore."
Moreover, Shapiro argues, income, job title, and even education are all misleading: The true middle-class measuring stick is wealth, or total assets and debts, and that's where the black-white gap explodes. At the century's close, the typical black family possessed 10 cents of wealth for every dollar held by its white counterpart. Even more telling, as both black and white families gained net worth during the booming 1990s, the gap between them grew as well.
"One of the ways that the wealth gap manifests is that most families just starting out have a rainy-day fund, or a crisis fund--a couple of months' worth of money for that health care crisis, that bad brother who keeps getting arrested," explains Shapiro, whose research team interviewed a couple of hundred primarily middle-class families. "There's a lot less likelihood that the African American middle class has that money set aside. And even when they do, there are a lot more demands put on them."
They help extended family members, support parents who are both more likely to be wealth-poor and more likely to have faced early retirement due to disabling conditions like heart disease. "It looks the opposite for the white middle class," Shapiro continues. "They have very few financial demands placed on them. In fact, it's pretty clear that they are still receiving."
Parents and grandparents help with the first down payment on a home, pay a greater share of college tuition to avoid loans, or have a comfortable retirement that allows them to help with the grandkids while mom and dad pursue career opportunities.
So, for white America, Shapiro concludes, class ascendance is a progressive, generation-by-generation process. The men in my family each had to start from near the beginning--and in some cases, as with my grandfather Troy, had their climb slowed and complicated each step of the way by their parents' illnesses.
I've never really known an old man. My mother's father was laid low by Alzheimer's while I was still a toddler; I was in grade school when he died. And Grandpa Troy Wright was long gone even before that.
Troy always wanted to be a doctor, but he started working the coal mines right after high school. His father's heart trouble began while Troy was still a student, so Troy and his two brothers supported the family. When Troy got drafted during World War II, he tested so well on the Army intake exam that his superiors tapped him as a candidate for the small crop of black officers that civil rights activists and Eleanor Roosevelt had advocated they create. But Troy did the math and realized it wouldn't work: The promotion would mean losing allotments the Army was paying out to his parents and wife, which because of his father's disabling illness they needed to survive. He dropped out of officer training school but made it to sergeant major, the top rank he could get without a commission.
After the war, he relocated to Indy. He lived on the proverbial black side of the tracks but slowly worked his way into the middle class by breaking color lines on the job. His brothers got him on at a naval ordnance factory. Ambitious as usual, he studied to become a machinist and eventually landed a spot building prototypes for classified projects. He spent 20-some-odd years as the only African American in his division. "He didn't never give it any thought," my grandmother insists. It may be more accurate to say that, like all Hoosiers, he learned to live with it.
He sent his oldest son to Korea and his other two kids, including my father, to college before packing up and buying his first home on his own--in a white neighborhood. They were the third black family to move in. Troy had spent his life deferring dreams, and with his new house he'd finally gotten something for himself. But by that point, he'd long been discreetly sliding pills under his tongue to ward off heart attacks.
We're not sure exactly when Troy developed heart trouble, because he never really let on that it was a problem. He rarely missed work, rarely complained. "He would go back and forth to the doctor, but he wasn't down sick," my grandmother remembers, before adding, "he had begun to talk though. He'd be talking about something, and he'd laugh and say, 'My time is running out.'"
He had a perverse sort of pride that doctors treating African Americans, particularly men, often point out--a reluctance to admit they need help or perhaps to accept that they may have to slow down in the work that's kept their families moving forward. My father never said as much, but I wonder if he concluded, watching his dad, that being a strong black man meant dying quietly.
When Troy left for church one Memorial Day weekend, he turned all the lights on outside of his brand-new house. My grandmother noticed it when they came home that evening. "I asked why. He say, 'Well, I can say I seen the house in the winter and I done seen it in the spring and I can almost imagine how it'll look in the summer and fall,'" she remembers.
They went inside. "He sits on the side of the couch and turn on the television. And I went on by, and he say, 'You going to bed?' I say, yeah. And he say, 'Well, I'm going to bed, too.' And he gets up and come on and sits on the side of the bed and say"--whooophm, she sucks in a deep breath--"and he was gone." He was 48 and died of heart failure. He'd likely been having a heart attack all day.
Today, Troy might be a candidate for the latest experiment in the debate over health and race. A Massachusetts-based drug manufacturer made big news in late 2004 when it published successful results of the first major trial of a "race drug"--a medication targeting blacks. Previous clinical trials had shown that many heart medicines often work less effectively for African Americans than for whites. The manufacturers of this new drug, BiDil, believe there must also be some that work better for blacks.
BiDil is designed to counter nitric-oxide deficiencies in the blood, which studies have suggested are more likely to befall African Americans. Nitric oxide helps expand blood vessels and thus fends off heart attacks. The manufacturers tested BiDil in a cohort of more than 1,000 African Americans already in treatment for heart disease and found that those using the drug had a whopping 43 percent better chance of surviving than those taking a placebo. Last year, BiDil became the first race-targeted drug to win approval from the Food and Drug Administration.
