Category: Public Health Reseach

     1 in 10 new HIV cases in the United States are attributable to injecting drug use due to the transmission of bloodborne pathogens via reused and unsafe needles. Sharing needles is the second riskiest behavior for contracting HIV right after unprotected sex, with the chance of contracting HIV from a dirty needle being 1 in 60 (CDC, 2021). And even though access to HIV treatment has expanded, injectable drug users generally face other social or economic barriers to healthcare which would make them more likely to postpone care –  increasing the risk of transmission to others in the period before treatment – and are compounded by the social stigma around both HIV and using injectable drugs. 10% of new HIV diagnoses in the U.S are attributed to people who inject drugs (CDC, 2022). And between 2007 and 2011, the total direct expenditure of HIV and AIDs treatment was 10.7 billions dollars annually (National Institute of Health, 2023)

     Though historically HIV is seen as an issue in urban areas, it is becoming increasingly prevalent in rural ones as well. As recently as 2015 in Austin, Indiana 235 people were diagnosed with HIV in a community of only 4,1000 (Ungar, 2020). This outbreak was caused almost exclusively via injectable drug use.  The only physician in Austin, Dr. Willian Cooke, said that the community already had an existing drug use problem with a high prevalence of those with opioid use disorder, but it worsened in 2010 to 2011 when users started turning to other, more extreme options like injectable drugs. He believes that the HIV outbreak was inadvertently caused by the opioid epidemic (Varney, 2015). This was later proven true in a 2016 study which found that 87% of HIV patients in Scott County Indiana reported injecting the prescription opioid, oxymorphone (Peters, P. J., Pontones, P., et al. 2016). 

In 2017, among 15 counties with the highest opioid prescribing rates, 14 were rural (García, M. C., Heilig, C. M., et al. 2019), which likely explains why the incidence of overdose death is significantly higher in rural communities than in urban ones. With this in mind, we can assume that rural areas are at a uniquely high risk of an HIV outbreak due to the incidence of injecting opioids. 

     Following the 2015 outbreak in Scott County, the CDC conducted a national assessment to determine what counties with similar characteristics – Hepatitis C incidence, opioid use data, etc. – would be at risk of a severe HIV outbreak. This totaled to 220 counties in the U.S (CDC, 2021). The Indiana HIV outbreak can be used as a model for how a well-informed and scientifically- backed federal response can significantly determine the resolution of an outbreak. In 2015, the then governor of Indiana, Mike Pence, announced a public health emergency two full months after the first surge of cases were reported, and then reluctantly authorized the  implementation of a targeted needle exchange program where he stated that he opposes such programs for combating drug use but had to make an exception for Scott County (Harper, J. 2015). A Brown University study using model predictions on the spread of HIV in Scott County Indiana estimated that an earlier implementation of needle exchange programs could have reduced the incidence of HIV in rural Indiana by 90% (Goedel, W. C., King, M. R., et al. 2019). 

     But the sentiment from Mike Pence is a common one. In 2012 former president Obama signed the FY2012 omnibus spending bill which reinstated the ban on the use of federal funding for needle exchange programs, reversing the 2009 decision allowing it, despite the evidence proving their efficacy in preventing HIV. This decision was largely due to conservative constituents believing that needle exchange programs promote and encourage drug use by making it safer, contradict the efforts of law enforcement, and worsen public health in general, despite strong evidence demonstrating that this is not the case; Individuals who participate in needle exchange programs are five times as likely as those who do not to enter drug treatment programs (CDC, 2019). But political opposition wouldn’t be the only barrier to the implementation of needle exchange programs, and would require coordination with the justice system as well. Most state drug paraphernalia laws mean that an injecting drug user who takes advantage of needle exchange programs could be charged with a misdemeanor and, in the state of Georgia, could face up to one year in prison (Kohn, 2020). In order to implement needle exchange programs, state legislators would have to be willing to cooperate with public health officials to make it so that those carrying drug paraphernalia are not criminally charged, something which completely alters how most state laws perceive the handling of drug abuse.

