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England’s National Health Service Is Suffering Growing Pains

Peter Byrne/PA Wire URN:34998098

As T.S. Eliot said, “This is the way the world ends. Not with a bang but a whimper.” Recently, much whimpering has come from the thousands of infirm people waiting in England’s overcrowded, understaffed hospitals. The sick lay on stretchers in hallways for entire days, or on the floor. Some wait for hours in the ambulances that brought them to the hospital.

For the London Review of Books, James Meek examines the crisis that has struck England’s National Health Service. Preparing for a surge of aging citizens with various ailments and a dependence on caretakers, NHS initiated a transition from an old hospital-based system to a new ambitious system centered around home health care. Unfortunately, the transition has not been smooth, and the future looks uncertain. The reform also has people asking what kind of country they want England to be: one of solidarity and publicly funded health care, or one of privately funded care where, like the United States, everyone fends for themselves.

A whistleblower told the Health Service Journal that ambulance delays in the east of England had led to the deaths of at least 19 patients and serious harm to 21 more. On 1 January, an 81-year-old woman in Clacton, Essex, dialed 999, complaining of chest pains. The ambulance took three hours and 45 minutes to arrive. It was too late. A few days later, a 52-year-old man in Norfolk collapsed with severe chest pain and vomiting. He was taken to the Norwich and Norfolk Hospital, but had to wait in the back of the ambulance that took him there for four and a half hours before being seen by a doctor inside the building. He was told to go home and collapsed again when he got there. Two ambulances sent to get him were diverted to other calls and by the time he returned to hospital, his life couldn’t be saved.

One doctor in a major A&E department in the east of England told me he’d witnessed short cuts taken by staff under pressure. For a time, ambulance crews had been allowed to leave patients in a hospital area that wasn’t technically A&E reception. One elderly patient with abdominal pain was diverted within the hospital from emergency medicine to a GP-style consultation, sent home, returned to the hospital a few hours later, and died. “What I’ve seen is the relentlessness of the shifts,” the doctor said. “The intensity. The feeling of higher and higher accountability. And then a lack of investment in staff. Asking them to do more and more and more, to cover more and more patients. There’s no give and take. The staff they should be investing in get more and more demoralized. You’re at risk of creating a Mid-Staffs environment where people don’t really know who they’re working for and start accepting risk that previously would have been deemed unacceptable. They stop reporting things because they reported them before and nothing happened. It’s creating a dangerous culture.” What should be done? “Stop decreasing capacity. Build capacity and build staffing. The party line is always ‘it doesn’t affect patient care.’ Of course it fucking does.”

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The Strike: Chemicals, Cancer, and the Fight for Health Care

Longreads Pick

Workers at Momentive Performance Materials had given their lives to the chemical plant. The strike was supposed to save what little they had left.

Author: Ian Frisch
Source: Longreads
Published: Apr 16, 2018
Length: 32 minutes (8,040 words)

The Strike: Chemicals, Cancer, and the Fight for Health Care

Ian Frisch| Longreads | April 2018 | 32 minutes (8,040 words)

When 59-year-old Jack Mack wandered from picket station to picket station to ask the Question, he tried as best he could to ease into the conversation. He didn’t want to scare anyone off. It was two months into the strike, and tensions were high. “You know, we handle some pretty nasty stuff in there,” he’d say. Or, if the guy was older: “C’mon, you’ve been here as long as I have! You know everyone!” Sometimes, if he already knew the person, he’d cut to the chase: “Wasn’t there a guy you worked with down there that was diagnosed with cancer a few years back? Did he make it through?” If they didn’t answer, staring instead at their steel-toed boots, Mack would lean in and say, “You know, I’m sure you heard, but I was diagnosed with cancer myself. Beat it, but — you know.” Then he’d turn toward the sprawling complex across the street — the site of the only job he’d ever had — and nod, adjusting the cap perched on his head. “Yup. Forty years.” He’d inhale deeply, nearly a sigh. “That’s a lot of hours around those chemicals.” He’d shake his head, unsure if he should blame himself or Momentive Performance Materials, the chemical plant in Waterford, New York, where he had dedicated so many years of his life.

Like Mack, many of the employees on the picket line had worked at Momentive for decades, and while they didn’t know for sure that working at the plant caused their cells to metastasize, the workers certainly knew of the inherent consequences that stemmed from handling carcinogenic chemicals on a day-to-day basis. That fear of a link is what troubled Mack and his cohort, and it’s why in November 2016, nearly 700 unionized workers at Momentive went on strike, protesting what they thought was an unfair contract — one that pushed for more expensive and restrictive health insurance for workers and the elimination of health care for retirees altogether, “many of whom,” according to leaflets handed out during the strike, “are suffering from job-related illnesses caused by exposure to dangerous chemicals.” For decades, the workers had mixed and churned chemicals in a variety of forms to produce an endless array of products, which included specialized goods such as F14 fluids and rubber stoppers on syringes along with items encountered on a day-to-day basis like exterior coatings for soft drink bottles and the rubber used to manufacture nipples for baby bottles.

Now, though, those same workers were walking out for the first time, and the union outfitted a defunct hot dog shack across from the plant into a headquarters. Nearly all of them had been picketing the plant’s nine entrances 24 hours a day, powering through snow squalls, huddling around burn barrels for warmth, trudging through slush puddles.

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Union strikers around a burn barrel outside Momentive’s Water Treatment Facility. (Jonno Rattman)

On the picket line, in rare close quarters with men who worked elsewhere in the massive plant, Mack learned his coworkers’ stories. He took a few minutes out of each day to ask strikers if they’d had cancer or knew anyone who did. Sometime after Christmas, Mack had started jotting down the names — current and retired, dead and alive.

He kept the handwritten list folded up in his jacket pocket, adding new sheets as he collected new stories: six pancreatic cancers, seven bladder cancers, nine brain cancers, 11 throat cancers, 18 prostate cancers — spine, skin, stomach, and more. While these are cancers that do afflict men of a certain age—according to the American Cancer Society, one in nine men will be diagnosed with prostate cancer—the diagnoses outpace certain national averages. Brain cancer afflicts .006 percent of adult males, far below the roughly 2 percent of the strikers with throat cancer whom Mack surveyed. By mid-January, he had 85 names. Many of these men had worked in the plant for more than 20 years, which meant they’d tallied up decades of exposure to dangerous chemicals. (Of the scores of men on Mack’s list, I’ve independently confirmed the cancer diagnoses of two dozen, through interviews with either the men themselves or, in the case of 11 who died, with family and friends.) Mack himself had long known coworkers with cancer. To him and other employees, it was almost commonplace to know a guy who had been diagnosed. “Three other electricians I worked with in waste treatment also have cancer,” he told me. “Long-term exposure — in some of these buildings, there’s no way you can avoid that.” Mack, an electrician who works on the machines that process the plant’s chemical waste was diagnosed with prostate cancer in 2014. His brother, who also works at the plant, was diagnosed with tongue cancer the next year. Their father, who worked at the plant for 36 years, died of cancer in 1994.

Mack’s oncologist, Dr. Kandasamy Perumal, who specializes in urology and has operated a practice in nearby Troy for 35 years, is no stranger to cases like his. “As time went on, more and more people came from that area with instances of malignancy, rather than Troy or Latham or other towns. My practice sees comparatively disproportionate numbers of tumors from people who live in Waterford and Mechanicville,” he said. “But do we know if they all worked at the plant? I don’t know for certain,” he added, explaining that his practice is not obligated to collect workplace information from patients. Momentive said that it was unaware of any chronic health problems among employees as a result of exposure to raw materials, and that their well-being is its highest priority. “The company takes all necessary actions to ensure strict adherence to all federal and state health guidelines,” said a Momentive spokesperson.

There were risks in taking on this kind of work, Mack knew. So did many of the men whose names were folded up in his pocket. But there had been some promise of security at Momentive, a belief that their jobs would take care of them — a good living, a secure retirement, health care. Today they’re not so sure. After the plant was acquired by a private equity firm in 2006, things took a dark turn. A decade of control by Wall Street brought pay cuts and a litany of increasingly rancorous labor disputes — culminating in the massive strike.

When I visited Momentive in January 2017, workers sat at the booths inside the hot dog shack wearing camouflage jackets, reading newspapers, drinking coffee, and eating hot dogs and stale pastries. One checked in picketers who, after nine weeks on the line, were eligible for unemployment. They were also paid $400 a week by the union. The 104-day walkout began November 2 and ended February 14, and during that time these men were constantly on edge, both about the security of their job but more importantly about the precariousness of the benefits they desperately relied upon. The men were on strike for many reasons, but high-quality, affordable health care was their main concern. It was what they needed most.

Bill Tullock, a 55-year-old senior advanced control operator, whose doctor had found a tumor in his throat during an endoscopy for acid reflux in 2015, maintains that he’d never have gotten the routine procedure that led to his cancer diagnosis without Momentive’s old health insurance. At the time, his annual deductible was $500; now it’s $3,500. Tullock doesn’t solely blame the plant for his cancer, but he’s adamant that were it not for the generous coverage, he’d never have known he was sick.

“I dodged a bullet,” Tullock said of his battle with cancer, which, thanks to the low deductible he paid courtesy of his previous health care coverage, was caught early. “With the new insurance, I am pretty confident I would’ve never had the endoscopy, and would’ve never known there was a tumor. Then it would’ve spread, and I wouldn’t have known.” Under the new contract, once he retires, he’s on his own. “I dedicated myself to this place,” he said during the strike in January, sitting in the basement of the hot dog shack, holding back tears. “I should have never started working here. And now they are trying to give us this shit insurance and just — what, ‘Go die?’” He rubbed his eyes with the palm of his hand. “Our health insurance is like the final firewall of personal protection,” he said. “It’s all we’ve got.”

