On some simplistic level, I don’t entirely understand why it is that when extremely rich, mainly white, people (and some, very few, colored people) have such a large percentage of the nation’s wealth, it is called affluence. And it has a positive connotation. And when the poorest of the poor in America begin to take shoes from stores, sell drugs to bring food home, strip in clubs to have the same level of affluence, obtain clothes without paying for them from a store; it is called looting, drug-dealing, prostitution and stealing. And it has a negative connotation. I find it fascinating how many, mostly black, people in America are condemned and put into jail for dealing and using drugs, and in the same breath, how many, mostly white, people in Hollywood are congratulated on Entertainment Tonight for checking into a drug rehabilitation center to face their “addiction.” What I’m talking about is, on a larger scale, about the often false dichotomy of right and wrong in the United States and the roles that history, culture and sociology play in the definitions of each. But it is also about the role each of us plays as individuals and citizens, and the individual choices we make about how we will use any privilege or marketable skill afforded to us. And on a personal level, what individual definition we create for ourselves as to the meaning of “stealing” vs. “entitlement” vs. “affluence.”

We all have heard the “statistics.” They go something like 95% of the nation’s wealth is concentrated in the top 1% of its most affluent citizens. But what exactly does this mean to those of us less versed in economic speak? Is it going too far for me to suggest that at some extreme point between rich and poor, this too can be construed as “stealing” from the people of the United States, in no different of a way than a bunch of poor people in Louisiana looting from a store because they want some of the merchandise inside? How does one come to “deserve” the wealth they have anyway? Capitalism is one thing, this new level of disparity we seem to have reached between rich and poor is another.

Or has it always been this way?

I have a friend who is a conservative Republican whom I like very much and learn a lot from. He often says (or the equivalent of) that we all get what we deserve in the world. Obviously, though, he cannot believe this without exception. I cannot imagine he really thinks a 3 year old little boy “deserves” to be beaten by his father or that a homeless woman “deserves” to be raped while sleeping on the streets. I think what he IS saying, however, is that there is an overall framework in the world that governs who attains a certain affluence and privilege and class and who does not, and to disrupt that framework is both foolhardy and impossible. A homeless person is homeless because they have created a life for themselves that has led to that point. Can I respect this opinion? Sure. Do I agree with it? No. Mainly because the equivalent is to say that so and so person deserves to suffer, and that, I believe, maybe controversially so, no one deserves.

So to try on for a minute the idea that instead of deserving anything, that our situation in life is simply a unique permutation of variables: certain neurons connecting during development in some certain way because of a certain sperm reaching a certain egg in a certain human being who lives a certain life. If we accept the idea that even willpower is a function of the brain no different than skin color is a function of melanin, than perhaps instead of deserving we could imagine that we don’t have 100% control over who becomes privileged, who has wealth, good supermarkets, healthy vegetables, safe places to exercise, money to view other cultures of the world; if we do actually recognize that perhaps it is something more than “deserving” so, or “entitlement,” than, I wonder in a tangential way perhaps……don’t we at some point of disparity have a moral obligation to turn around and “give” some of that unique permutation and privilege back to others? Could it even be construed as “stealing” not to? That is, can it be construed as stealing IF my thought process towards the notion that our lives our made up of a complex permutation of variables that have no relationship to control, is correct?

And to follow along these lines of “moral obligations” to give back—I’m not just talking about donating money or volunteering once a week at the local homeless shelter. That is awesome to do and worthwhile in its own right, but it’s not really what I’m getting at. I’m referring more to questioning oneself and one’s own motives, privileges and gifts and about sacrificing some of the comforts we feel we inherently “deserve” as a result of them. I’m talking about having a moral conscience so strong that you DON’T join the throngs of rich, white, upper-class Americans. I’m not talking about President Bush spending a day touring the state of Louisiana and hugging those who have lost homes and who are suffering. I’m talking about President Bush stepping off the Air Force helicopter and setting up a tent outside the Louisiana Superdome and camping out alongside the horror. At least, as metaphor. And it’s not just President Bush who should take the guilt of this on his shoulders. It’s all of us. On a more personal level to me, I’m beginning to think that I really have no choice but to use my medical education to take care of the people who can take care of themselves the least. Or anyway, that is the direction in which I am beginning to feel I have absolutely no choice but to go. Because otherwise, I wonder selfishly, how exactly could I possibly live with myself? It would be, I think, as if to live with the guilt of stealing from others, every day of my life.