     The method in which a needle exchange program is implemented is just as critical for its efficacy as the legislation surrounding it. Some states such as Nevada and New York implemented a needle vending machine program in 2017 and 2022 respectively. This allows the individual to remain anonymous, encouraging utilization in the absence of social stigma. However, though beneficial, sterile needle vending machines haven’t been proven yet to have the same long term benefits as intervention programs with provider-to-user interaction such as those run in clinics or mobile health units (Stewart, R. E., Cardamone, N. C., et al. 2023). Intervention programs can provide a way to connect users to other relevant resources while they participate in the needle exchange, such as referral to substance use disorder treatment programs, screenings for Hepatitis C and HIV, wound care, and Naloxone distribution supplemented by education on how to respond to an overdose (CDC, 2019). These supplemental interventions are most common in needle exchange programs operating out of clinics, however, given the prevalence of healthcare deserts in rural America, this may only exacerbate existing health disparities. 

     One alternative solution which allows for face-to-face contact while still expanding access to healthcare to rural areas, which are already at a greater risk of HIV outbreaks, would be through the mobile clinic model. The mobile clinic model was popularized during the COVID-19 pandemic for similar reasons related to rural healthcare accessibility. With this method, medically underserved regions can easily get in touch with healthcare providers regardless of the availability of standing clinics. In 2020, the Substance Abuse and Mental Health Services Administration offered the Colorado Department of Human Services, Office of Behavioral Health a federal State Opioid Response grant to expand access to treatment for opioid use disorder (Rural Health Information Hub, 2021).  These mobile health units were RVs converted into clinics, which had on-board a nurse, a licensed addiction counselor, and a peer support specialist. These units traveled to 32 counties in Colorado where they supplied services like counseling, drug testing, naloxone, and syringe disposal where they served hundreds of residents. 

 Providing similar grants to mobile health unit companies such as The Health Wagon or Remote Area Medical could help smaller organizations to expand their client base to more cities in rural America, and provide them with the resources to offer a greater variety of services so that they could include needle exchange and overdose prevention. This method allows needle exchange and other drug related programs to provide users face-to-face contact which is associated with a greater chance of quitting drug abuse, while also reaching areas which otherwise would have had little to no access to a physician.

References

Centers for Disease Control and Prevention. (2021, April 21). HIV and injection drug use. cdc. Retrieved April 27, 2023, from https://www.cdc.gov/hiv/basics/hiv-transmission/injection-drug-use.html#:~:text=Risk%20of%20HIV,and%20blood%20can%20carry%20HIV. 

Varney, S. (2015, May 7). Rural Indiana struggles with drug-fueled HIV epidemic. KFF Health News. Retrieved April 27, 2023, from https://kffhealthnews.org/news/rural-indiana-struggles-with-drug-fueled-hiv-epidemic/ 

Ungar, L. (2020, February 16). 5 years after Indiana’s historic HIV outbreak, many rural places remain at risk. NPR. Retrieved April 27, 2023, from https://www.npr.org/sections/health-shots/2020/02/16/801720966/5-years-after-indianas-historic-hiv-outbreak-many-rural-places-remain-at-risk 

Goedel, W. C., King, M. R., Lurie, M. N., Galea, S., Townsend, J. P., Galvani, A. P., Friedman, S. R., & Marshall, B. D. (2019). Implementation of syringe services programs to prevent rapid human immunodeficiency virus transmission in rural counties in the United States: A modeling study. Clinical Infectious Diseases, 70(6), 1096–1102. https://doi.org/10.1093/cid/ciz321 

Centers for Disease Control and Prevention. (2021, August 31). Vulnerable counties and jurisdictions experiencing or at-risk of outbreaks. cdc. Retrieved April 27, 2023, from https://www.cdc.gov/pwid/vulnerable-counties-data.html 

Peters, P. J., Pontones, P., Hoover, K. W., Patel, M. R., Galang, R. R., Shields, J., Blosser, S. J., Spiller, M. W., Combs, B., Switzer, W. M., Conrad, C., Gentry, J., Khudyakov, Y., Waterhouse, D., Owen, S. M., Chapman, E., Roseberry, J. C., McCants, V., Weidle, P. J., … Duwve, J. M. (2016). HIV infection linked to injection use of oxymorphone in Indiana, 2014–2015. New England Journal of Medicine, 375(3), 229–239. https://doi.org/10.1056/nejmoa1515195 

García, M. C., Heilig, C. M., Lee, S. H., Faul, M., Guy, G., Iademarco, M. F., Hempstead, K., Raymond, D., & Gray, J. (2019). Opioid prescribing rates in nonmetropolitan and metropolitan counties among primary care providers using an electronic health record system — United States, 2014–2017. MMWR. Morbidity and Mortality Weekly Report, 68(2), 25–30. https://doi.org/10.15585/mmwr.mm6802a1 