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Bill Tullock was told by his doctor to get an endoscopy in 2015; it turned out he had a tumor in his stomach. Jack Mack sits down with his list of sick workers while on a break at union headquarters. (Jonno Rattman)

The men who’ve worked at the plant for decades and battled cancer — whether they think it’s from the chemicals they handled or not — now face a task familiar to millions, one from which they thought they had a reprieve: They must either sign up for the company’s onerous coverage or fend for themselves to get health insurance, with costs varying widely through the complicated, cumbersome public exchange overseen by the government — the precariousness of which is compounded by the Trump administration’s promise to gut the Affordable Care Act, leaving workers in an even more fretful state of uncertainty.

Like so many Americans, they’re threatened by a toxic triumvirate of lax chemical-safety regulations, costly health coverage, and growing pressures on Wall Street to perform — the latter of which has forced businesses to perform under expectations that set them up to fail, with employees taking the brunt of the downfall

The decade of private equity ownership had gradually worn down a generation of workers, stoking a divide between those who would be taken care of and those who would go without. “Sacrifices were made with the expectation that we would get adequate health care when we retired,” Mack said. “If you are going to work in environments like this, you are going to need affordable health care.” The strike marked dividing lines between worker and owner and financier, but it also revealed a rift so deep that it was often left unspoken: What do American workers owe to one another?

***

Waterford, New York, is one of a cluster of manufacturing towns situated north of Albany, where the Mohawk River joins the Hudson. It blossomed into a factory hub as early as the mid-1800s and was known for its paper mills. A reported stop on the Underground Railroad, it was even visited by Alexander Hamilton and Frederick Douglass. Drive into town from across the Hudson and you’re greeted by a memorial to Waterford’s veterans, including men who fought in the Revolutionary War. Keep driving north on Route 4, past the village center, and the Momentive complex flanks both sides of the road, sprawling across an 800-acre plot.

The town greeting in Waterford, New York.

The town greeting in Waterford, New York. (Jonno Rattman)

The chemical plant is one of Saratoga County’s largest employers. First built by General Electric in 1947, it anchors the region both economically and culturally. For decades, the plant with its hundreds of union jobs offered its primarily male workforce a stable, middle-class kind of prosperity, one where high school graduates could eventually earn a six-figure salary. There was a sense of local pride: The soles of the boots in which Neil Armstrong took his one small step were made of silicone rubber manufactured here. “If you’re from here, this is where you work,” said Vinny Anatriello, a third-generation employee. “And if you don’t work here, you work in the school where all the guys’ kids go to, or you work in the doctor’s office where the guy’s sick wife goes, or you work in the grocery store.”

It’s no secret to the workers that materials used in Momentive’s Waterford plant can be dangerous. It’s been this way for decades. The plant sources silicone ore and, through reactions with various chemicals, produces materials used in consumer products ranging from shampoo and medical equipment to caulking and car parts. Numerous longtime workers say that the current operations use dozens of toxic chemicals, among them benzene, lead, mercury, and hydrochloric acid. The waste it has produced over the years — over 11.4 million pounds in 2015 alone — has at times included more than three dozen toxic chemicals, 11 of which are carcinogens, according to the Environmental Protection Agency.

There used to be even more, workers say, decades ago when GE owned the plant. Numerous workers said that until the early 1980s, they cleaned their winter coats with pure trichlorethylene, now a known carcinogen, and used fiberglass and lead as fillers in chemical mixtures. For some processes, they weighed out raw lead by hand. “Back then we’d scoop it like it was salt,” said George LaMarche, 65, who retired in July 2017 after 44 years at the plant and whose doctor is closely monitoring his elevated prostate-specific antigen levels — potentially an early sign of prostate cancer. “We never wore any protection for that.” In a statement, a Momentive spokesperson said that the company provides all its employees with protective equipment, extensive training, and instructions in how to properly handle the materials they work with: “When employees act in accordance with the policies and procedures Momentive has in place, potential risks are mitigated.”

Millions of American workers are exposed to carcinogens, or possible carcinogens, according to the National Institute for Occupational Safety and Health, the division of the Centers for Disease Control and Prevention that researches and investigates workplace safety and health. In 2012 alone, upward of 45,000 diagnosed cases of cancer — and, since the agency is still investigating and uncovering potentially carcinogenic materials used by the American worker, perhaps twice that many — were caused by past workplace exposure. On average, nearly eight times as many people die each year of diseases acquired on the job as die from injuries sustained on the job.

He kept the handwritten list folded up in his jacket pocket, adding new sheets as he collected new stories: six pancreatic cancers, seven bladder cancers, nine brain cancers, 11 throat cancers, 18 prostate cancers.

Since 1976, federal law has required all new industrial chemicals to be submitted for review by the Environmental Protection Agency. (Tens of thousands of industrial chemicals already in use were grandfathered in.) But after that initial environmental review, many industrial chemicals — which don’t necessarily have to get tested before being used in manufacturing — may never get a closer look by regulators. Once chemicals have entered the market, U.S. law only requires the EPA to collect data on the roughly 3,700 of them that are used at a rate of at least 500 tons per year. The data collected pertain mainly to their effects on the environment or the consumers of the products they produce — not on the workers who handle them.

“These chemicals are never sent back with actual information from the workplace,” said Jennifer Sass, a senior scientist with the Natural Resources Defense Council’s health program. “The regulations are focused on the end of the pipeline. But you can’t put the genie back in the bottle at that point. People are already affected.”

Updates to the Toxic Substances Control Act, which was amended by Congress in 2016, mandated more pre-market testing for new chemicals seeking federal approval and required the EPA to review already-approved chemicals in widespread use. Ten of the most toxic of those are slated to be tested in 2018, but it’s unclear whether that deadline will be met. (Two of the chemicals have been commonly used at Momentive.) Since then, however, President Donald Trump has promised to scale back regulations broadly and has targeted federal agencies, the EPA chief among them, for sharp funding cuts.

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Momentive Performance Materials, a chemical plant in Waterford, New York (Jonno Rattman)

In May 2017, Nancy Beck, a former industry advocate and executive at the American Chemistry Council (of which Momentive is a member), was selected to become the deputy assistant administrator of the EPA unit tasked with implementing the updates to the toxic-chemicals law. Just two months earlier, she had gone before a Senate subcommittee as a then-executive at the ACC to push back against the review process. According to an investigation by Eric Lipton at The New York Times, the EPA has spearheaded “a broad initiative by the Trump administration to change the way the federal government evaluates health and environmental risks associated with hazardous chemicals, making it more aligned with the industry’s wishes.” This included reevaluating plans to ban certain uses of two chemicals that have caused dozens of deaths or severe health problems: methylene chloride and trichloroethylene, both of which have been used by Momentive employees.

Regardless of these policy reversals, tens of thousands of chemicals that have been in production for decades still need review. The Union of Concerned Scientists, an environmental-advocacy group, estimated in 2015 that it could take 50 years to reevaluate 1,000 of the most toxic chemicals on the market. “Most toxins have not been adequately studied, employees have no tools to act on their suspicions, the companies have a disincentive to learn the full truth about what its chemicals do in terms of health impact, and the government is underfunded and doesn’t have sufficient tools to fully investigate,” said Dr. Steven Markowitz, director of the Barry Commoner Center for Health and the Environment at Queens College. “It’s a recipe for making the health consequences of working with toxic chemicals invisible.”

***

Tim Larson is a tall, broad-shouldered man who wears a musty cap tossed on his head. When I met him during the strike, he carried a megaphone that he used to shout chants on the picket line. His face lit up when he screamed, and his eyes — which seemed to hang out of his skull — bulged even further from their sockets. I stood with Larson most nights while I was there — he held the late shift on the picket line — and he explained that the plant is a complex of various buildings, each housing in a different part of the production line. You’re either breaking down raw ore, reacting the rock with chemicals, mixing together intermediate materials, packing products, or organizing them for storage and shipment.

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Tim Larson steps off a bus before a protest in Momentive CEO Jack Boss’s neighborhood in Saratoga Springs. (Jonno Rattman)

Larson, a chemical operator, began working at Momentive in 1988 when he was 35 years old. He told me stories about the different parts of the plant, including Building 78. This area of the massive plant is home to the Waterford plant’s fluorosilicone manufacturing operations. There, a silicone base is reacted in roughly 100-gallon “dough” mixers at more than 240 degrees Fahrenheit to produce fluorosilicone gum for use in automobile gaskets and aerospace products. (The mixers are also used to produce “intermediates,” which are unfinished products that passed from building to building within the plant, and included different grades of polymers and fluids.) Long-term exposure to seven chemicals used in Building 78, according to Momentive material-safety data sheets, are suspected of or known to be reproductive toxins. Another chemical, Tris(2-chloroethyl) phosphite, is a carcinogen. Workers call the building the One-Nut Club, for reasons that to them seem less ominous than inevitable.

When GE owned the plant, risks from fluorosilicone production had been on the company’s radar since the 1970s. In a “strictly private” 1977 safety audit, a safety specialist said that research had shown that materials created by these processes, when ingested — which could mean breathing in the chemical or having it touch one’s skin — shrank rats’ prostates and testes “and may have similar effects in man.” The specialist also wrote that tests showed that the chemical compound handled by workers was “probably not a carcinogen.” GE performed a similar toxicity review 20 years after its initial testing and analyzed several chemicals used to the produce fluorosilicones. “The data, although not definitive, did not give rise to any concerns over the potential for carcinogenicity,” the report concluded.

