Exposure and Exclusion: Disenfranchised Biological Citizenship among the First-Generation Korean Americans

Exposure and Exclusion: Disenfranchised Biological Citizenship among the First-Generation Korean Americans

Exposure and Exclusion: Disenfranchised Biological Citizenship among the First-Generation Korean Americans

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Based on fieldwork with a highly uninsured and underinsured Korean American population, this article maps how the current healthcare system in the

United States disenfranchises those of marginal insurance status. The vulnerability

of these disenfranchised biological citizens is multiplied through exposure to dis-

proportional health risks compounded by exclusion from essential healthcare. The

first-generation Korean Americans, who commonly work in small businesses, face

the double burden of increased health risks from long, stress-laden work hours and

lack of access to healthcare due to the prohibitive costs of health insurance for small

business owners. Even as their health needs become critical, their insurance status

and costly medical bills discourage them from visiting healthcare institutions,

leaving Korean Americans outside the ‘‘political economy of hope’’ (Good, Cult

Med Psychiatry 52:61–69, 2001). Through an ethnographic examination of the daily

practice of doing-without-health among a marginalized sub-group in American

society, this paper articulates how disenfranchised biological citizenship goes

beyond creating institutional barriers to healthcare to shaping subjectivities of the

disenfranchised. Exposure and Exclusion: Disenfranchised Biological Citizenship among the First-Generation Korean Americans

T. Kim (&) Department of Anthropology, Chonnam National University, Gwangju 500-757, South Korea

e-mail: tkim7777@yahoo.com

C. Haney

Department of Anthropology and Cross-Cultural Studies, University of Houston, Clear Lake,

TX 77058, USA

e-mail: HaneyC@UHCL.edu

J. F. Hutchinson

Department of Comparative Cultural Studies, University of Houston, University Park,

TX 77204, USA

e-mail: jhutchinson@uh.edu

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Cult Med Psychiatry (2012) 36:621-639

DOI 10.1007/s11013-012-9278-7

Keywords Biological citizenship � Risk � Uninsured � Underinsured � Korean Americans

Introduction

In his book The Politics of Life Itself, Nikolas Rose uses the term biological citizen ‘‘to encompass all those citizenship projects that have linked their conceptions of

citizens to beliefs about the biological existence of human beings’’ (2007, p. 132).

He further argues that producing vitality, which he labels the production of

biovalue, has become an important citizenship project. Rose points to a new

biological age in which agents are inclined to see themselves in somatic/biological

terms and become active citizens in the vitalization of that biology through self-care

programs and through collectivizing around shared biological states to demand care.

He suggests that such actions have become ‘‘routine and expected’’ (Rose 2007,

p. 147). However, studies of uninsurance in the United States show that the current

medical payment system creates barriers to care and conditions differential access to

biological citizenship (Becker 2004, 2007; Hadley 2003; McWilliams 2009).

Through detailed ethnographic research with uninsured and underinsured Korean

Americans working in family-run businesses, this article focuses on the daily

practice of doing-without-health and pushes our discussion of the barriers to

healthcare seeking toward an examination of how such barriers cultivate subjec-

tivities of disenfranchised biological citizenship. We also describe, illustrating a

case of ‘‘bio-devaluation,’’ how such disenfranchisement multiplies the study

participants’ vulnerabilities by exposing them to disproportionate health risks and

excluding them from essential care.

Responding to the critique that much of the discussion of biological citizenship is

‘‘programmatic and decontextualized’’ (Whyte 2009, p. 11) as well as calls for more

anthropological research into the uninsured (Horton 2007; Rylko-Bauer and Farmer

2002), this study employed an ethnographic approach in which the researchers were

situated in the same settings where the un/underinsured live and work. By sharing in

these settings, the researchers contextualized the study participants’ multi-layered

predicaments through firsthand encounters—observing the whole fabric of these

predicaments rather than segregated factors. In-depth interviews allowed the

researchers to move between life history narratives and affective accounts of

experiences in current settings.

This paper examines the predicament of the un/underinsured, taking Korean

Americans, one of the most highly uninsured populations in the United States

(Hughes 2002), as an example. Based on a multi-sited ethnography of Korean–

American communities in Houston, Texas, and Los Angeles, California, this study

attempted to delineate the condition of marginal insurance in the United States. In

order to present a comprehensive picture of the uninsured, this study traces health

risks among Korean Americans, from daily life to life in crisis. Studies of risk have

shown that ethnographically contextualized risk provides a window into ‘‘the

primary mechanism through which social inequality is embodied and is visible in

622 Cult Med Psychiatry (2012) 36:621–639

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different prevalences of diseases and outcomes between different social groups’’

(Nguyen and Peschard 2003, p. 457). In particular, anthropological examinations of

HIV risks have exemplified the effectiveness of ethnographically contextualized

risks in linking inequality and ill health (Chapman 2006; Parikh 2007; Farmer

1999). By mapping the connections from an unequal social structure, in which risks

are unevenly distributed, to the disproportionate prevalence of disease, these studies

chart the inscription of inequality on the bodies of the disenfranchised population.

