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COUNT MENA IN
The case for Middle Eastern and North African (MENA) legal recognition
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by zeke hertz ’23 illustrator julie sharpe ’22
Sarah Shabbar grew up with an identity problem. As a child, she was constantly reminded by her community to be proud of her Jordanian heritage, but, as she told the Los Angeles Times, “none of these forms are allowing me to feel proud of it, because I’m just white, according to them.”
Shabbar, like an estimated five million other Middle Eastern and North African (MENA) individuals in the United States, feels erased by the American government. “The federal government label[s] us as white, while our social status is anything but,” said David Shams, another MENA individual plagued by this problem. “It makes me feel unheard, like I’m shouting into this void, saying that we’re not white, and no one is listening.” Furthermore, because of their legal status as white, MENA groups are denied access to many legal protections enjoyed by non-white minorities, even though many MENA Americans are subject to racism and do not enjoy the social benefits of whiteness. To address these problems of identity and law, the US must create a new classification for MENA individuals.
How MENA people came to be legally classified as white is a convoluted story that began in 1909 with a lawsuit. George Shishim, a native of Lebanon living in the United States, was unable to claim citizenship because until 1952, non-white individuals could not legally become naturalized citizens. Shishim, who was then legally categorized as Chinese-Mongolian, launched a legal campaign to identify himself as white so that he could gain the practical benefits exclusive to white individuals in an era of unabashedly institutionalized racism. The Superior Court of Los Angeles ruled in Shishim’s favor, granting him the legal status of white, a status that today extends to all MENA people in the US.
Times have changed, however, and what was once a legal blessing is now more often seen as a curse. Many in the MENA community today do not identify as white and recognize that American society does not see them as truly white, either. The classification of MENA-identifying Americans as white bars MENA participation in federal programs designed to help racial minorities in universities and business ownership and makes it less likely that their communities will qualify for language assistance—such as having ballots available in their native languages—under the Voting Rights Act. While an outright legal reclassification is unlikely, the most feasible first step toward rectifying the situation is census recategorization. The inclusion of a MENA census classification would enable the government to address problems like underfunded MENA-majority schools, employment and housing discrimination, and health and wealth gaps.
In 2015, the Census Bureau under the Obama administration announced plans to test the introduction of a MENA category ahead of the 2020 Census. The results of the research were clear: If given the option, most people of Middle Eastern or North African descent would check off a MENA category rather than white, a categorization which 80 percent of MENA individuals have selected in the past. Furthermore, the report stated resolutely that “it is optimal to use a dedicated ‘Middle Eastern or North African’ response category.”
Despite apparent progress on a MENA census category, the issue soon hit a roadblock: In 2018, the Census Bureau announced that it was receiving pushback from “a large segment” of the MENA population, who preferred
to be categorized as an ethnicity rather than a race. Since the government claimed that it did not have sufficient research to understand the effects of listing MENA as an ethnic group, the Census Bureau’s plans to add a MENA category were cancelled. Instead, the Trump administration announced that there would be an option to include one’s “origin” after indicating racial identification. Given that the announcement came just months after the Trump administration’s travel ban on multiple nations in the MENA region, some speculate the “origin” option may be an effort to undercount the MENA population by exploiting the hesitance some MENA Americans may feel to associate themselves with countries affected by the travel ban.
It is clear from the research that the census needs a MENA category, but progress largely depends on support from the executive branch. Lobbying and activism will persist, but it is clearer than ever for all involved that to protect a minority group erased by its classification as white, the US must add a MENA category to the census.
Zeke Hertz ’23 is a Political Science concentrator.
Interview with Maggie Williams
by Amelia Spalter ’23 Illustrator Vienna Gambol ’20
Maggie Williams is a scholar and political leader who served as director of Harvard University’s Institute of Politics, director of communications for the Children’s Defense Fund, deputy press secretary of the Democratic National Committee, and congressional aid to Morris Udall. From 1993 to 1997, Williams worked as President Bill Clinton’s assistant and was then named First Lady Hillary Clinton’s Chief of Staff, becoming the first person to hold both positions concurrently. Williams went on to become the campaign manager for Hillary Clinton’s 2008 presidential campaign. After leaving the White House, Williams took on the role of President for Fenton Communications, becoming the highest ranked Black woman in an American public relations firm at the time. Williams is now a partner at the consulting firm Griffin Williams, a director of the Scholastic Publishing Corporation, a director of the Clinton Health Access Initiative, a trustee of the Rhode Island School of Design, and a US Commissioner for the United Nations Educational, Scientific, and Cultural Organization (UNESCO).
