Urban Injustice: How Ghettos Happen
By David Hilfiger, MD


When we Americans want to do something about poverty, we usually set about "improving" poor people. We may offer education or job training, establish programs to develop the parenting skills of young mothers, require addiction treatment as a condition for receiving housing, put time limits on welfare benefits in order to motivate poor people to work, or refuse additional welfare payments to discourage further childbearing.

This practice of improving poor people has a long history. Early American reformers traced extreme poverty to intoxication, laziness, and other kinds of unacceptable behavior. They tried to use public policy and philanthropy to elevate poor people's characters and change their behavior. As the years passed, different sets of behaviors were blamed for poverty and successive methods suggested to improve the poor. Later reformers looked to evangelical religion, temperance legislation, punitive poor houses, the forced breakup of families, and threats of institutionalization- all to improve poor people.

This approach has rested on the persistent belief that the individual faults of the poor are the primary causes of poverty. Ignorance, lack of training, addiction, laziness, defective character, sexual promiscuity, too many children: the list goes on and on. It is not surprising, of course, that a nation so strongly committed to individualism should so often search for the roots of poverty within the poor persons themselves.

In this short book, I want to consider poverty from a different vantage point. I want to suggest that the primary causes of poverty lie not in individual behavior at all, but in specific social and historical structures, in forces outside any single person's control. This is not to deny that most poor people's character could use some improving (as could most of the rest of ours), but it is to suggest that the essential causes of American poverty lie elsewhere: in the paucity of jobs on which someone might support a family, in inadequate access to health care and child care, in meager educational resources, in specific government policies, in nonexistent vocational training, in the workings of the criminal justice system, and, for African Americans, in a painful history of slavery, segregation, and discrimination.

The American stereotype of poverty has become the single-parent, black, inner-city family. And, indeed, African Americans are three times more likely to be poor than whites. In the 2000 Census, however, almost half (46.8 percent) of America's poor were white, close to another quarter (23.0 percent) were Hispanic, and 6.2 percent were Native American, Asian, and Pacific Islander. Only just over one-quarter (26.2 percent) were African Americans. Of those poor Americans, almost a quarter (22.0 percent) lived in rural areas and more than a third (36.4 percent) in suburbs. Of African Americans in poverty, less than half live in the urban ghettos that have come to be the almost exclusive definition of poverty in the American mind.


This book is largely about those black Americans, only about 12 percent of all our poor people, who do live in the inner-city ghettos. Many other books could be (and have been) written about white poverty, about Hispanic poverty, about Native American poverty, about poverty in general. Why, then, is this white, middle-class physician writing about black, urban poverty?

The simplest answer is that it's what I know about.

In 1983, after seven years as a rural physician in northeastern Minnesota, I moved to Washington, D.C., to practice medicine in two small inner-city clinics. African Americans are Washington's predominant population and—aside from immigrant groups that have recently been expanding—the poor here are overwhelmingly black. For five years, my family and I lived in Christ House, a medical recovery shelter for homeless men. In 1990, we started Joseph's House, a community and hospice for formerly homeless men dying with AIDS, where we lived for three years. For almost two decades, then, I have lived and worked among the black, urban poor. Their plight has been my primary professional concern.

More important, what I know about and what concerns me the most unfortunately fits all too well with both public and media stereotypes of poverty. When most Americans think about poverty, or see the poor on television, or read about them in the newspapers, the images are of poor black men hanging around the street corner, poor black teenagers selling drugs, poor black single mothers living on welfare, poor black inner-city schools failing their children. In spite of the statistics, in our country poverty has become synonymous with black, urban poverty. Since the late 1960s, when President Lyndon B. Johnson's War on Poverty ended in "failure," poverty has been almost a code word for the inner-city black ghetto, its drugs and its crime. If, then, we are going to face the larger questions of what to do about poverty in America, there's really no way to go but through the ghetto—both as it really exists and as most Americans imagine it.

Finally, I'm writing about poverty and the ghetto because the reasons for their existence and the links between them are not at all mysterious but lie clearly in history. It's nowhere near as hard as most of us imagine to grasp the causes of black, urban poverty (or, for that matter, white, rural poverty), and it's important not to attribute those causes simply to slavery. If we were to decide to put our minds, our energy, and some of our nation's resources to work, there are solutions we could choose. Right now.

Yes, most of us tend to ascribe poverty to the behavior of the poor themselves, and yet, if we were honest, we would admit to at least some puzzlement over, say, why young black children are four times more likely to be poor than their white counterparts, or even why the black ghetto exists in the first place.