Building on the advances of previous ethnographic studies of risks, the present study

attends to risks as they become visible in the context of the Korean American

community, and attempts to illuminate the embodiment of the social inequality

among uninsured and underinsured Korean Americans by linking exposure to health

risks and exclusion from healthcare.

In order to examine ethnographically contextualized risks, the fieldwork was

conducted within the Korean American community. Choosing community settings

provides three noticeable benefits. First, the field sites enable us to include data

concerning the un/underinsured who have never visited healthcare institutions, an

unfortunately common health-seeking (or unseeking) practice among the un/

underinsured. To date, most qualitative studies of the uninsured have presented

accounts only of those uninsured who finally resort to healthcare institutions. By

conducting research in community settings, we were able to provide more inclusive

data of how healthcare seeking is delayed or stymied among the un/underinsured.

Second, fieldwork within community settings allowed observation of the unhealthy

working and living conditions that many un/underinsured face, giving us a more

complete picture of their predicaments. Although many studies have separately

examined either the impact of social forces on health disparity (Dressler et al. 2005;

Nguyen and Peschard 2003; Wilkinson 2005) or the influence of healthcare

accessibility on the health of the uninsured (Becker 2001, 2004, 2007; Hadley 2003;

Institute of Medicine 2002; McWilliams 2009; Rylko-Bauer and Farmer 2002), few

studies have addressed the peril created by the combination of disadvantageous

social conditions and unequal healthcare. Linking the issues of health disparity and

healthcare inequality, this study shows a comprehensive picture of the consequences

of disenfranchised biological citizenship. Third, fieldwork in community settings

allowed us to see the manner in which the underinsured are also disenfranchised. As

we will see, the underinsured experience many of the same barriers to health found

in the uninsured population. A consequence of these barriers is the double burden of

increased exposure to major health risks and exclusion from necessary healthcare.

When study participants encounter deteriorating health due to these unfavorable

work conditions, their limited access to healthcare makes the process of seeking

appropriate diagnosis and treatment a baffling undertaking, one in which they have

little hope of success. The ill health of the un/underinsured is often exacerbated by

this synergy of exposure to risks and exclusion from care. Thus, by setting our

research within the community in which people suffer and make choices, we are

able to observe how biological disenfranchisement leaves people outside ‘‘the

political economy of hope’’ (Good 2001).

Although Rose acknowledges that ‘‘not all have equal citizenship in this new

biological age’’ (2007, p. 132), his focus remains on the projects of biological

Cult Med Psychiatry (2012) 36:621–639 623

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citizenship. Drawing on Good’s work, Rose argues that these projects grow out of a

‘‘political economy of hope.’’ States enact projects that they hope will bring greater

vitality to their citizens. Biological citizens enact practices that they hope will

increase their health and band with others who they see as biologically similar to

support one another and lobby the government and researchers for greater hope for

their conditions. However, in this paper we argue that the study population is left out

of vitalization projects, invisible to these projects due to the participants’ place in

the employment structure and the current healthcare payment scheme. The high

concentration of small business owners among the first-generation Korean

Americans, conditioned by the limited economic opportunities available to

immigrants, leads to long work hours in risk-laden conditions as well as high

rates of marginal insurance driven by sky-rocketing private health insurance costs in

the United States. Long work hours expose Korean American small business owners

to the health risks of overwork, physical inactivity and stress. These risks are

compounded by limited access to timely preventive measures and appropriate

medical intervention. This combination of exposure to risk-laden working

conditions and exclusion from healthcare increases Korean Americans’ vulnerabil-

ity, in particular, to chronic illnesses including hypertension, high blood cholesterol,

diabetes, and heart disease. These conditions are the bio-devaluation that results

from biological disenfranchisement. Rather than engaging in the hopeful endeavor

of maximizing vitality, the study population engages in the disenfranchised’s

practice of doing-without-health, pinning their hopes on improving their economic

status and their children’s education. Exposure and Exclusion: Disenfranchised Biological Citizenship among the First-Generation Korean Americans