“Nobody admits there is a correlation, but we put stickers on the tanks that hold this stuff, saying that it causes cancer,” Larson told me, referring to the warning stickers that California state law required them to affix. (Many of their products are shipped to the Golden State.) “It’s right there in front of you.” 

“After six years, my eyes started bulging out of my head,” he told me, pointing to his face. He was diagnosed in early 1996 with Graves’ disease, an autoimmune disorder that affects the thyroid. “I had to get my eyelids sliced, because I couldn’t close my eyes,” Larson said. He knows he can’t prove a direct link, he added, but he is “convinced that all my autoimmune problems are directly related to working here.” Soon after his diagnosis, Larson transferred to another area of the plant.

The men were on strike for many reasons, but high-quality, affordable health care was their main concern. It was what they needed most.

Other workers voiced their concerns about Building 78. In 1998, a GE-employed research chemist named Herman Krabbenhoft wrote a letter to two operators who worked there, Joe DeVito and Dan Patregnani, explaining that the previous year he had expressed concerns to managers about the vapors released during fluorosilicone operations. Krabbenhoft wrote that GE’s health and safety manager was supposed to have initiated a study of how to measure the vapors’ concentration, but that after a year nothing had been done, adding that he was told by a colleague to “back off on pushing this because it might affect how GE’s managers viewed me and my performance.”

“Herman was on our side,” DeVito said.“He said, ‘Stay away from it. It’s going to kill you.’” Shortly thereafter, DeVito said, Krabbenhoft was fired. (Multiple attempts to reach Krabbenhoft for comment were unsuccessful; GE declined to comment for this article, referring all questions to the plant’s current ownership, who also declined to comment on the specific incident.)

The building’s ventilation system was updated in the early 2000s, multiple employees who worked there said. The system was supposed to be air and temperature controlled. “It never worked, never sealed the room properly,” said John Ryan, who worked in Building 78 at the time, adding that temperatures could reach 110 degrees in the building due to the faulty system. In 2005, Ryan said he filed a formal grievance, asking to spend less time near the mixer, explaining that he didn’t want to be exposed to the hazardous mixture and its vapors. “But nothing changed,” he said. “And they never fixed the dough mixer either. Materials would come out into the air or spill onto the ground. That’s still going on, until this day.” In mid-2017, Momentive installed a second dough mixer to Building 78 to ramp up production, and though the machine suffered at first from issues relating to its packing seal, there haven’t been any recent health-related complaints. (Both the venting system and the initial dough mixer have also been serviced and are reportedly in working condition.)

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Joe DeVito was diagnosed with throat cancer in 2013. He worked in Building 78. (Jonno Rattman)

Now, DeVito said, workers must wear full-face respirators when they clean the mixers, which have to be pristine before the machine can be used to produce another product. The fluorosilicone is so sticky, Larson claimed, that he used to have to climb into the 100-gallon drum and scrape off any lingering substance with a razor blade. “Fluorosilicone is a highly resistant chemical — oil, water, you name it,” he said. “That’s why it is used on gaskets and car bumpers, or in rocket ships.” According to DeVito, “Momentive took more steps for safety over the years,” but the process itself and the chemicals used in it remained the same. Additionally, the company’s material-safety data sheets do not indicate whether the vapors produced from these chemicals are hazardous to humans, despite there being a warning that TFPA vapors, which are highly toxic, may evolve from the products used to make fluorosilicone gums and polymers. “The company raised certain health issues related to the chemicals used in this building, but despite a very incomplete knowledge base, they draw the conclusion that there is no cause for concern,” said Dr. Markowitz of Queens College, who reviewed the documents. “My conclusion would’ve been: ‘There’s a big gap in what we know versus what we don’t know.’ That’s the proper conclusion.”

DeVito was diagnosed with stage 4 throat cancer in 2013, after a bump on his neck swelled to the size of a golf ball. DeVito told me he knows of five other control operators who worked in Building 78 who were diagnosed with cancer. He told his doctor about his decades of exposure to fluorosilicone vapors. “She said, ‘It would take years to prove that it happened from work,’” he explained. “‘Take care of this and just move on.’” His treatment, radiation, and chemotherapy, were successful. He retired in early 2018.

Some workers, like Tony Pignatelli, who worked in the plant for 34 years, weren’t so lucky. Pignatelli was diagnosed with brain cancer in January 2000 and passed away three weeks later. “My dad knew the risks, but he did it because they took care of them with good pay and health care,” his daughter said. “But I can’t even begin to understand what those guys are going through down there now with this new contract.”

***

Employees accepted the risks associated with working in the plant, the backbone of their community, for over half a century. They felt taken care of: stable pay, a sizable pension, affordable and quality health care, good communication with management, camaraderie with fellow workers. But that all changed when GE sold its global silicone operation, with the Waterford plant as its centerpiece, to a Wall Street investment firm in 2006 in a leveraged buyout. “When it was GE, they treated you like family,” Jack Mack said. “After the sale, everything changed.”

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Matthew, Kenny and Vinny Annatriello—father, nephew, and son—on the picket line. (Jonno Rattman)

Apollo Global Management, a private equity firm that manages $249 billion in assets, bought a controlling stake for $3.8 billion, then saddled the corporation (which changed its name to Momentive Performance Materials in December 2006) with $3 billion in financing debt while it collected a $3.5 million that first year for “financial and strategic advisory services.”

Many employees didn’t understand the implications of the sale until 2009, when nearly 400 production workers received surprise pay cuts. Brian Cameron Jr., a 34-year-old second-generation employee, was making $27 an hour as a chemical operator. He had just bought a house in Waterford and a new Dodge Ram pickup the previous summer. “Everything was going good. I paid my bills,” he said. “I thought I was set for life.” Then his wages were slashed to $17 an hour. He eventually took a higher-paying position at the plant, but his debt piled up too fast. “I thought if I moved quickly, I would be able to save my life,” he said. “But it was too late.” He lost his house, gave back his truck, and moved into a coworker’s apartment.

The cuts meant that his coworker Ron Gardner, then 53, and his wife, Donna, could no longer afford the $1,300 monthly payments on their two-bedroom ranch home in Grangerville. “We were struggling,” he said. A few years later, in 2013, they abandoned it and moved into a trailer park in Saratoga Springs, just two miles from Momentive’s current CEO Jack Boss’s $950,000, 4,375-square-foot home. They took out personal loans to pay for a $23,000 double-wide, then used savings and loans from family members to pay for the roof and the lot’s rental fees. Unable to sell their ranch, they filed for bankruptcy and began paying off their new debts.

The local union contested the wage cuts, and 18 months later, in 2010, with their contract soon to expire, Momentive agreed to settle by issuing back pay — more than $50,000 before taxes for some workers — while making the wage cuts permanent going forward. Gardner, Cameron, and others who had lost their homes or been pushed into bankruptcy by the cuts couldn’t turn down the chance to repay their debts. “People were so broke from the wage cuts, they voted yes for that contract,” said local union president Dominick Patrignani, who has worked at the plant for over 30 years and was the chief bargainer during last year’s strike. “They were given no alternative.”

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Ron and Donna Gardner lost their home, then Ron developed esophageal cancer. Dominick Patrignani, president of the local union, is the chief bargainer for the 700 strikers. (Jonno Rattman)

But Momentive wasn’t done. In 2013, the company froze pensions for workers under 50 and those with less than 10 years of service. “Every contract, they slashed benefits and made it harder for me to do what my father did: provide for his family,” Cameron told me during the strike. All of this is par for the course for private equity firms like Apollo. According to a study led by Josh Lerner, professor of investment banking at Harvard Business School, private equity buyouts lead to sizable reductions in earnings per worker compared with traditional companies, as well as modestly greater job loss, with a comparative decline of 4 percent over a two-year period.

“If a private equity firm needs to goose their returns, they will take it out of worker’s compensation — wages, pensions, benefits, all of it,” said Eileen Appelbaum, a co-director at the Center for Economic and Policy Research and the co-author of Private Equity at Work: When Wall Street Manages Main Street. To her, private equity firms only care about one thing: profit. “The fastest and easiest and least controversial way, in their point of view, is to cut compensation. They make a dollar every time they take a dollar out of workers’ compensation,” she said. “Private equity controls management and the board of directors. They can fire anyone at any time. They sit at both sides of the table. There is no one looking out for the workers.”

In 2014, still under Apollo management, Momentive filed for Chapter 11 bankruptcy, trimming its debt obligations from $3.2 billion to $1.2 billion. This is also a familiar tactic for the firm. “It makes sense [Apollo did that] because you create money out of thin air,” said Tony Casey, professor of law at the University of Chicago, who studied the Momentive bankruptcy case. “Apollo is an aggressive investment firm,” he added. “They are not shy when it comes to using bankruptcy to their advantage.” The company announced a public offering three years after it emerged from bankruptcy, but the offering was postponed. When it did, Apollo owned the largest stake of shares.

Taking advantage of bankruptcy courts is also a preferred method of President Trump, who counts Apollo CEO Leon Black as a friend. And while Trump boasts about his dedication to the American worker, the company he keeps deliberately erodes the foundation upon which the middle class is built. In a 2011 interview with George Stephanopoulos on ABC News, Trump said: “If you look at our great businesspeople today — Carl Icahn, Henry Kravis, Leon Black of Apollo — all of them have done the same. They use and we use the laws of this country, the bankruptcy laws, because we’ll buy a company. We’ll have the company. We’ll throw it into a chapter. We’ll negotiate with the banks. We’ll make a fantastic deal. … You know, it’s like on The Apprentice. It’s not personal. It’s just business. OK?”