This all has been building in my mind for far longer than just since Hurricane Katrina, though I admit it’s been heightened since seeing those images on television. It has been on my mind especially now because I am watching my fellow medical school classmates apply to residency programs this summer and fall of 2005. And I have watched as, time and time again, friends and acquaintances have changed their career plans from pediatrics to dermatology. From internal medicine to otolaryngology. From general surgery to plastic surgery. From general surgery to anesthesia. From adolescent medicine to dermatology. And to be honest, I find myself both sad and angry. I am tired of hearing this news when I run into a classmate at the supermarket and I force a smile and say “wonderful!” Because to argue with them in the middle of a crowded supermarket, seems futile (though perhaps not?) And also because my first response to that anger and sadness is to question it. Why, exactly, should I be angry? Do I not think these fields are important and worthwhile? Of course not. Is it because I wish that I could allow myself to go into these fields? It would mean a life free of at least some of the “worries” I fear I may have with some of the less-paying specialties. My creature comforts would, more likely than not, be guaranteed for life. And no one could argue that dermatology isn’t a needed field. It is a field full of serving and giving, as are ophthalmology, otolaryngology, plastic surgery and anesthesia. Both domestically and internationally, ophthalmologists, otolaryngologists and plastic surgeons are just a few of the people who can work absolute miracles, allow blind children sight, remove cataracts from the infirm, repair cleft palates and reconstruct bodies disfigured in accidents or fires. And in fact, each are extremely needed on an even more American and middle class level: I worshipped my dermatologist when I was young because he changed the course of my middle school, acne-strewn, years. Not to mention my ophthalmologist, who gave me normal sight by allowing me to start using contacts in the 8th grade which, I remain convinced, played some role in allowing me to escape middle school relatively popular and relatively unscathed. And though I haven’t had the misfortune to yet need surgery, I suspect at some point in my life I will and I will be extremely grateful to have a talented and knowledgeable anesthesiologist keeping me alive. So one cannot just say that any of these specialties are not “important” to all of us, rich or poor or anything in between.

So then, what is my point? (I should say here that I probably don’t have one). I suppose it is more inflammatory. Because in the same breath; isn’t it more than simple economics that these most competitive residencies just so happen to be the highest paying? No, it’s basic economics, Danielle, I am told by my PhD economist Father. Is that really it, I question further? Isn’t that one of the criticisms of its validity, that sociology is not taken enough into account in the devising of economic theory? Taking a larger step back, is there something more to why dermatology is a higher paying field than say, family medicine (other than simple cost and demand)? Why anesthesia more than general surgery? Why? Is there some inherent part of dermatology that makes it rewarding of a larger paycheck? Or could I venture to suggest that it may be, in some small part, because the practice of dermatology often serves some of the most affluent, and whitest, of our citizens? And could I venture to suggest that pediatrics and internal medicine is lower paying because, in part, it is one of the more accessible routes to the poorest, and least influential, people in the country and world? Or because pediatrics is one of the most accessible route for women in medicine to have both a family and a career? Because it leads to an already paved role towards community advocacy and service? Pediatrics, general surgery, family medicine and internal medicine can, at their best, serve some of the people who are left behind in our society, and whom we see reflected back at us by television cameras trained on the Louisiana Superdome. And who are, we cannot avoid seeing, overwhelmingly colored.

Returning to the many arguments one could raise about why different paychecks abound in different specialties: perhaps one could argue that it is because the skills required in dermatology are more specific and require more training. But if so, then wouldn’t one have to go to school for longer for them? How long is a dermatology residency? A cardiology residency? Aren’t they more or less the same length? So that can’t quite be it. Does dermatology have more billable procedures? What is it? Is it because at least some of the dermatologic practice serves procedures that aren’t “needed” to survive, but rather, are “needed” for specific persons to advance within very specific segments of our society? Wrinkles on a poor 40 year old person’s face who is working two jobs and bringing home Grade DDD beef to feed their children, somehow seems of less importance than it might be to a person for whom a wrinkle could in some ways constitute a weakening, a failing, a sense of regular-ness. And so, who obtains highly billable Botox treatments in dermatology? Is it the poor people in the Louisiana Superdome, who couldn’t pay for it even if they had time to obtain it? No, of course not. So then is it so hard to believe that dermatology pays more, because at least in tiny part, it overwhelmingly serves some of the richest, and most influential, percentiles of our citizenry?

