Beyond the Pink Police State: Community Health Workers

James Poulos’ recent exploration of what he dubs the Pink Police State lays out an argument that is clear, even if not immediately accessible: our obsession with health coincides with a desire for impulsivity that has not only led to social permissiveness regarding sexual behavior, but state involvement to ensure that all behavior, even that which is considered transgressive, is appropriately hygienic. Those who prefer the sacrifice of political freedom for interpersonal hedonism are all too happy to lean on whatever political categories– libertarian, progressive, or indifferent– are in vogue at any moment, so long as our existential restlessness leads us to either sexual satisfaction or continually cruising for the next round of jollies. Similarly, our economic restlessness should leave us either satisfied with buying things or continually cruising for the Marxist revolution. His solution to this not-quite-Brave New World era is human conversation and an assent to human malleability to overcome the comfortable patterns of thought that enslave us in the Pink Police State.

Poulos’ diagnosis, which pins the statist delineation of safe and unsafe sex on “elitist technocrats and erotic populists,” is close enough to the truth to throw us off the chase. There is indeed reason to fear the erotic populists, as I’ve already elucidated how sexual libertinism is class warfare, a point that Ross Douthat has extended to the technocrats. However, even once we have understood the siege tactics of our new regime, we must not only discern its architects more carefully, but we must also embrace more specific policies to facilitate the sort of face-to-face conversations that are necessary.

The main weakness in Poulos’ piece– the moment I was practically salivating for, especially when he deploys the metaphor of a tender pink steak– is that sex is the centerpiece of his conception of the Pink Police State instead of food. While the tempests of sexual politics are often the most pitched in American discourse, the food and drink we consume is of far more interest to our hygienic overlords. Most people end up caught in the natural endgame that ensues when sex is free enough to be used to sell anything and transgression is revealed as masturbatory: either they are consumed in an endless cycle of identity politics or they gently drift into something resembling monogamy. Sex is the sideshow in the Pink Police State, but food and drugs–which are responsible for far more deaths and subject to far more regulations–are in the center ring.

The arch-villains in the Pink Police State are those who profit off disease. When we raise our fists against statist manipulation of what goes into our orifices, we forget that these powers have been accorded to the state in part because industrial capitalism gave individuals, companies, and institutions power to destroy lives and communities. While there are certainly plenty of sex-peddlers who chew up and spit out the vulnerable, the profits extracted in the course of damaging the land and our bodies are far more formidable–as are the dangers posed to our health. When an enormous acreage of good soil can be abused to grow a vast monoculture of corn that is then turned into a large quantity of sugar that is subsequently exported across the world in carbonated beverages to drive up amputations due to diabetes, the djinn is literally out of the bottle.

The Pink Police State wishes to stem this tide through a variety of means, for better or for worse. I am happy to say that I have met some technocrats in my day (I do not know how “elite” any of them have been.) A great number have cared for such amputees and other people who have suffered harm from what we call “lifestyle” diseases. They are almost entirely moved by compassion and while they are paid (often by the state through one means or another) to treat or prevent disease, most would be happy to be out of a job if it meant that fewer people became disabled or dead at younger ages. While libertarians and conservatives frequently bristle at attempts to control the sale of certain substances (or, even worse, to make other substances safer to inject), it is crucial to recognize that the habits of behavior and thought that Poulos elucidates in Part 4 of his series can be shaped in ways that prolong lives. Regardless of whether or not one thinks that any restriction on tobacco whatsoever is worthwhile, it is useful to recognize that the effort made to reduce its use in America has resulted in a reduction in death and disability.

However, public health and population health are not merely measures of extending lives or preventing amputations. These things are measurable, which makes them useful to the technocrats, but health is far more than the absence of disease. Health is wholeness, as Wendell Berry has observed, and it is at this point that my sympathies with the Pink Police State part ways. A measurable decrease in amputations is hardly a victory if the preserved feet are still pointed at the droning television for the rest of the days that they are attached. Understanding the natural order of creation leads us to understand that our bodies are better suited for vegetables than soda; it takes only slightly more effort to realize that face-to-face conversations are just as much a part of our reflection of this order. Words like “holistic” are often thrown around casually to describe this philosophy, but we must appreciate the weight of holism that requires change in every aspect of our lifestyles from what is sold to how we have our conversations before this language can be useful.