“Every contract, they slashed benefits and made it harder for me to do what my father did: provide for his family.”

During Momentive’s bankruptcy proceedings, GSO Capital Partners, the credit arm of Blackstone Group, one of America’s largest hedge funds — headed by Steve Schwarzman, who chaired President Trump’s defunct Strategic and Policy Forum — translated its bond investment in Momentive into public stocks, a 6.8 percent stake. (A spokesman for Blackstone said the firm sold its stake in Momentive on August 3, 2016 — the same day union workers voted to strike if a contract agreement could not be reached. The spokesman, however, could not provide documentation of the sale. The spokesman also confirmed that Blackstone senior adviser John Dionne is still on Momentive’s board of directors.)

In 2013, Blackstone had bought a 20 percent controlling stake in another longtime upstate New York employer, then-declining Eastman Kodak, which had already slashed retiree health care benefits and pensions (though the company did restore elements of its pension plan upon emerging from Chapter 11 bankruptcy in late 2013). When Carl Icahn, the recently ousted special adviser to the president on regulatory reform — whom Trump also counts as a close friend — came to Trump’s rescue and retained full control of his Taj Mahal casino through a bankruptcy proceeding, he shut down the operation rather than give the union employees better health benefits. Roughly 3,000 people lost their jobs. “It’s a classic take-the-money-and-run — Icahn takes hundreds of millions of dollars out of Atlantic City and then announces he is closing up shop,” Bob McDevitt, the president of the local union, said in a statement after the closing.

Others in Trump’s family and inner circle have deep ties with these Wall Street operators, whose business tactics, like those being implemented in Waterford, affect middle-class families. Blackstone has loaned Kushner Companies, the real estate empire of Jared Kushner, Trump’s son-in-law and senior adviser, more than $400 million for real estate deals since 2013. The firm is one of the company’s largest lenders. Two months ago, the New York Times reported that Joshua Harris, a founder of Apollo, met with Kushner several times in 2017, at one point even discussing a possible job opening in the White House; by November of last year, Apollo would lend $184 million to Kushner Companies. (While Kushner is no longer CEO of the real estate company and has sold a chunk of his stake, he still reportedly holds properties and other interests in Kushner Companies — those investments are worth upward of three-quarters of $1 billion.) Kushner Companies is also on the clock to pay the $1.2 billion mortgage debt for 666 Fifth Avenue, a 41-story albatross in Manhattan that the company purchased in 2006, which is due February 2019.

Jack Boss joined Momentive as an executive vice president in March 2014, one month before the company filed for Chapter 11 bankruptcy, and he officially became CEO that December. The union believes that Apollo brought in Boss specifically to weaken the union during the next contract negotiation, which was slated for 2016. “They planned this entire thing,” Dominick Patrignani, the local union president, told me. “They knew what they were doing.”

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Dan Patregnani, a union member who worked in Building 78, and the headquarters of Apollo Global Management at 9 West 57th Street in. New York City. (Jonno Rattman)

In mid-January 2017, workers rallied outside the midtown Manhattan headquarters of Apollo Global Management, the private equity firm that had bought their company more than a decade prior. About a month later, members of their parent union, the Communications Workers of America, also handed out leaflets near the White House as President Trump met with Schwarzman, whom he had named an economic adviser and head of the Strategic and Policy Forum during the early days of the strike. (The 16-member group would disband just months after this meeting.)

Jack Mack, the second-generation worker who compiled the list of employees with cancer, trekked down to New York City to participate in the demonstration outside Apollo HQ. He stood with dozens of other workers and supporters, and his hot breath crusted in the frigid air as he called out Leon Black by name. This was the first time I met Mack — the strike had just begun. As the event came to an end and the NYPD began to shuffle protesters off the street, I asked Mack what he planned to do next.

He looked me in the eye and said, “Go back up to the plant and stand out there until this whole thing comes to an end — until we get what we deserve.”

***

The labor negotiations broke down over the summer of 2016, and by August a strike seemed imminent. In early September, 85 percent of workers rejected an offer that would have forced current employees into more expensive health insurance plans and eliminated the much-beloved benefit for future retirees altogether. They officially went on strike November 2. Five days later they voted again, with the same result — they rejected the offer by a larger margin.

Ron Gardner retired on New Year’s Day 2015. He was 61. He’d already lost his home and moved into his trailer, and he’d spent much of the previous summer at Saratoga’s venerable racetrack, watching and sometimes betting on the races. “I won enough to keep going the entire season,” he said, seated at his dining room table, television game shows audible in the background. Soon after he retired, he changed his health insurance on Momentive’s recommendation, switching providers and opting for a plan that was cheaper from month to month but caused his deductible to rise from zero to $3,500. He wasn’t worried. “I had never been sick a day in my life,” he said. But shortly before he retired, right around Thanksgiving 2015, he began having trouble swallowing. “It scared me,” he recalled. “I couldn’t even swallow my own spit.” There was a nearly two-inch tumor in his esophagus: adenocarcinoma, a form of cancer.

Gardner had begun working at GE’s Schenectady plant in 1973 and transferred in 1988 to Waterford, where he held various positions over the years, including the production of chemical mixers for caulking After GE sold the plant in 2006, he worked for more than two years refining chemicals in Building 30, filtering out cloudy imperfections before transferring those same liquids into drums to be sold to consumers. “I often inhaled a lot of vapors,” he said.

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The water treatment facility at Momentive Performance Materials. (Jonno Rattman)

Gloves, Gardner said, weren’t required for the job. According to material-safety data sheets, gloves are required only if a risk assessment deems them necessary. “He would come home covered in this caulking shit, all over his clothes and his hands,” his wife, Donna, said. “It would be everywhere.”

He transferred five years later to wastewater treatment, where he ran presses that compacted hazardous waste into dry, disposable cakes the size of kitchen tables before dropping them into trailers for disposal. He had to clean up spilled waste by hand and scrape out the presses if the cakes didn’t fall properly. The plant, he added, didn’t require respiratory protection for that particular job. “I breathed that stuff in for three and a half years,” he said. By the time Gardner began his last job at Momentive, the white walls of the facility had long turned gray from the dust produced by the waste. “That’s where I think I got the cancer from.”

Starting in January 2016, Gardner began a six-week course of chemotherapy and a month of radiation, paying off the $3,500 deductible in installments. Despite the treatment’s apparent success, Gardner’s doctor pressed him to undergo an esophagectomy. The operation — which would remove part of his esophagus and reconstruct it with the upper portion of his stomach — would be risky, and one of his lungs would have to be temporarily deflated during the procedure. Gardner decided against it.

By October 27, 2016, his cancer had returned. He needed the surgery to survive. But now he was racing against two clocks: the cancer and the company. Labor negotiations had broken down months before; the strike would begin within a week, and his current insurance coverage would run out at the end of December. “Company-paid medical, dental, vision, and drug coverage will not extend for the duration of employee strike activity,” a letter to employees from Momentive said.

“I wrote all the numbers down, in case I didn’t make it through the surgery, so Donna could get my pension,” Gardner said. “I didn’t trust Momentive to call her and say she was entitled to it.” He called his lawyer and had his will updated. He went into surgery on November 29, and spent nearly two weeks in the hospital. “I wish I could’ve been out there on the picket line,” he said. “It was all such bad timing.”

Once home, Gardner was told by Momentive to sign himself and Donna up for new health insurance through Mercer, a private online benefits marketplace, where employees can choose from a variety of providers and plans. A 2014 Aon Hewitt survey found that despite accounting for only 5 percent of current plans, 33 percent of employers said they would begin offering insurance through private marketplaces in the next three to five years. In a 2016 report, Mike Gaal of Bloomberg BNA wrote that large employers pitch private exchanges to employees as a way for them to “buy down” to more appropriate levels of coverage. “While this may be true,” he wrote, “the reality is that the plan savings, in this example, are derived through shifting costs to employees through high deductible, copayments and out-of-pocket limits.”

“I wrote all the numbers down, in case I didn’t make it through the surgery, so Donna could get my pension,” Gardner said. “I didn’t trust Momentive to call her and say she was entitled to it.”

The Gardners’ 2017 deductible would drop to $600 each, but their monthly premium soared from $262 to $1,152 per month — a hike Momentive promised to offset for already-retired workers under 65 with a $400 monthly subsidy. He got his first subsidy check on January 27, 2017. As a retiree, Gardner was one of the lucky ones. The younger generation was battling a contract that offered them expensive insurance while they worked — and nothing when they were finished with their working lives.

***

As the strike wore on, it drew the attention of elected officials in the area. Twenty-one Albany County lawmakers wrote to Momentive chief executive Jack Boss that the proposed contract seemed “to greatly hurt retirees and take too many health care and retirement benefits away from active employees.” State comptroller Tom DiNapoli reached out to Apollo; he has New York’s state-employee pensions partially invested through the firm. “I urge you to encourage Momentive to work diligently towards an expeditious settlement of this dispute on terms that are fair to labor and management,” he wrote. On the picket line in Waterford, one popular sign slung around the necks of strikers called out Apollo’s chief executive by name: hedge fund billionaire leon black, tell momentive: don’t destroy good jobs.