BiDil's success in keeping blacks alive where other drugs so often fail has been impressive, but it's still unclear whether the drug works better for blacks than whites--largely because the manufacturer is decidedly uninterested in that particular question. In an October article in Health Affairs' online edition, researchers Pamela Sankar and Jonathan Kahn lay out the disturbing process by which BiDil won its race-specific patent. The drug combines two generic components long known to be individually successful in reducing mortality from heart disease. BiDil's manufacturer, NitroMed, put the generics together and studied the new combination's effectiveness for one racial group. The combo is likely just as successful for all groups, but proving that would not have won NitroMed a new patent--one that is expected to generate $120 million in just the first year of sales.
Such untidy facts notwithstanding, the thesis that health disparities are driven by biology is popular, in part because of its convenient political implications: If our bodies and genes are the culprits, then targeted drugs--not social change--are the solution. Yet researchers point out that there is greater genetic diversity within the commonly defined racial groups than between them. And, the University of Michigan's Williams notes, many health disparities are actually more dramatic between classes than races--between rich and poor blacks, as opposed to between blacks and whites of the same class. Black people are healthier the better off they are--just not nearly as healthy as whites.
To Williams, a big part of the problem is that many middle-class blacks live daily with the sorts of health threats researchers have long associated with poverty. Environmental hazards, unhealthy food, a surplus of killers like cigarettes and booze--these are all concentrated in black neighborhoods like the one where Troy raised my father. And rising income and a fancy title rarely break you out of residential segregation.
"I travel and speak on this a lot," says Brandeis' Shapiro, "and the angriest I hear middle-class black audiences get is when I talk about home ownership." Since whites tend not to buy in black neighborhoods, the houses there face a narrower market and are thus worth less (Shapiro's study put the gap at $28,600); the fear of falling property values that instigates white flight is self-fulfilling. The once all-white neighborhood Troy and my grandmother moved into in 1971 is today entirely black.
For scholars like Harvard University public health researcher Nancy Krieger, the subtle dynamics of racism point to a deeper cause for health disparities. In 1994, she articulated a theory that posits we all "embody" the social and economic contexts we live in.
"What happens when you are constantly engaging your response to danger?" she asks. "The systems that are supposed to be compensating for the wear and tear of daily life get worn out." Hypertension, or high blood pressure, is the most obvious example of a stress-related illness that kills blacks at far higher rates than whites. Studies have established that people who report more experience with discrimination are more likely to have high blood pressure.
In a similar vein, Krieger has found that women--of any class--who reported high levels of experience with racial discrimination were nearly five times as likely to deliver underweight babies as those who reported no experience with it. Low birth weights offer an ideal example of how embodiment works because they illustrate how health problems extend over a lifetime and pass from generation to generation: Underweight babies are more likely to develop heart disease, diabetes, hypertension, and respiratory disease later in life, and women who have these problems are in turn more likely to give birth to underweight babies.
Scholars pursuing the embodiment theory also point to cultural norms that grow out of inherited social and economic inequalities. Many sociologists have noted America's differing cultural ideas about what makes a body ugly or beautiful--a woman built like Julia Roberts is considered grotesquely thin in most black and Latino neighborhoods. As a young gay man living in New York City, I find no one remarks on my unsculpted frame. But when I go home, my thin waistline makes me a "health nut." "You still eat rib tips?" one cousin asks skeptically each time I visit.
These ideas stem at least in part from diet, which itself is shaped by environment. None of us has to eat the soul-food dishes that have been in our family since slavery, but that's what we've come to want. Likewise, no one has to eat fast food--but it's awfully convenient when your neighborhood has three McDonald's and not a single grocery store.
All of this begs a chicken-and-egg question. Does lower socioeconomic status cause health problems, or do health problems cripple a family in its effort to move up? For now, the answer largely depends on whether you ask an economist or a doctor. What's clear is that health problems can and do make middle-class people "fall from grace," as Shapiro puts it.
The bubbly young nurse reverently dabbing Dad's drool could have no idea how precipitous his plummet had been. Long gone was the house, the car, the medical practice. He'd had neither enough resources nor enough time in the workplace to build a retirement nest egg, so in his final years he lived on Social Security disability insurance. All of his long hours, shuttling back and forth between his office and this hospital, ultimately failed to change our family's class fate much.
At least we held our ground: Troy and Grandma got my father to college, and my parents did the same for us. But none of us will take part in the historic wealth transfer now under way in America: According to another study Shapiro likes to cite, parents will pass on a total of more than $10 trillion to their adult kids between 1990 and 2040.
My brother and I, like our dad, tally a different inheritance--a zeal for learning, a willful temperament, and a boundless ambition to climb at least a little farther up the success ladder than the old man made it.
This article was produced under the auspices of the George Washington Williams Fellowship of the Independent Press Association.