Harper, J. (2015, March 26). Governor declares public health emergency as HIV outbreak spreads. WFYI Public Media. Retrieved April 27, 2023, from https://www.wfyi.org/news/articles/governor-declares-public-health-emergency-as-hiv-outbreak-spreads 

Centers for Disease Control and Prevention. (2019, May 23). Syringe Services Programs (ssps) faqs. cdc. Retrieved May 1, 2023, from https://www.cdc.gov/ssp/syringe-services-programs-faq.html 

Kohn, L. (2020, March 28). Georgia drug laws on Paraphernalia: Drug Objects Charges. Criminal Defense Matters. Retrieved May 1, 2023, from https://criminaldefensematters.com/georgia-drug-laws-on-paraphernalia-drug-objects/ 

Stewart, R. E., Cardamone, N. C., Loscalzo, E., French, R., Lovelace, C., Mowenn, W. K., Tarhini, A., Lalley-Chareczko, L., Brady, K. A., & Mandell, D. S. (2023). “there’s absolutely no downside to this, I mean, except community opposition:” a qualitative study of the acceptability of vending machines for harm reduction. Harm Reduction Journal, 20(1). https://doi.org/10.1186/s12954-023-00747-4 

Rural Health Information Hub. (2021, April 8). Rural Health Information Hub. Rural Project Summary: Mobile Health Units for Opioid Use Disorder Treatment. Retrieved May 1, 2023, from https://www.ruralhealthinfo.org/project-examples/1089 

Centers for Disease Control and Prevention. (2022, June 28). HIV among people who inject drugs. Centers for Disease Control and Prevention. Retrieved May 2, 2023, from https://www.cdc.gov/hiv/group/hiv-idu.html 

National Institute of Health. (2023, March 23). Cost considerations and antiretroviral therapy: NIH. clinicalinfo. Retrieved May 2, 2023, from https://clinicalinfo.hiv.gov/en/guidelines/hiv-clinical-guidelines-adult-and-adolescent-arv/antiretroviral-therapy-cost-considerations 

  Safety net hospitals are broadly defined, but a common characteristic is that they are not owned by investors or shareholders, and their primary motivation is to serve the community rather than make a profit (Hefner & Hogan & Opoku-Agyeman, et al. 2021). SNHs are usually located in low-income, medically underserved communities where most of their patients are uninsured or Medicaid beneficiaries. Most safety net hospitals struggle to break-even or are operating at a deficit which threatens closure, or forces them to privatize (Khullar, D., Song, Z., & Chokshi, D. A. 2018). This is because with the large proportion of uninsured patients, healthcare services go uncompensated. And even when those patients are on Medicaid, it is often not enough to close the gap in spending for the hospitals.

     The federal government provides supplemental payments, which are distributed by state governments, to compensate for the revenue hospitals lose from Medicaid. However, because revenue is used to calculate the size of a hospital, this means that much of these supplemental payments go to hospitals who don’t need it (Evans, M. Whyte, L.E., & McGinty, T. 2022). In fact, these supplemental payments covered only 51% of the costs of uncompensated care at hospitals receiving payments nationwide (U.S Government Accountability Office. 2019)

     This gap between the supply of SNHs in low-income areas and the demand for healthcare creates a shortage of health resources that we could define as a market failure, due to the inefficient allocation of federal funds to hospitals, usually private, that usually do not face a similar, proportionally large client base of Medicaid beneficiaries. 

     But this poses the question, if a hospital cannot manage to operate independently, should their services be subsidized by the federal government? Would a more competitive healthcare market incentivise better care? I argue that the healthcare market does not meet the five qualifications of a competitive market: many small buyers and sellers, all firms producing identical products, all market participants have full information about price and product characteristics, transaction costs are negligible, and firms can easily enter and exit the market. Therefore a competitive model shouldn’t be applied to the hospital system, and government subsidies to safety net hospitals are crucial for access to care and the reduction of health disparities.