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Union strikers hold a sign outside of Momentive CEO Jack Boss’s home near Saratoga Springs. (Jonno Rattman)

In early February 2017, likely facing pressure from the governor’s office and intense publicity around both the strike and Momentive’s high-profile shareholders, Boss contacted the union’s regional leadership, bypassing the local chapter, and offered to resume negotiations. Four days later, a tentative deal was reached. Governor Andrew Cuomo, in his first public statement on the strike, announced his support for the deal, calling it key to “investing in the [union’s] world-class workforce, restoring operations at the plant and keeping upstate New York moving forward.”

Under the proposed new contract, to be voted on February 13 and 14, Momentive would keep matching 401(k) contributions of workers whose pensions had previously been frozen and would pay each striking employee a $2,000 bonus upon returning to work. In exchange, the union would accept the proposed health care amendments for current workers — more expensive premiums and deductibles. The company, rather than provide health insurance to future retirees, agreed to give at least 100 veteran workers a $40,000 cash bonus upon retirement — around $23,000 after taxes — that would hopefully cover any medical expenses before workers were eligible for Medicare at age 65. Though this was a win for the union, the next round of negotiations, in 2019, could decide the future of whether retirees will continue benefitting from Momentive’s medical coverage. “We have the right to negotiate now, which we didn’t have before last year’s strike,” says Patrignani. “It was going to sunset, but it’s still a topic of bargaining for future contracts.”

“You either have a preexisting condition, or you have an underlying condition, or you have an undiagnosed condition because of the inherent risk of working in a chemical plant,” said Robert Hohn, a 55-year-old employee. “You would probably have to pay a high premium and a high deductible. Would $23,000 cover that if something went wrong?” Hohn’s wife has degenerative disc disease, which requires constant care, and chronic gastrointestinal inflammation. Under the new contract, Hohn would have to pay $74 per week for him and his wife, with a $3,500 deductible and an annual maximum payment of $7,000. (Most workers signed up for this plan, which is the cheaper of the two; the other option has a $12,000 out-of-pocket maximum for a family). “The health care is going to kill me,” he said the day of the vote. “With my wife’s condition, we will definitely be hitting the maximum every year.” When the new contract came up for a vote, he felt he had no choice but to vote no. (At the beginning of 2018, Hohn’s wife left the insurance plan; he now pays $36 per week and a deductible for himself of $1,750.)

But many other workers feared that if the contract didn’t pass, some would cross the picket line to return to work, giving up their representation and fracturing the union. “They are pitting us against one another and using that to their advantage,” one worker said as he waited in line to vote on the proposed contract. “People are scared, feeling forced to vote ‘yes,’ even though the contract isn’t much better than what we went on strike for.”

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A classified ad for temporary replacement chemical operators in the Saratogian newspaper on a table in the union’s break house.

This internal tension became more and more apparent as the strike wore on, endless weeks of picketing outside during the coldest part of the year for upstate New York. “When it comes to these guys losing their health care, I should give a fuck?” one Momentive worker, speaking on condition of anonymity, wondered aloud in January, before the new union contract was ratified. “Why should I care about you when you didn’t give a shit about me in the past?”

Like some other younger union workers at the plant, he was in the minority and had voted yes on the contract back in September, recalling the wage cuts and pension freezes of years past. To them, the older generation were on their way out; the younger workers needed this place to provide for their families for decades to come. They wanted a fair contract for everyone, but they didn’t want to ruin what they had already — a stable job — and were willing to sacrifice benefits in the process.

Apollo has shut down other manufacturing plants in the past, and that threat was real for workers on the picket line. Noranda Aluminum’s Missouri plant once employed over 800 union workers. Then it began a slow decline, and after Apollo sold its position in 2015, the plant shut down in early 2016. To some workers, a long and intense strike could make that possibility a reality. “To me, it’s not worth losing all of this. If they shut down, where will we go?” said another during the strike. “Stop whining and move forward. These old guys, they’ve had it so good for so long that they don’t want to give anything up. Sometimes, to me, it’s better to take one step back so I am able to still move forward — not like this situation now.”

The contract passed on February 14, 2017. The men went back to work within days. “They didn’t achieve everything they wanted,” said Bob Master, the union’s legislative director for the region. “But sometimes the fruits of victory don’t show up until later on, during the next round of negotiations, when the company remembers the spirit and determination of a united workforce.”

***

Robert Hohn and his coworkers are already anxious about what new concessions their next contract negotiation in 2019 might bring. Since the company’s sale to private equity a decade ago, men like Ron Gardner, who went into bankruptcy after leaving his home for a double-wide trailer and fought cancer from exposure at the plant, have watched as their Wall Street–backed corporation trimmed job benefits they’d counted on for decades — benefits all the more crucial now, as they face retirement tinged with the threat of cancer. This time around, it was health care for retirees. What will it be next time?

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Outside the entrance gate of the Momentive chemical plant. (Jonno Rattman)

Apollo, meanwhile, announced in July 2017 that the firm had raised $24.7 billion for its latest global buyout fund, the largest sum of leveraged-buyout capital ever raised by a private equity firm, poised to pave the way for many more acquisitions like the one that created Momentive. Up in Waterford, there are whispers that Apollo is even trying to force the landlord to sell the hot dog shack — which the union still uses as it’s headquarters — and its surrounding land rights.

But despite these big-picture moves by corporate financiers, workers at the plant are still focused on their benefits — assets that are crucial to their survival. “I still don’t trust Momentive,” Gardner told me. The company had already cut his pay. What, he wondered, would prevent it from eventually taking away the insurance subsidy he received each month? If he lost the subsidy before he got Medicare, he explained at his dining room table, he won’t be able to afford health insurance. “After that, I don’t know what would happen,” he added, looking out the window. It was starting to rain. “If the cancer came back and I didn’t have coverage, I would die.”

***

Ian Frisch is a journalist based in Brooklyn. He has written for The New Yorker, The New York Times, Bloomberg Businessweek, Wired, Playboy, and Vice, among others. His first book, on magic and the secret lives of the subculture’s most prominent young magicians, will be published in 2019 by Dey Street Books, an imprint of HarperCollins. 

Editor: Michelle Legro
Photographs: Jonno Rattman

Fact checker: Matthew Giles
Copy editor: Sean Cooper

It’s Hard to See Seafood As a Healthy Choice After Reading This

Rex Features via AP Images

Canadian aquatic physiology researcher Laura McDonnell quit eating fish, but not for the usual environmental reason like protecting endangered stock or because of the taste. She’s too aware of fraud and plastic pollution to put herself at risk.

At The Walrus, McDonnell explains how mislabeled fish makes it onto our dinner plates, and how mislabeling a mackerel for a tuna, say, can have health consequences. She doesn’t dislike fish or want to quit it, but there are just too many players in the supply chain to identify the culprits in frauds. Worse yet are the pollutants: with the staggering amount of microplastic now floating in the Earth’s aquatic systems, she doesn’t believe there is any natural body of water pure enough to produce a safe, edible fish, so she quit. Even to a diehard fish-eater like me, who eats canned saury for breakfast and sardines for lunch, she makes a convincing case.

As much as I love fish, I can’t pretend that they’re wise animals with refined palates. Researchers have found that when given the choice between natural and microplastic food items, fish tend to choose the plastic. For most aquatic animals, finding food while avoiding predators is a struggle, so being picky or discerning is not evolutionarily beneficial; most species grab their desired snack quickly and head right back to their hiding place. As a result, aquatic animals often ingest floating bits of plastic, either by confusing colourful microplastics for something else, or by ingesting plastic-contaminated prey. Filter-feeding animals such as clams, oysters, and mussels obtain their nutrients by sucking in water, trapping small floating particles within in it, and then spitting the water back out. Mussels are so efficient at this process that they’ve been used to clear up polluted waterways. Unfortunately, much of what they trap these days is plastic: a recent study estimated that the average European could ingest about 11,000 microplastics per year just by including mussels and oysters in their diet.

Due to bioaccumulation (when a substance’s concentration increases in an animal over time) and biomagnification (when a substance’s concentration increases as it moves up the food chain), the concentration of microplastics in larger, older, and predatory fish such as tuna is likely to be higher than in smaller species or younger individuals. So what happens to other top predators—humans—who eat a seafood-rich diet during their lifetime? Even though current research shows we do not absorb most plastics, it’s possible that a small amount (about 1 percent) can still accumulate in our bodies over time.

Read the story

“No Fatties”: When Health Care Hurts

Illustration by Hannah Perry

Carey Purcell  |  Longreads  |  October 2017  | 4280 words (16 minutes)

Kasey Smith began gaining weight as a teenager. The numbers on the scale started increasing overnight, and no matter how few calories she consumed, they continued to go up. “It will even out,” she thought, crediting the change to puberty and hormones. But it didn’t, and her hair and skin began changing as well. “Something was definitely wrong.”

Each medical appointment, and there were many, concluded with doctors telling her to go on a diet. Smith (not her real name) remembers telling the endocrinologist about her frustrations with burning off the 900 calories she consumed each day and still gaining weight. “He looked at me and said, ‘Maybe you can cut back your McDonald’s to twice a week.’ I was stunned silent, and I went into the bathroom and broke down. ‘He doesn’t believe me. He thinks I’m just fucking with him.’”

As Smith’s weight went up, her food intake went down. Her mother signed her up for Nutrisystem, and her diet hung on the fridge for everyone in her family to see. Shame and humiliation narrowed her life down to three questions: what to eat, what not to eat, and how to burn more calories. She began to form dangerous habits, sometimes eating little more than lettuce.