While I’m at it, I might as well mention the discrepancy between the ethics of earning vs. stealing and the ethics of corporate America. The state of California just passed two bills, SB12 and SB965, which, among other things, prohibit the sale of soda beverages on California school campuses during school hours (effective July 2007). This comes in the wake of data showing that, contrary to popular belief, obesity and diabetes rates CONTINUE to rise among children nationwide, and California especially, despite all of the hullaballoo the issue has gotten in the last 2 years. In opposition to it was intense state lobbying which, until I learned about it, I didn’t quite believe could be possible (I am apparently naive, I realize). How could someone want rates of adult-onset diabetes and obesity to continue to rise amongst US children? But there it was, the Grocery Manufacturer’s of America, with US sales topping $460 billion a year, claiming that these new bills will do nothing to help children to choose healthier foods and paying boatloads of money to try to convince the governor that this indeed is so. Agreed, these bills aren’t 100% solutions. But to claim (when soda consumption in children is shown to be one of the most highly correlated risk factors for pediatric obesity) that these measures do nothing…..is ethically arrogant and ethically wrong. So at what point I wonder are companies, and the humans behind those companies, responsible for the health effects of their products on consumers (a whole other topic, I realize)? Can it ever be construed that a company is, at least in efforts like those described above, “stealing” away health from US (not to mention international) children? And of course, as seems to be the theme here, stealing it at a disproportionate rate between white and colored children.

And so, on a larger scale and in a more evened breath, I wonder about our collective conscience, as UCSF medical students, and on a broader scale, as privileged young people in America. Do my friends whose families were born in China, who immigrated to the US with nothing, and who built their lives up from scratch here, not now “deserve” to “make it” and choose freely their professions? Of course I cannot say this. But if one is to argue this I cannot help but reflect back my earlier thoughts, which is to say in the same breath that, if so, than it should be equal to say that poor people who have been born into poverty, who haven’t finished middle school, much less a high school education, also deserve in turn to be living on the worlds fattiest foods, in the grimiest of neighborhoods, neighboring the nastiest of environmental hazards and faltering along without health insurance. For if we all get only what we deserve, than this is the only conclusion we can make. These people, who are incidentally mostly colored, must deserve this, in the same way that I must deserve what I have worked so hard for. And if one accepts this statement, than I suppose, a collective conscience more than what is present, is un-needed; and reacting to my essay is rather pointless. But if one finds any discomfort at all in this statement, has any conscious inkling at all that perhaps, at least in small part, “I” am lucky, to be in the place that I am, “I” am lucky to be eating the food that I do, “I” am lucky to be using the brain I have; than perhaps “deserving” isn’t the most appropriate word. And if so, than doesn’t one have some sort of moral obligation to repay some of that privilege, as it is not owned, but rather, on some sort of god-given, nature-given, loan? And as intelligent UCSF medical students, applying to any field in the world of medicine that we desire, does that mean we have any obligation to NOT join the richest 1% of America, and instead join specialties that place us below these highest of income brackets? Do we have any obligation not to “steal” from the poor, even if, one argues, it is a socially acceptable, if not celebrated thing to do within our society?

Because otherwise, I suspect, we can more than 100% guarantee that there will be future insufficient Hurricane Katrina responses. Just as there have been unstoppable patterns of terrorism, genocide and holy war in the history of the human race. And each time we will ask why and how and what can we do? And though the answer will seem clear in front of our noses, if we do not hold ourselves accountable on an individual level, it will not change on a community or societal level.

But then, perhaps, this is simply what we deserve.


Harnack L, Stang, J, Story, M. Soft drink consumption among US children and adolescents: nutritional consequences. Journal of the American Dietetics Association 1999;99(4):436-441.

Ludwig DS, Peterson KE, Gortmaker, SL. Relation between consumption of sugar-sweetened drinks and childhood obesity: a prospective observational analysis. Lancet 2001; 357(9255): 505-508.

Nielsen, SJ; Siega-Riz AM, Popkin BM. Trends in energy intake in US between 1977 and 1996: similar shifts seen across age groups. Obesity Research. 2002 May; 10(5): 370-378.


Also see texts and references of California 2005 SB12 and SB965 for references on pediatric nutritional trends in 2004/2005.

Also see texts and references of California 2005 SB12 and SB965 for references on pediatric nutritional trends in 2004/2005.

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