I am no stranger to the individual weaknesses of the poor and black in America. It’s the nature of a doctor’s work to see people who are in trouble one at a time, and it has often seemed to me that the immediate causes of my patients’ poverty did lie in their own behavior. For some, addictions consume their time and energy. Others would not (or could not) cooperate with my medical treatment plans. Still others lacked parenting skills or discernible job skills. And some just didn’t seem to want to work.


But the more time I spent with even the most troubled of my patients, the more obvious it became that virtually all of them were doing close enough to the best they could in the overwhelmingly difficult environment they inhabited. The odds against which they struggled, however, are massive. If you haven’t lived it or even seen it firsthand, there’s almost no way to imagine it. Living in the ghetto, one faces problems with public housing, family violence, drug and alcohol abuse, the drug trade, negligent landlords, criminals, illness, guns, isolation, hunger, ethnic antagonisms, racism, and other obviously negative forces. Even forces that might seem positive in other circumstances—the law, the media, government, neighbors, police—can, in the ghetto context, make life miserable for the poor. And one has to contend with all of these forces—any one of which might be overwhelming—all at once, without a break. Turn to deal with one problem, and three attack you from behind. Experience a little unexpected bad luck, and you find yourself instantly drowning. The cumulative effect of the "surround" is more than the sum of any of these individual forces. There is simply no space to breathe.

When I first arrived in Washington, I was already familiar with many of the structural causes of poverty. But like so many of us, I was convinced that if the individual could be strengthened enough, he or she could make it out of the ghetto, and if enough people could be strengthened, the ghetto itself would collapse. I have spent the better part of a professional career trying to strengthen individual poor people. While that may have been a positive endeavor, I no longer believe that individual efforts to improve individual poor people will substantially reduce poverty.

The argument that inner-city poverty comes primarily from the personal weaknesses of poor people simply cannot be sustained. Among African-American children under the age of six, half live in poverty. Among African-American males between the ages of eighteen and thirty-four in the city of Washington, half are in the criminal justice system. There are only two possible explanations for these and many similar statistics. Either African Americans are genetically predisposed to poverty, or specific forces in their environment have kept large numbers poor!

For centuries, whites have consciously or unconsciously found the explanation in theories of racial inferiority.

In this book, I will argue what has long been evident to African Americans and should long since have been obvious to everyone else: something awful has been done to the black poor in this country. Allowing for that monumental injustice, however, how does one explain the individual behavioral deficiencies that seem so prevalent among poor African Americans (and other groups of Americans in poverty)? How can one account for the extraordinarily high rates of single parenthood, widespread substance abuse, problematic parenting, and criminal behavior within the black ghettos? If the reason is not some genetic inferiority, what does cause these problems in the first place? And why do they persist?


Even after a decade of practicing medicine in the inner city, I found I couldn't answer those questions in ways that satisfied me. This proved so frustrating that, in a foolhardy moment, I volunteered to teach a course on the causes of urban poverty. It was undoubtedly my way of putting myself on a collision course with what I felt I still needed to learn. In search of answers, I plunged into an extensive, often impressive, and remarkably consistent library of books and articles of all sorts on the nature, causes, and consequences of urban poverty. I was often shocked at how little I had known.

The result is this book, for which I make no claim to originality. Quite the opposite. What I've tried to do is take the work of many scholars and journalists—often long, sometimes inspiring, but also sometimes dry or written for academic peers—and condense the essence into a single, short work that might explain urban poverty to anyone: exactly the book that in all those rushed years of doctoring I might have longed for and used.

Complex as urban poverty and the behaviors that surround it might seem, there is, in fact, a certain basic simplicity to the problem and to the sorts of solutions that are (this perhaps surprised me more than anything) not hopelessly utopian and suitable only for an unimaginable, distant future. These solutions are, instead, remarkably close at hand, practical, and capable of being instituted were we only of a political mind to do so.

After a decade of unprecedented economic prosperity in the richest country the world has ever known, the poverty rate at the time of the 2000 Census was at its lowest in a generation. Nevertheless, 11.3 percent of all Americans, more than one out of every nine people, lived below an official poverty level that severely underestimates what most of us would consider poverty. Even more distressing, almost one out of six American children under eighteen (16.2 percent) and almost one out of three of African-American children under eighteen (30.9 percent) lived in poverty. Why?