Smith ultimately received a diagnosis of polycystic ovary syndrome, a hormonal disorder that can lead to excess male hormones, irregular menstrual cycles, and weight gain. She was prescribed Metformin and quickly began to lose weight, but the damage had been done. The 18-year-old developed anorexia, leaving for college at 130 pounds and coming back four months later and 30 pounds lighter, her hair falling out in clumps.

No one thought anything was wrong.

“I would go to the doctor, and there were no red flags. It was ‘You look fantastic!’ Not ‘This is alarming.’” Smith continued starving herself for another year until she ended up in the hospital, undergoing a colectomy to remove a foot and a half of her intestines, which had twisted as a result of her severe calorie restriction.

One year after the surgery, her worst nightmare returned: She was gaining weight. Celiac disease was the cause this time, but it wasn’t diagnosed until after Smith was in the habit of purging the little food she ate every day. She would regularly run in the park and pass out afterward. “I would starve all day, then I’d eat something at night, then I would purge it. In my head, I’m thinking, ‘I’m literally not consuming anything. The weight has to fall off.’”

She realized she needed professional help, and Smith found a therapist who specialized in eating disorders and began treatment at The Renfrew Center, a residential facility in Pennsylvania. She continues to struggle with discussing her weight at medical appointments. After she told her endocrinologist about her treatment at Renfrew, his reply was “I see you need to lose some weight.”

* * *

According to the National Association to Advance Fat Acceptance, one out of three doctors responds to obesity negatively and associates it with poor hygiene, hostility, dishonesty, and noncompliance, viewing fat patients as “lazy, lacking in self-control, non-compliant, unintelligent, weak-willed and dishonest.”

“Doctors may think they are doing their jobs by focusing on patients’ weights,” said Dr. Rebecca Puhl, deputy director of the Rudd Center for Food Policy and Obesity. But the effects of weight discrimination, both physical and mental, can be harmful to patients. “I do see this in health providers just as much as the general population, which is that maybe stigma isn’t such a bad thing. Maybe it will motivate people to lose weight. Maybe it will provide incentives for weight loss. But that is not what we see in research. We see the opposite — that in fact, stigmatizing people about their weight actually reinforces behaviors in health that increase body weight and obesity.”

The doctor looked at me and said, ‘Maybe you can cut back your McDonald’s to twice a week.’

As weight discrimination has increased in recent years — roughly 40 percent of adults report having experienced some form of weight stigma — so have obesity rates. A positive correlation between experiencing weight bias and developing eating disorders has been documented, and two studies have reported that overweight children are more likely to binge after being teased about their weight. Nor do these habits change as we age. In a 2006 study of more than 2,000 overweight and obese women who were part of a weight loss support group, 79 percent said they turned to food after experiencing weight stigma. Another common response: refusing to diet.

Johanna Tan encountered that stigma when she gained 80 pounds in three months after beginning the hormonal birth control Depo-Provera. Her doctor suggested weight loss, and she chose a weight loss clinic. In the weeks after undergoing her doctor-mediated diet of 500 to 800 calories a day, Tan began experiencing episodes of chest pain so severe she made more than one trip to the emergency room. Her general practitioner blamed her symptoms on her large breasts. “Never mind that my boobs have always been this big, and this was a new symptom,” Tan said, laughing wryly as she explained she had been performing special exercises and getting massage treatments to help ease the symptoms. But it wasn’t her breasts that were causing the pain, it was her gallbladder. Gallstones had blocked her common bile duct, and if left untreated it could cause acute liver failure. The cause of the gallstones? Rapid weight loss. Neither Tan’s weight gain nor her loss had been correctly assessed by her doctors. (Depo-Provera lists weight gain as a common side effect. When Tan voiced concerns to one doctor, she was told, “Everyone gets more hungry. You just need to not eat more.”)

The assumption that any health issues a fat person experiences can be chalked up to weight has not gone unnoticed by the fat community. Marilyn Wann was motivated to pursue fat activism after what she describes as her Really Bad Day, when a man she was dating told her he was embarrassed to introduce her to his friends because of her weight, and she was denied health insurance because Blue Shield of California deemed her morbidly obese.

“This double whammy of social and institutional exclusion based on my weight woke me up,” she said. “Until then, I had hoped to avoid the impact of anti-fat attitudes by avoiding the whole topic. But hiding and silence and avoidance didn’t keep the yuck from finding me. So I recognized that I had to come out as a fat person. The next day, I went to a copy store and made up business cards for my new print zine, which I decided to call FAT!SO? — ‘For People Who Don’t Apologize for Their Size!’ Immediately, my life became less stressful. Of course, I still encounter anti-fat attitudes and weight-based exclusions, but I have drawn a line between me and the hatefulness. It makes a huge difference.”

Wann still experiences bias, especially at the doctor. “I know before I enter the door that the whole system prioritizes its prejudice over my well-being,” she said. “The prejudice is what’s necessary to the institution as it stands. The medical establishment, the insurance agencies, public health agencies that are government-based have always advanced their agenda on the back of fat people. … The institutions of our supposed health systems — in the government agencies, in the insurance companies, in all of the medical practices — are saturated or have deeply ingrained anti-fat bigotry.”

Establishing the balance of information and compassion while discussing a patient’s weight is constantly on Rebecca Zuckerman’s mind. “It puts medical professionals in a weird catch-22,” said Zuckerman, a fourth-year medical student at the Pritzker School of Medicine at the University of Chicago, who understands the motivation of fat activists but whose education includes the negative medical impacts of obesity. “It’s something I’ve struggled with personally. You can only explain it and tell people their options. You can ask if it’s OK to talk about weight loss or give more information. If they say, ‘No, I don’t want to hear it,’ you have to respect that.”

Still, the intense schedule of medical professionals, who are often allotted only 15 to 20 minutes per patient, often results in less-than-ideal communication. It’s easier to reach for the quickest conclusion: telling the patient to lose weight. Says Zuckerman, “A lot of doctors and nurses experience burnout, and they start losing empathy and don’t view the patients as people anymore. Your hands are tied to stay within those 20 minutes. Everyone’s trying to make more money, and the doctors are a cog in the wheel.”

That’s along with pervasive stereotyping about fat people in the medical community. In a study of 318 family physicians, two-thirds reported that their obese patients lacked self-control, and 39 percent stated that their obese patients were lazy. Even health care professionals specializing in nutrition thought poorly of their obese patients: “Attitudes toward obesity and the obese among professionals,” a study in the Journal of the American Dietetic Association, reports that 87 percent of health care professionals specializing in nutrition believe that obese persons are indulgent, 74 percent believe that they have family problems, and 32 percent believe that they lack willpower. In 2013, the American Medical Association labeled obesity a disease.

The misdiagnoses that occur lead directly to poor health outcomes. Johanna Tan ultimately spent three years in pain, leading to four weeks of hospitalization, a series of invasive surgical procedures, and lengthy rehab — procedures that wouldn’t have been necessary had the gallstones been caught earlier. While she was enduring severe pain following her first surgery and struggling to complete her postsurgical rehab, the hospital staff accused her of being lazy. “I spent two weeks in hospital post-surgery,” she said, “copping abuse for being lazy and not participating in my own rehab, before they realized they fucked up.” Tan said the nurses were condescending, saying, “I know it hurts. It’s major surgery. You still have to get up.” The pain didn’t ease until her doctors realized they had missed some gallstones and had to perform a second surgery. Tan wasn’t able to walk more than 10 feet at a time for the first month following her surgeries. It took six months for her to be able to walk further than a block.

* * *

Fat patients also often find themselves facing off with doctors who refuse to write prescriptions or referrals until patients lose an arbitrary amount of weight, a common scenario for those seeking joint replacement surgery. Despite being in “crazy amounts of pain,” Melinda Belles-Preston was required to lose 30 pounds before receiving an operation on her hips. Losing between one and two pounds a week, a healthy pace according to the Centers for Disease Control, would delay her surgery by several months. Heavier patients see longer lags. A required loss of 50 to 100 pounds can postpone a procedure for months or even years unless the patient undergoes weight loss surgery. Without surgery, the time spent in pain is prolonged, opening the door to painkiller dependence. It took Belles-Preston roughly six months to lose the weight, and she was in pain the entire time.

“Going in nutrient-deprived and starved is probably not a good way to send someone into heart surgery or major any surgery,” Wann said; her tone made it clear she was stating what she thought should be obvious. “Someone who’s been losing weight may have worse outcomes than someone who’s stayed the same weight. … It’s amazing how someone can just look at you and decide how a random number of pounds can shift you from someone who doesn’t deserve care to someone who does.”

Pain management was barely discussed when Virgie Tovar, activist and author of Hot & Heavy: Fierce Fat Girls on Life, Love & Fashion, went to the doctor after being injured on an amusement park ride. Suffering what she described as “debilitating back spasms” that made movement “electrifyingly painful,” she was told she had to lose weight before anything could be done for her. “It was like this dogged commitment to not helping me until I was at a different weight,” she recalled. “Let’s say I lose weight at what is considered a normal pace that doesn’t endanger a person’s life. For me to get to the weight you’re talking about is like 10 years. So I just get to be in pain until I’m at that weight. And if I’m still in pain after a decade of weight loss, then you’ll think about taking care of this?”

Ideally, preventive care helps patients avoid catastrophic health problems, but it’s not always accessible to fat patients, whether because of issues with doctors, issues with technology, or both. Fat patients have been refused medical screenings, such as Pap smears, mammograms, and colonoscopies, that are considered routine and vital for thin patients. The American Cancer Society advises women to get mammograms yearly beginning at age 45 and colonoscopies every 10 years beginning at age 50, but fat people often struggle to find facilities that will perform the screenings and are told they cannot fit in the machines.