     The demand for uncompensated care (Medicaid) has increased; National health expenditure increased 2.7% in 2021, Medicaid spending increased 9.2% that same year, and hospital expenditures grew 4.4% – This was a slower rate of increase than 6.2% in 2020, however the spike in hospital expenditures in 2020 is most likely a result of the COVID-19 pandemic response (Centers for Medicare and Medicaid Services. 2023). As Medicaid takes up a higher percentage of GDP annually, so does the cost of supplemental payments. And yet the supply of affordable and accessible healthcare is constantly under threat by bankruptcy and closure due to inefficient allocation of government supplemental payments. 

1. The market consists of many small buyers and sellers

     One local example: The Atlanta Medical Center, owned by Wellstar, was a safety-net hospital and was one of only two level 1 trauma centers in the area. Low income residents in the area who benefited from access to the non-profit hospital were given little to no option as to which hospital to go to given the lack of available care centers, cutting off any opportunity for competitive behavior from the hospitals.  State officials have since then advocated for increased funding to Grady Hospital to compensate for the new healthcare deficit. However, it’s unlikely that investing in Grady alone is sufficient enough to cover the displacement of patients (Thomas, D, J. 2022)

     But the issue of hospital closure is predominantly a rural health issue, not an urban one like described in Atlanta, and it affects the majority of Americans. “Health-care deserts” are defined as areas where residents lack adequate access to pharmacies, primary care providers,  hospitals, hospital beds, trauma centers, and low-cost health centers. 80% of Americans live in a county with at least four of the six types of healthcare deserts (Nguyen, A., & Kim, S. 2021). This means that the majority of Americans are not given adequate choice as health care consumers.

  2. All firms produce identical products.

   Hospitals vary significantly in terms of nosocomial infections, medical errors, and wait times, not only at a state level, but even within a county (Agency for Healthcare Research Quality, 2023).  Safety net hospitals and privately owned, for-profit hospitals differ dramatically in terms of the range of their services provided. Their revenue will determine how much they can invest in high-tech care, the number of services provided, and the number of healthcare providers, which will affect patient wait times. This means that they do not in fact produce comparable services. 

3. All market participants have full information about price and product characteristics.

     Because of the nature of health insurance, patients usually do not know the true cost of care until after they have received a service and their copay is charged, while the charge of services does vary by hospital, even within a region (Kurani, N., Rae, M., Pollitz, K., Amin, K., & Cox, C. 2022). Because of the lack of price transparency, patients cannot effectively allocate their spending to which medical costs are optimal for their budget, this process only occurs in the health insurance marketplace. 

4.  Transaction costs are negligible.

     Transaction costs for healthcare would involve the cost of transportation and wait times on the patient-end. For hospitals themselves, the transaction cost of healthcare administration is incredibly high; in 2017 the cost of healthcare administration in the united states was 34.2% of national health expenditures, compared to only 17% for our neighbor, Canada (Himmelstein, D. U., Campbell, T., & Woolhandler, S. 2020). The transaction costs are anything but negligible.

5. Firms can easily enter and exit the market.

     Hospitals mergers and acquisitions drive up the cost of healthcare services (Ginsburg, P. 2017). The market consolidation of private hospitals makes it increasingly difficult for smaller hospitals to enter and thrive in the market, since it’s more lucrative for newly licensed physicians to pursue employment at a larger practice. This further contributes to the monopolization of healthcare by blocking the opportunity for smaller, more accessible practices to enter the market and hire a sufficient number of practitioners. 

     Because the hospital system does not meet the qualifications of a competitive market, it will not benefit safety net hospitals or healthcare consumers to allow non-profit hospitals and smaller practices to continue to operate without additional government funding and support. By not supporting these kinds of healthcare providers, it is only increasing the prevalence of healthcare deserts and driving up the cost of care when patients can finally access it. By shifting the allocation of supplemental payments from larger private practices to smaller ones or those with more Medicaid beneficiaries, it can close the gap between the demand for healthcare and the supply of affordable providers. 

