We’re proud to share that author Danielle Raudenbush has won the 2020 C. Wright Mills Award for her book, Health Care Off the Books! This honor, awarded annually by the Society for the Study of Social Problems, is one of the most prestigious book awards in sociology. The award recognizes “the most outstanding book written in the tradition of C. Wright Mills and his dedication to a search for a sophisticated understanding of the individual and society.”
In this interview with Raudenbush, we take a deeper look at the book, including what motivated the project and how the book’s insights have continued to be especially relevant through the COVID-19 pandemic, which has disproportionately impacted African American communities.
Informed by three and a half years of fieldwork in a public housing development, Health Care Off the Books shows how residents who face obstacles to health care gain access to pharmaceutical drugs, medical equipment, physician reference manuals, and insurance cards by mobilizing social networks that include not only their neighbors but also local physicians. However, membership in these social networks is not universal, and some residents are forced to turn to a robust street market to obtain medicine. For others, health problems simply go untreated. While the practices described in the book may at times be beneficial to people’s health, they also have the potential to do serious harm.
Danielle T. Raudenbush is Assistant Professor in the Department of Sociology at the University of California, San Diego.
What motivated you to write Health Care Off the Books?
My book draws on two well-established findings in health research. The first is that low-income African Americans face significant obstacles to accessing healthcare. The second is that African Americans have, on average, worse health across many measures compared to others.
I was motivated by a question that arises from these trends but has been overlooked in past research: If people are unable to access health services, how do they treat their health problems when they become sick? This question is of fundamental importance if we are going to understand and improve the health and well-being of African Americans.
One of your key findings is how low-income African Americans mobilize their social networks to get care. Can you talk more about the significance of this finding?
Oftentimes we envision healthcare as involving only activities that occur within the formal health care system, meaning within places like hospitals and clinics and delivered by professional health care providers. Healthcare for people like the participants in my study is very different from this conceptualization. My book shows that people’s social relationships —including relationships with friends, family and others—become a central conduit through which all kinds of health-related resources pass, including items like pharmaceutical drugs, medical equipment and medical manuals.
This demonstrates that we need to reconceptualize the U.S. health care system as a formal-informal hybrid. Health care for low-income, Black, urban populations is not a bounded system limited to formal health care delivery. Instead, it also extends into an informal social realm.
When we understand health care as a formal-informal system, we can better evaluate its effects and gain new insights into sources of social and racial disparities in health outcomes.
How can Health Care Off the Books help us understand the experiences of African Americans and the COVID-19 pandemic?
African Americans have been severely affected by the COVID-19 pandemic. Compared to whites, they are more likely to become sick with COVID, more likely to be hospitalized for the disease, and also more likely to die from it. While the explanations behind these outcomes are multi-faceted and complex, one involves the fact that many African Americans lack access to care.
Health Care Off the Books provides new, previously unrecognized insights into the obstacles to care that African Americans face, particularly those who live in areas characterized by disadvantage. It also highlights how, when people are not integrated into the health care system, they are forced to develop alternatives that do not necessarily provide them with effective means for protecting their health and well-being.
What is the one message you hope readers will take from your book?
My book describes the experiences of a community of people as they attempt to navigate a healthcare system that is fundamentally unequal. The lives of residents of this community are marked by considerable disadvantage, and many face significant obstacles to accessing care. Because of this, they are often left to develop healthcare strategies that may at times be helpful but can also clearly be harmful to their health. After reading the book, I hope that people understand the moral obligation we all have to work for a more just and humane healthcare system in the U.S.
What are you working on now?
My current project examines healthcare among Mexican immigrants who live in San Diego, CA, which is located on the border with Mexico. A central finding from this project is that some members of this group strategically combine the use of health services in the U.S. with health services in Mexico to achieve what they believe to be optimal care results. Their behaviors include, for instance, seeking care in the U.S. for a health condition and, if dissatisfied, going to Mexico for care; getting care in the U.S for certain health conditions and Mexico for others; going to Mexico for specialist care when their U.S. doctors will not refer them to specialists; and going to Mexico for pharmaceuticals their U.S. doctors will not prescribe.
Similar to Health Care Off the Books, this project reveals what health care looks like in practice for a population that is often marginalized within the U.S. healthcare system and highlights the on-the-ground processes through which people co-construct a new system of care.