A required loss of 50 to 100 pounds can postpone a procedure for months or even years… It took Belles-Preston roughly six months to lose the weight, and she was in pain the entire time.

The importance of an MRI comes from its ability to provide higher-quality images. But the machines that provide those images are small, and other options, like CAT scans or ultrasound, don’t provide a comparable alternative. “All those scans need to penetrate the body to create an image. If a body is larger and has more fat tissue to penetrate, the image quality is poorer and blurrier, and it’s harder to make out structures,” Zuckerman explained. “It’s harder for skilled radiologists to diagnose things in patients who are larger for that reason. … The fact is, MRI machines are tiny. Some people literally cannot fit in them. So we do something else like an ultrasound or CT that is not quite as good. It’s better than nothing, but it doesn’t give us the image quality that an MRI does. You run the risk of missing something because the picture that you’re getting is not clear.”

The need for hospital equipment that can accommodate fat people has grown, and imaging devices are now available. This equipment is not available everywhere, however, and sometimes patients are referred to their local zoos. When Wann called the San Francisco Zoo’s medical department to ask about accessing its technology, the person on the phone sighed and said, “I wish people would stop saying that,” referring to requests to use the department’s CT and MRI scanners. While vet schools and zoos have larger-capacity devices, they can’t allow human subjects, and scanning humans in machines intended for animal subjects is banned by formal policies in most facilities. “That’s really beyond their certification,” explained Wann. They’re not licensed as an institution to practice medicine on people. Their entire institutional certification is being put on the line because our human medical system refuses to accommodate people above a certain size. It draws an arbitrary line and says, ‘Go beyond this line, and they’re monsters.’”

Without being properly screened, patients can’t be diagnosed. A 2008 review of previously published studies, 32 in total, reported that white, female, obese patients were less likely to be screened for breast and cervical cancer. A study from 2006 reported that only 68 percent of women with a BMI of greater than 55 were given Pap tests, while 86 percent of other women were tested.

In some cases, this is a result of fat patients opting out of health care entirely, even if they otherwise have the ability to access health care facilities and are insured: According to the International Journal of Obesity, 19 percent of participants reported that if they felt stigmatized about their weight by their doctor, they would avoid future medical appointments, and 21 percent said they would seek a new doctor.

“Fat people don’t go to the doctor often. They tend to avoid it,” writer and activist Kitty Stryker said. “A lot of fat people are ashamed of being naked. They don’t want to be touched. When I say I have a lower-back problem, I know they’re going to say, ‘Lose some weight, and that will go away.’ So what’s the point? Why bother continuing to try to get to the root of my health problems when I know the only thing they will ever tell me is ‘Lose weight’?”


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Patients often face added risk beyond concerns of being dismissed or the necessary treatment being denied: the possibility of weight loss treatments and procedures being strenuously suggested at inopportune or irrelevant moments. While the American Academy of Family Physicians recommends screening for obesity along with monthly sessions of counseling and behavioral interventions, the timing of these suggestions is crucial to the impact of motivational interviewing — and execution is often poor. Tan was mid-Pap smear when her doctor asked if she wanted a Weight Watchers pamphlet.

“The speculum’s already in and open. And she says, ‘I can tell you’re getting upset. Do you want me to continue?’” Tan recalled in disbelief. “I said yes because I didn’t want to have to make another appointment for my Pap smear. I was so mad, I was crying at this point. I couldn’t move. I couldn’t yell. She said, ‘I can tell I’ve made you upset, but weight is a serious issue.’”

Although familiar with the prejudice that came with her weight, Belles-Preston was still shocked when her general practitioner recommended weight loss surgery — while she was pregnant. “I walked out of the room. It was so incredibly offensive to me. I’m coming to you for medical advice about my pregnancy, and you’re talking to me about weight loss surgery, which is the furthest thing from my mind.”

“I have tons of resources and attitudes for confronting this kind of stuff, and it can still kill me,” Wann said as I marveled at her calm approach to discussing prejudice so severe it can result in death. “I understand not going [to the doctor]. I think it’s self-protective to some extent.… Every time I go to any kind of medical appointment I anticipate facing weight bias. I anticipate being denied the sort of services thin people would receive with no problem or being targeted for weight-based treatments that I don’t want and could harm me. I’m not interested in stomach amputation or stomach squeezing. I don’t think those are therapeutic practices in any sense. Every time I go see a doctor I’m aware they may casually say the only thing they want me to do is have my stomach cut off.”

* * *

The effects of that bias were traumatizing and long-lasting for Tan. Triggered by her uncomfortable experiences in hospital environments, Tan’s first job as an audiologist after graduate school provoked frequent panic attacks because of its location at a hospital. “I used to have to go to work early so that I could tamp down the panic associated with being in a hospital at all,” she said. “This fear of hospitals hasn’t quite gone away. Most recently, a few months ago, we had to spend a few days in ICU as my partner’s dad passed, and just being back in ICU rattled me so badly it was a month before I could stop popping several Valium a day.”

It was the adversarial relationship she had developed with doctors and nurses that contributed to Tan’s panic. And she’s not alone. For many, thin means healthy and fat means unhealthy. So small and slender equates with good health and is encouraged by medical providers, often resulting in strained relationships with their patients.

The idea that the lower the weight, the healthier the person, escalated into life-threatening conditions for Smith, who was frequently complimented on how healthy she looked while she was starving herself. “When you’re restricting [calories] you can brag about it,” she said, recalling her preparation for the colectomy. “[Doctors] asked, ‘Are you eating well and exercising?’ I said, ‘I’m very healthy. I exercise all the time. I only eat vegetables.’ It’s a funny dichotomy. Just because the scale is low does not mean that you’re healthy. A lot of doctors forget to be careful of that.”

But as the number on the scale climbs, the less flattering characteristics — greed, lack of control, messiness, lack of self-care, laziness, automatic unhealthiness — are associated with fat people, only to be furthered by the media’s portrayal of fat characters, who are typically the butt of jokes or seen as slovenly and undesirable. Women are often the punch lines, much more than men. BMI standards also are more harsh for women than for men, which is apparent in the statistics regarding weight loss surgery: Obesity rates in America are split fifty-fifty between genders, but 80 percent of bariatric surgeries are performed on women. In a 2014 study from Kansas State University, 72.8 percent to 94 percent of overweight and obese men were satisfied with their health as compared with 56.7 percent to 85 percent of overweight and obese women. There’s a reason all the stories and sources here are about and told by women.

“The truth is that there are reasons why fit people live longer, better lives,” Tovar said. “It’s because the entire culture is constructed to benefit them.” Weight discrimination is associated with an increase in mortality risk of nearly 60 percent for both women and men.

Fat activists are working to provide recourse at the community level; patients share the names of fat-friendly doctors or establishments, and Wann uses her social networks to help people get referrals for doctors and other medical providers. She also assists people with planning responses to doctors and providers who inflict weight bias. Fat activist Stef Maruch maintains a list of doctors who do not inflict bias or are fat positive, and Wann encourages people to update it whenever they can. NAAFA also publishes brochures and tool kits to assist fat people in navigating bias and fighting anti-fat legislation. A monthly newsletter updates recipients with the latest research and provides referrals to practical tools like products made for people of size. After Hurricane Harvey devastated Texas, NAAFA released a special-edition newsletter and sent plus-size clothing and supplies.

Obesity rates in America are split fifty-fifty between genders, but 80 percent of bariatric surgeries are performed on women.

The organization has also updated the brochure it gives health care providers treating fat patients. It was last updated in 2011, and per the recommendation of one of NAAFA’s advisers, its language is being revised to be much more aggressive when discussing weight bias with medical professionals. “Up until this point we’ve been trying to inform and be a little bit gentle,” explained Peggy Howell, NAAFA’s vice chairman and public relations director, citing the research scientists, Ph.D.s, and professors in medicine, law, nutrition, social work and more who serve on NAAFA’s advisory board. “The advisers came back and said, ‘I think we need to take a different approach. I think we need to be more assertive about this. There are lots of studies that support that this bias does more harm than good to the patients.’” The nonprofit’s 2011 brochure states, “NAAFA is working to help ensure that health care providers provide the best possible care by keeping in mind the special needs of their fat patients.” The new brochure reads, “We currently live in an environment that stigmatizes anyone who does not meet the aesthetic or medically defined categories of an ‘attractive’ or ‘healthy’ weight… [it] creates and sustains fat phobia and oppression, which includes weight bias, prejudice, stigma, discrimination, bullying, violence, and cultural imperialism. … Sometimes the internalized biases of health care providers directly contribute to further stigmatization of fat people.”

There is some movement on the medical end as well, driven by health care providers seeking training and resources. The Rudd Center has developed educational videos, which have been tested and found to reduce weight bias. Viewing the two 17-minute films — “Weight Prejudice: Myths and Facts” and “Weight Bias in Health Care” — resulted in improvement in attitudes toward obese people. The Rudd Center has also created a media repository of 400-plus photos and more than 80 B-roll videos that portray children and adults with obesity in non-stigmatizing ways, intended as a resource of respectful, rather than stereotypical, images for the media as well as scientists and health professionals to use when making educational presentations.

“We’ve created online courses and all different kinds of resources to use to try to increase awareness about this issue and educate providers that this is more than a social justice issue,” Puhl said. “This is a full public health issue. The stigma is making their patients’ health worse.”