References

Hefner, J. L., Hogan, T. H., Opoku-Agyeman, W., & Menachemi, N. (2021). Defining safety net hospitals in the Health Services Research Literature: A systematic review and critical appraisal. BMC Health Services Research, 21(1). https://doi.org/10.1186/s12913-021-06292-9 

Khullar, D., Song, Z., & Chokshi, D. A. (2018, May 10). Safety-Net Health Systems at risk: Who bears the burden of … Health Affairs. Retrieved April 24, 2023, from https://www.healthaffairs.org/do/10.1377/forefront.20180503.138516/ 

Evans, M., Whyte, L. E., & McGinty, T. (2022, December 4). Billions in covid aid went to hospitals that didn’t need it. The Wall Street Journal. Retrieved April 24, 2023, from https://www.wsj.com/articles/billions-in-covid-aid-went-to-hospitals-that-didnt-need-it-11670164570 

Government Accountability Office. (2019, July 19). Medicaid: States’ use and distribution of supplemental payments to hospitals. U.S Government Accountability Office. Retrieved April 24, 2023, from https://www.gao.gov/products/gao-19-603 

Centers for Medicare and Medicaid Services. (2023, February 17). NHE fact sheet. CMS . Retrieved April 24, 2023, from https://www.cms.gov/research-statistics-data-and-systems/statistics-trends-and-reports/nationalhealthexpenddata/nhe-fact-sheet#:~:text=Medicaid%20spending%20grew%209.2%25%20to,28%20percent%20of%20total%20NHE.

Thomas, D. J. (2022, October 31). After weeks of Drama, disappointment, Atlanta Medical Center to close. ajc. Retrieved April 24, 2023, from https://www.ajc.com/news/atlanta-news/after-weeks-of-drama-disappointment-atlanta-medical-center-to-close/WCORMLKD7FEEJAD3NA4XI3KY7A/ 

Nguyen, A., & Kim, S. (2021, September 9). Mapping healthcare deserts: 80% of the country lacks adequate access to healthcare. GoodRx. Retrieved April 24, 2023, from https://www.goodrx.com/healthcare-access/research/healthcare-deserts-80-percent-of-country-lacks-adequate-healthcare-access 

Agency for Healthcare Research and Quality. (2023, March). National Healthcare Quality & Disparities Reports. AHRQ. Retrieved April 24, 2023, from https://www.ahrq.gov/research/findings/nhqrdr/index.html 

Kurani, N., Rae, M., Pollitz, K., Amin, K., & Cox, C. (2022, June 30). Price transparency and variation in U.S. health services. Peterson-KFF Health System Tracker. Retrieved April 24, 2023, from https://www.healthsystemtracker.org/brief/price-transparency-and-variation-in-u-s-health-services/ 

Himmelstein, D. U., Campbell, T., & Woolhandler, S. (2020). Health care administrative costs in the United States and Canada, 2017. Annals of Internal Medicine, 172(2), 134. https://doi.org/10.7326/m19-2818 

Ginsburg, P. (2017, February 3). Health Care Market Consolidations: Impacts on costs, quality and access. Brookings. Retrieved April 24, 2023, from https://www.brookings.edu/testimonies/health-care-market-consolidations-impacts-on-costs-quality-and-access/ 

Abstract

Though it is seen by most as a purely utilitarian piece of tailored cloth, most people would still recognize and affirm the social meaning and impact of clothing. It’s the most conspicuous non-natural representation of the self. It can be used to communicate something as simple as personal taste, to someone’s profession or social status. Though a practical object, it is ultimately a personal one. This recognition of clothing as a form of personal agency also means that it has historically been targeted, particularly in internment, prison camps or other violent institutions, as a means of controlling a group of people or to reinforce ideas around power hierarchies. In addition to the robbing of any personal item. Okubo’s Citizen 13360 supports this idea of clothing as a tool of agency and power, and she clearly portrays these ideas through her illustrations of internees throughout the text. Her images directly confront the viewer with what it truly means to be forced to wear someone else’s clothes and how that fits in the context of the Japanese internment camps. Furthermore, the central figures who usually lead the resistance to forced clothing, seized belongings, or internment in general are women, and they often do so in the form of bespoke embroidery and knitted products which are used as individuality-affirming tools in addition to being practical objects..

  August Wilson’s work cannot be properly understood independent of the periods in which they take place. His collection of ten plays called the 20th Century Cycle all focus on the experiences of  black American families for each decade of the 20th century and detail the unique social challenges they faced in each era (Nadel 2). Each play was designed to be not only an exploration of individuals and universal truths but also how they operate in the context of the time and place that they exist in. For example, Ma Rainey’s Black Bottom dealt with themes relating to the exploitation of black artists by the music industry in the 1920s, and his other play Seven Guitars addressed topics surrounding Black manhood and its implication in 1940s America where black men were often the subject of brutal racially motivated violence. The characters simply cannot exist or make sense independently of their setting. And the same is true for Wilson’s play The Piano Lesson.

