Down and out in New York City: a participant-observation study of the poor and marginalized.

Abstract: Poor and marginalized individuals have greater difficulty accessing health care compared to more privileged members of society. Classic theories on poverty help to explain the relationship between poverty and health. In an attempt to understand the experiences and perceived needs of the poor as well as their interactions with health care providers, a participant-observation study was conducted. The investigator spent time on the streets of New York City among the poor and homeless and attempted to access various health care services specifically set up for this population. The purpose of this article is to describe what it was like to be "down and out" and in need of basic health care. Key Words: Homelessness, Marginalization, Poverty Approximately one in every seven American citizens lives at or below the federal poverty level, and one in every five American households has difficulty meeting basic needs including buying food and paying utility bills (U.S. Census Bureau, 2000). More than 44 million Americans, including nine million children, have no health insurance, and every month more than 100,000 people lose their health insurance (National Coalition for the Homeless, 2005a). In New York City during the winter of 2004-2005, more than 36,000 homeless men, women, and children slept each night in shelters, and thousands more slept on the sidewalks, in the parks, or over subway vents (Coalition for the Homeless, 2005). When estimates of poverty and homelessness are compared across subgroups of the population, it is clear that the chances of living in poverty are not randomly distributed in society. Minorities, children, the elderly, and female-headed households have a greater chance of being poor than other segments of the population (National Coalition for the Homeless, 2005b). Such a non-random distribution of poverty raises questions about the nature of poverty. What characteristics increase a person's risk of living in poverty? What is it about the nature of American society that promotes higher rates of poverty among some groups than others? Most importantly, what is it about American society that allows such staggering rates of poverty to exist? THEORIES OF POVERTY The Culture of Poverty Theory There are four basic theories of poverty in the classic social science literature. The culture of poverty theory, having the longest history in anthropology and sociology, suggests that the characteristics of the poor help to cause and perpetuate poverty (Banfield, 1970; Galbraith, 1979; Lewis, 1966a, 1966b, 1998). Originally intended as a "liberal, innovative perspective since the 'poor' had previously been construed as lacking culture" (Solinger, n.d., ¶1), this theory has now been largely rejected by social scientists. Even so, the theory continues to be popular among conservative politicians and policymakers as well as the general public. Analysts and proponents of the culture of poverty theory argue that poverty produces people with unique personal characteristics (e.g., present-oriented outlook, hopelessness, sense of fatalism, lack of work ethic, "disorganized hedonism," "irresponsible self-indulgence") that in turn help ensure that the poor and their children remain in poverty (Samuelson, 1997; Solinger, n.d., ¶1). Social scientists have paid considerable attention to the trait of present-time orientation. This trait is hypothesized to be important in perpetuating poverty and preventing upward mobility out of poverty because the poor learn not to delay gratification or plan for the future, and they are not psychologically prepared to take advantage of new opportunities. Alternately, this trait is thought to be a coping mechanism since it would be psychologically damaging to continually worry about or plan for a future that holds no promise of improved life circumstances or a better life (Lewis, 1966b). In short, the poor must learn to live for today. On an individual level, the poor are believed to have strong feelings of helplessness, dependence, inferiority, and marginality (Lewis, 1998). …