For many fat people, the response is too little, too late. “I would rather doctors have signs on their door saying, ‘I don’t treat fat people,’” Wann said. “It would save everyone time and money if they had a sign on their door that said, ‘No fatties.’ At least they would be honest and own their bias.”

***

Carey Purcell is a New-York based writer who covers culture, politics and current events from a feminist perspective. She has been published in The New York Times, Vanity Fair, Politico and other publications. She has been a featured guest on AM Joy and Good Morning America, and her writing can be read at CareyPurcell.com.

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Editor: Michelle Weber
Illustrator: Hannah Perry
Fact checker: Matt Giles
Copy-editor: Sylvia Tan

The Fight for Health Care Has Always Been About Civil Rights

Longreads Pick

“Of all the inequalities that exist” said Martin Luther King in 1966, “the injustice in health care is the most shocking and inhuman.” The ACA did the most in American history to extend coverage to people of color; “they have never been closer both to racial equality of, access and to, the federal protection of health care as a civil right. But if Republicans have their way, that dream will be deferred.”

Source: The Atlantic
Published: Jun 27, 2017
Length: 10 minutes (2,500 words)

What Are the Secret Moves Being Made on the Senate Health Care Bill?

(Photo by Chip Somodevilla/Getty Images)

As most Americans are riveted by former FBI Director James Comey’s hearing on his firing, Senate Republicans are rushing behind-the-scenes to put together a bill to repeal and replace the Affordable Care Act. Amanda Michelle Gomez, health care reporter at ThinkProgress, reported that while eyes are on the Comey hearing, “Senate Republicans leaders and the health care working group will still be meeting for a working luncheon to continue negotiations.”

Read more…

A Tale of Two Americas Through the Lens of Health Care

(Christopher Furlong / Getty Images)

Two articles published by the Washington Post and the New York Times this weekend focused on extremely different versions of the U.S. healthcare system: The Post feature— part of a series on “Disabled America,” which focuses on rural populations receiving federal disability checks — bears the dateline of Pemiscot County, Missouri, a place where the dwindling population has an unemployment rate of eight percent. The Times’ feature is part of the series “The Velvet Rope Economy,” which focuses on “how growing disparities in wealth are leading to privileged treatment of the rich.” Nelson Schwartz reports from San Francisco, currently the second-most densely populated major city after New York, with the third-highest median household income. Known for being plagued by homelessness, the poverty rate is 12 percent, lower than the national average, and the unemployment rate is 2.6 percent.

In the Post, Terence McCoy reports on a multi-generational family on disability that struggles to make ends meet in “a county of endless farmland, where the poverty rate is more than twice the national figure, life expectancy is seven years shorter than the national average and the disability rate is nearly three times what it is nationally.”

Read more…

Popular Enough to Live: A Reading List About Crowdfunding Health Care

Postman76 / Flickr

I’m part of the 63 percent of Americans who don’t have money to cover an emergency costing $500 or more. I don’t own a car or a house, so in the unlikely event of the aforementioned emergency (knock on wood for me, please), my personal crisis would be health expenses uncovered by Medicaid. Like the people you’ll meet in the following stories, I too would turn to crowdfunding.

Everyone, in my opinion, deserves healthcare coverage, and crowdfunding shines a spotlight on the insufficiency of the United States healthcare system. It also demonstrates that the internet is far from democratic. Crowdfunding takes time, energy, and a knack for marketing. Not everyone has these privileges or skills, and when it comes to paying medical bills or seeking life-saving surgeries, that chasm can be fatal.

1. “Sometimes, It Does Hurt to Ask” by Caitlin Cruz (Digg, January 2017)

Just today, a trans man I follow on Instagram posted a picture of the letter he received in the mail saying his health insurance would not cover his top surgery. For trans and gender non-conforming people, the cost of life-affirming medications and operations are steep—financially, physically, and spiritually. According to GLAAD, 19 percent of transgender people don’t have any form of health insurance. Hormone therapy and gender confirmation surgeries can cost tens of thousands of dollars. Instead, many trans people have turned to the internet, using PayPal donations or hosting YouCaring or GoFundMe campaigns, to ask their friends, families, and total strangers for financial assistance.

2. “Is It Fair to Ask the Internet to Pay Your Hospital Bill?” by Cari Romm (The Atlantic, March 2015)

Donating to a medical crowdfunding campaign requires donors to be at once more intimate with and more judgmental of the recipients. At its most basic and most callous, the act of giving boils down something not unlike comparison shopping: Who, out of all the people who have shared their tragedy on the Internet, is the most deserving of money? And, before that, who can entice donors to click?

As medical crowdfunding has become more popular, so too has the idea of its so-called “perfect victim,” said Margaret Moon, a bioethicist and professor of pediatrics at Johns Hopkins University: the person whose inability to pay for their care came down to sheer bad luck—and bad coverage, if they had any insurance at all. “They’d done everything right, they’d explored all the possibilities and were still left short,” she said. “The people donating to these sites don’t know if somebody’s made a request because they just couldn’t figure out their insurance, or because their insurance failed them. Wouldn’t you be more willing to donate to someone who had played out their insurance?”

3. “Who Should Pay for Evan Karr’s Heart?” by Anne Helen Petersen  (BuzzFeed, March 2017)

Evan Karr is a a precocious 13 year old Kentuckian who was born with tetralogy of Fallot, a heart defect. Evan has had three heart surgeries, and at the top of Petersen’s story, he’s gearing up for a fourth.

4. “The Real Peril of Crowdfunding Health Care” by Anne Helen Petersen (BuzzFeed, March 2017)

Most of the successful campaigns on a crowdfunding homepage fall under the rubric of “fighting unfairness,” a designation that expands to include one of GoFundMe’s most successful campaigns of all time (for Standing Rock) but mostly signifies struggles against diseases that seemingly strike at random: cancer, genetic disorders, and other afflictions ostensibly out of the victim’s control. Such conditions are often referred to as “faultless.”

It’s far harder to fund so-called “blameworthy” diseases—addiction and mental health in particular—that are popularly conceived as either the fault of the victim or somehow under their control. You rarely see campaigns for adult heart disease, for example, or “getting my life together as a single mom”—both are viewed as the result of “choices” instead of “needs.” If there’s already a hierarchy of affliction and need in this country, then crowdfunding often works to exacerbate it.

5. “Go Viral or Die Trying”  by Luke O’ Neil, Esquire, March 2017)

Luke O’Neil’s feature for Esquire opens with an anecdote about Kati McFarland, a 25-year-old young woman with Ehlers-Danlos syndrome who turned to crowdfunding to offset the cost of medical care. McFarland garnered national attention when she confronted Sen. Tom Cotton about his perspective on the Affordable Care Act.

After reading several of these crowdfunding stories, I was feeling a little jaded. I couldn’t help but cringe at the following, from YouCaring’s director of online marketing:

“The secret prize for people who raise money on the site is they find out how much people care about them,” says YouCaring’s [Jesse] Boland. “The money is the primary ask but they end up being better off for having connected to their community, so they get a sense of peace and belonging.”

O’Neil also spoke to editors from Gizmodo, Uproxx, Upworthy, and the Washington Post about their experiences studying and spotlighting viral campaigns.

6. “Kickstarting a Cure”  by Noah Rosenberg (Narratively, July 2013)

Jimmy Lin is the founder of the Rare Genomics Institute, which he describes as “Amazon-slash-Kickstarter for science.” Lin’s organization matches families with researchers and geneticists from RGI affiliates and helps them raise money to cover the costs of expensive tests:

“The biggest thing we talk about with our team is, ‘If this was our child who was sick, what extent would we go to to help them?’” Lin says of RGI’s efforts. “If this was our kid that was sick, this is exactly what we’d do.”

Who Says Healthy Food Can’t Be Accessible and Affordable?

Patterson stepped out the back door onto a sunny patio where three neighborhood men worked as “ambassadors” — greeters, really, but also unofficial security guards and community liaisons tasked with convincing neighbors that Locol really was for them. Watts has such a deep history of economic betrayal and abandonment, such pervasive skepticism about outsiders making big promises, and such well-founded fear of gentrification — a billion-­dollar “urban transformation” plan has the support of Mayor Eric Garcetti — that acceptance of a splashy new restaurant created by two famous outsider chefs who are not African American was not a given.

Patterson embraced an ambassador named Anthony “Ant” Adams, a 44-year-old poet who was in the middle of telling a visitor about getting shot five times with an AK-47 during a 2007 attempt on his life a few yards from where he was currently standing. Patterson then walked past an ATM/lottery/tobacco shop where floor-to-ceiling bulletproof Plexiglas separated customers from the cashier and inventory. He entered a store called Donut Town & Water, where a young man sold doughnuts, water, and other convenience foods, also from behind Plexiglas. Patterson ordered coffee to go and said, as if exhilarated by the speed and audacity of his own thoughts, “I can’t remember if I told you that Roy and I might start a coffee company, too. We’re bringing back the great $1 cup. The fancy coffee industry is not going to be happy with us. We’re going into institutional food, too. We’re already talking about prisons and hospitals and schools. It all comes back to this question of ‘Why does our society always serve the worst food to the neediest people?’ It makes no sense. And everybody always says, ‘That’s just the way it is, there’s no other way,’ but we are going to prove that whole paradigm is fundamentally false.”

In the California Sunday Magazine, Daniel Duane narrates the difficulty of establishing a new way of serving fast healthy food in the impoverished neighborhoods that the conventional industry has helped trap in a food desert.

Read the story