     The Piano Lesson takes place in Pittsburgh, Pennsylvania like most of Wilson’s plays – with the exception of Ma Rainey’s Black Bottom – which indirectly references the Great Northward Migration. In the 1900s, the vast majority of Black Americans still lived in the southern region of the United States. But between the mid 1910s and the 1970s, roughly 6 million black Americans had migrated and settled in the northern states, mostly in major cities such as Chicago, New York, Detroit, and Pittsburgh (Arora 8). Northward migration only increased in the 1930s during the Great Depression, as many Black Americans moved to major cities in search of financial opportunities, such as sharecroppers from the south who now had debts as a result of the Depression, or to escape racial violence in the Jim Crow South.

     Themes about Northward migration and the search for better opportunities are evident in the very first few lines of the play when Boy Willie arrives in Pittsburgh all the way from Mississippi in the hopes of selling the watermelons he carries at the back of his truck. The watermelons also symbolically parallel the property that Boy Willie wishes to purchase. He’ll own the very land that brought so much suffering to his ancestors. His achievement is tinged with the pain of racial violence.  This same dichotomy is evident in the watermelons which Boy Willie desperately tries to sell to cover the expenses. While the fruit is a symbol of opportunity and financial independence, they historically have hateful and negative connotations as props which were frequently used in minstrel shows and generally have racist connotations (Black 69). But in this play, the watermelons have been repurposed in a way that is liberating and empowering. The watermelon, just like the land, is an opportunity tinged with a racist and violent history. But the opportunity is fleeting and transigent, watermelons – like all fruits –  will eventually rot, and they ultimately act to symbolize the transiency of opportunity. The sense of urgency to sell the watermelons and the brief moment of opportunity also parallels the plight of black Americans in this era.

     The Charles family is forced to make the best of the limited options that they’ve been dealt.  This is evident in Boy Willie’s line from act one, scene two.

BOY WILLIE: […] Now, I’m supposed to build on what they left me. You can’t do nothing with that piano sitting up here in the house. That’s just like if I let them watermelons sit out there and rot. I’d be a fool. […]

     In this line Boy Willie describes the parallels between the piano and the watermelons. He declares that he can’t stand to let an opportunity like that simply fade away, and that this sense of urgency is motivated by the need for a legacy; the burden of the past means he must build on what’s been left to him. Boy Willie was so desperate to fulfill this legacy that the mass of watermelons he gathered caused his car to break down from their weight. 

DOAKER: You got all them watermelons stacked up there, no wonder the truck broke down. I’m surprised you made it this far with a load like that. Where you break down at?

BOY WILLIE: We broke down three times! It took us two and a half days to get here. It’s a good thing we picked them watermelons fresh.

     The imagery of these watermelons, a mass of fruit, a symbol of abundance, weighing down on the truck to the point that it breaks is a visual representation of the burden of capital. To the Charles family, this object of wealth is also a reminder of the sense of urgency they share as the working class during the Great Depression. Just like the highly valuable yet unplayed piano, this mass of unused potential is weighing on the space and characters around it. The piano that sits in Bernice’s home is an asset and yet its presence as a mass of unused opportunity is a major source of conflict for Boy Willie and Bernice. 

     It’s extremely evident that finances and wealth are a major source of anxiety for the Charles family, and this especially makes sense considering that the characters live in a post-Depression America. Prior to the collapse of Wall Street in 1929, the economic status of black Americans more closely resembled their white counterparts post-collapse, the crash only exacerbated it. They faced serious obstacles regarding land ownership, educational attainment, and vocational opportunities. Most men were limited to working in agriculture, and in 1910, only a quarter of black farmers owned the land they worked on (Greenberg 2).

      Many black men found vocational opportunities in the railroad industry such as the Pullman porters in sleeper cars, including Charles Doaker in the play who took pride in his occupation. After the Civil War the Chicago investor George Pullman made an active effort to hire recently freed slaves to work on his trains for lower wages and longer hours. But given the other options available, the Pullman cars were the best option for many, and was generally seen as a more prestigious occupation given the wide range of duties. In the early 20th century the Pullman Company was the single largest employer of black Amricans in the country. And in 1925, Pullman porters formed the first all-black union, the Brotherhood of Sleeping Car Porters (National Parks  Service)

     Throughout The Piano Lesson the characters are forced to grapple with the pain from the past, which is tinged with racism. For example, several central male figures in the play discuss their trauma from incarceration, first hand or secondary. This is evident when Boy Willie begins singing the song “Berta, Berta” in which an imprisoned man working in a federal prison is singing to his partner Alberta to forget about him and marry someone else while he’s away.