Yet the powers that profit from disease and the state that wishes to magnify itself to save the day both seem to have little interest in holism; minimizing the power of one will only give the other more latitude to damage both creation and creativity. How then can conversation– beyond eloquent appeals on blogs– be fostered?

A better policy is needed, one that distributes the power of the state downward to facilitate conversations–perhaps, frankly, to subsidize them. This solution may be inherently unappealing to advocates of political freedom, who may see such subsidization as the most dastardly move of the Pink Police State yet. However, short of a sudden, spontaneous embrace of beloved community (which we can always hope, pray, and work for), we will have to use the apparatus of the state against itself and rebuild the power in neighborhoods and small towns.

What is this policy that might make more face-to-face conversations happen, improve the measurable health outcomes of our population, promote healing in wholeness, and perhaps even destroy the Pink Police State with its own money? James Poulos said that the future belongs to community organizers. I would suggest that the ideal kind of community organizer for this task of battling the twin powers of corporatist high fructose corn syrup and statist hygiene is a community health worker.

The concept is fairly straightforward, if perhaps unfamiliar. Like bidets and decent mass transit, community health workers have only shown up in America when decided effort against the status quo met an appropriate funding source. We probably have doctors to blame for not implementing the use of community health workers (CHWs from here on); the number of things that a good corps of CHWs could do would either directly compete with a physician’s business or prevent enough complications to put a dent in any hospital’s income. While no grand proposal at any state or federal level has (to my knowledge) ever emerged, the concept of publicly funded CHWs equipped to practice the right kind of medicine opposes the American health industry so obnoxiously that any number of existing powers would feel quite skittish about their existence (the exception to this may be hospitals in my own home state, which have been told by Medicare that they are receiving a predetermined sum for services this year and it is up to them to figure out how to spend less than that sum.)

What do CHWs do? Well, it depends on where they are and who is paying them, but in general they are responsible for ensuring that every member of their community gets the services that benefit everyone (e.g. vaccines and primary screening), and they keep an eye on members of the community who already have a chronic disease and need help managing it so that complications do not develop. More importantly, they are the facilitators for any community decisions regarding health and the link between any one cluster of people and the state funds for infrastructure necessary to keep people from dying young. They can be very specialized– for example, focusing specifically on HIV-positive patients– or more general, covering a broad range of needs for a community.

I like face-to-face conversations with my patients. It’s one of the best parts of my job. Quite frankly, though, for the healthy–or the almost-healthy, those who have one or maybe two chronic diseases–my seven years of medical training is overkill for ordering their shots and their mammograms. Those seven years might be useful if someone is trying to ascertain exactly what benefit they may gain and what risks they may run by submitting to my suggestions, but rarely are they necessary (also, rarely are doctors good at this.) Someone with a high school education and perhaps a 1- or 2-year certificate could probably do the majority of what I do for a much cheaper price, and with the right tools at their disposal, they could probably do it more efficiently than I could. Furthermore, if a CHW or team of CHWs were assigned to particular areas, then the face-to-face conversations that they have all day long about what their patients are eating and how their patients are feeling could have a great deal less rush to them than a similar set of conversations than with a primary care physician (who can usually only give you 15 minutes of your time unless you’re dying or paying extra.)

CHWs must be based in the community and (whenever possible) from the community that they serve, for it is in the intangible relationships and the tangible presence that they draw their power to communicate and distribute their knowledge that they have acquired outside their locale. These ties are also what gives them the power to organize their community against the forces outside that would take their money in exchange for a higher risk of diabetes or would take their political freedom to protect them from their own decisions. The best CHWs do not change health behaviors through coercion (as does the Pink Police State) nor through seduction (as does the transgressive factory farm), but through collaboration. They have been an instrumental part of empowering communities all over the world and fit naturally into the institutions like chuches and neighborhood associations that help to sustain civil society. When people have embraced healthy behavior for themselves, the only thing that they will need from the state is protection from forces beyond their control (like pollution) and provision of medicines beyond their means (like antiretrovirals.)

The Pink Police State is truly a menace to the natural order, but before we beat it we’ll have to join it. If we can extract the goodwill of the elite technocrats to put money and power in the hands of people tied to local communities, the erotic (or gluttonous) populists will finally have a real set of countermeasures opposing them–members of a place who have learned discipline through conversations individual and corporate. In a world where our power of over nature has must be carefully stewarded, the care of our bodies is inseparable from policy. Our bodies, individual and corporate, can only be built up– and the Pink Police State can only be torn down–by the wisest policies.