The characters Lymon, Winning Boy, and Doaker lastly follow. This song was historically used as a prison labor song to keep the beat of the field work which they were forced to do, and can be traced back to the Parchman Farm, a prison labor camp. 

      Starting in the 1860s the formerly confederate states were reintegrated back into the Union, this was known as the Reconstruction Era. During this phase of reintegration the Southern states were now free to implement laws which were designed to limit the opportunities of the newly freed black American population in the south with what was known as the Black Codes. The Black codes included laws which prevented Black people from starting businesses, owning land, and essentially having any form of employment other than in sharecropping (Salem Press 123). These coincided with vagrancy laws which criminalized homelessness and unemployment. Because of this, Black people were disproportionately targeted by vagrancy law and would be incarcerated where under prison laber they were met with conditions akin to slavery. During the play the men bond over the horrid conditions at the notorious Parchman Prison Farm in Mississippi. Established in 1901 in Sunflower County, it was one of three state prisons designed to collect revenue through prison labor for the Mississippi government. Between 1870 and 1910, the conviction population at Parchman grew ten times faster than the state population did, and 90% of the convict population was black (Wardi 509).

From the play’s setting to the small details within its dialogue, August Wilson’s The Piano Lesson is packed with very real and historically accurate data on the setting in which the play takes place and offers a genuinely well researched glimpse into the early 20th century in the U.S. Not a single piece of information is arbitrary world building but paints a very accurate picture of the black experience in the 1930s, both artistically, – with the music the characters sing, for example – culturally and economically. The broader experience of the black men and women during this era are reflected through its central characters, their relationships to the central objects in their life, and the spaces and times that they exist in.

Citations

Greenberg, Cheryl. To Ask for an Equal Chance : African Americans in the Great Depression. Rowman & Littlefield Publishers, 2009. EBSCOhost, https://search.ebscohost.com/login.aspx?direct=true&AuthType=ip,shib&db=nlebk&AN=281856&site=eds-live&scope=site.

Nadel, Alan. August Wilson : Completing the Twentieth-Century Cycle. University Of Iowa Press, 2010. EBSCOhost, https://search.ebscohost.com/login.aspx?direct=true&AuthType=ip,shib&db=nlebk&AN=373110&site=eds-live&scope=site.

Arora, Sabina G. The Great Migration and the Harlem Renaissance. Britannica Educational Publishing, 2016. EBSCOhost, https://search.ebscohost.com/login.aspx?direct=true&AuthType=ip,shib&db=nlebk&AN=1031189&site=eds-live&scope=site.

Black, William R. How Watermelons Became Black: Emancipation and the Origins of a Racist Trope. no. 1, Mar. 2018, pp. 64–86. EBSCOhost, https://search.ebscohost.com/login.aspx?direct=true&AuthType=ip,shib&db=edspmu&AN=edspmu.S2159980718100033&site=eds-live&scope=site.

Salem Press. Reconstruction Era : (1865-1877). Salem Press, 2014. EBSCOhost, https://search.ebscohost.com/login.aspx?direct=true&AuthType=ip,shib&db=nlebk&AN=802130&site=eds-live&scope=site.

“African Americans and the Railroad: Gauley Bridge Depot; Gauley Bridge, WV.” National Parks Service, U.S. Department of the Interior, https://www.nps.gov/neri/planyourvisit/african-americans-and-the-railroad-gauley-bridge-depot-gauley-bridge-wv.htm#:~:text=African%20American%20railroad%20workers%20African,employed%20thousands%20of%20black%20laborers. 

Wardi, Anissa Janine. “‘The Colored Man Can’t Fix Nothing with the Law’: Carceral Spaces in August Wilson’s ‘The Piano Lesson.’” Journal of African American Studies, vol. 17, no. 4, 2013, pp. 506–17, http://www.jstor.org/stable/43525524. Accessed 17 Apr. 2022.