what they do and how doing it works? People don’t realize how much of their life government touches. The FDA regulates the quality of your food and monitors the safety and efficacy of your education. The FDA is the government. The DMV issues your driver’s license and determines who is allowed to be on the road with you and your family. The DMV is the government. If we started to think about it that way, maybe people would be more galvanized to assume civic responsibility and really understand how the government operates and why it does it that way. amelia spalter You’ve spoken with great passion on multiple occasions about the importance of voting. What ignites that passion? maggie williams You get to determine the answers to the most important questions in the nation when you exercise your right to vote. What’s important? What is the character of our country? Who do we want to be? People who don’t vote should be put in prison. Even when you don’t like what you have to vote for, or the choices seem too narrow, it is really important that you vote. Not only that you vote, but that you get other people to vote. When you go to the movies, you don’t want to go alone; you call a couple friends and organize a group to go with you. If you can rouse that much passion and persistence to go watch Avengers, then at a bare minimum, you can do the same when tasked with selecting the next President. as What is your biggest concern about the government’s relationship to the American people? mw I don’t think people understand what the government does. I know grown, adult people who didn’t know that the government gave them their Social Security check. There is a lot of ignorance about what the government actually does, unless there’s something that you need from the government and manage to get. Otherwise, why would you know the breadth and the bandwidth that the government actually has in terms of services, or what it does in schools, what it does in this, in that, in the other thing? There needs to be clear and transparent education about what the government actually does and how it does it. We can name the three branches of the government, but can we articulate be President, Maggie? Huh?” I was speechless, just thinking, “Oh my God, what do I say to that?” But then he just started laughing at me and my reaction, so I could exhale, knowing we were okay. He’s pretty fabulous. With the election then over, it was a moment I could really cheer for him. as What do you think must be done to get politics back on track to working for the people? mw My easy out is that everybody young takes over. I’ve been trying to figure out how to expedite that. Sometimes I think we should lower the ages of participation, the age to vote, the age to run for office, if we should just bring everything down a few years. All the hope is in the next generation. This might be a bit old-fashioned, but I believe in the Constitution, and I believe in the Bible, and both say that we are all created equally. We can’t waste any more time trying to persuade those who have chosen to isolate themselves in a box and be brainwashed not to believe that, yes, really, all men are created equal. So I’m not in the business of trying to persuade anyone of that anymore. I don’t think it’s an effective use of time. The only people that we must ensure understand this concept is your generation and all the next generations. They already understand this concept more, so this is where all of my hope is put. After a certain age, it’s hard for people to make changes in how they see the world. I wish there was a school for people who can’t make changes on their own, to help them let go of outdated ideas, but there just isn’t. So, I don’t know what we can do for the many people of certain generations who were not taught this concept. I don’t know what we can do, except to, as my mother would say, pray for them. If you can rouse that much passion and persistence to go watch Avengers, then at a bare minimum, you can do the same when tasked with selecting the next President. “ as What was it like seeing President Obama for the first time after the 2008 election? mw I was at an event just after Hillary had become Secretary of State. I had been Hillary’s campaign manager, so Barack and I knew each other, but this was the first time I was seeing him in person post-election. He came over, looked me in the eye, and the first thing he said was, “So, you didn’t want me to ”
as Are you optimistic about potential for climate action from officials within our current administration? mw Overall, some are better than others. I personally know people in this administration and can attest that there are some good people in this administration. I don’t agree with them all the time ideologically, but do I believe that there are people in this administration who work like dogs, who are good at what they do, and care about the American people? Yes, I know them. I talk to them. And part of why I know them is because I worked in politics where, as I always say, you cannot get anything done without encountering people who hold opinions that differ from yours. as What will have to happen politically for you to feel as though we’ve reached the future? mw The future is now. I see it. I see people, institutions, and laws that have begun to do this work for us. Take, for example, the fact that I can walk into any restaurant I want. My niece cannot even comprehend the idea that Black people couldn’t even walk inside of certain restaurants. It’s a foreign concept to her. But to my mother, who just turned 93, it is a lived experience Within a single lifetime there is, on the one hand, my mother. She remembers, really knows, what opportunities were taken from her because of her race. She knows what it means to not have choice. Then on the other hand, there’s my niece, a Harvard graduate and a professional soccer player. She can do both of those things because she is free to make those choices. That’s progress; that is the future; that is a thing to be protected. We have to be vigilant. You didn’t get to desegregation of the schools by people standing around and singing Kumbaya. You got to it because it was forced. We are in the United States, where we’ve got everything we need to keep the country aware and alert, but we have to diligently police it to make the changes stick. Some of the things my mother experienced could easily resurge. Racism is mostly about people needing to feel other people are doing worse than they are in order for them to feel okay about themselves. as What is our most powerful tool to combat racism at present? mw The ground floor of leveling the playing field is education. Without Brown v. Board of Education, we’d be going nowhere. But once isn’t enough; the field must be leveled and releveled continually over time as new issues arise. For example, our schools are integrated, but now we’ve got to do something about the high cost of education. What’s the point of opening your doors to all students if the students then can’t afford to walk through them? as What is the most radical shift you’ve noticed in the political landscape since you entered it? mw Early in my life, I worked for Mo Udall. What I remember most from those days was a different political chemistry from that which we are experiencing today. The woman across the hall from me worked for a Republican Congressman, and when she had to go to lunch, I could see her desk from where I sat, and I watched it for her until she got back. It went both ways. If she went to get a soda, she’d always bring me one. Red or blue, people talked with each other, people partied together, and while it was not ever lost on us that we had dramatically different views on the issues, it was also never lost on us that we were in the government of the same country. That basic understanding is something we’ve got to return to. as It sometimes seems as though the country is more politically polarized now than at any time in recent history. Do you feel there is reason to be concerned? mw The American people have pretty goodeyes. We’ve always had ideological differences in this country. That’s what makes it great; that’s what makes it a democracy. Everyone can go vote about anything that affects their community. Anything from selecting the commander in chief to whether or not to add a basketball court to the local park. You can vote about anything in this country, which means you have a say about anything in this country. But, at the end of the day, your allegiance is to the common good. Maybe I hold this perspective because I worked for someone like Mo Udall. I always saw him reaching out to his fellow representatives, because there was always a chance that they’d do a deal together sooner or later. There is supposed to be an ongoing debate; more than that, there is supposed to be an intense argument, because we’re talking about decisions that directly impact people’s lives. But there is not supposed to be any, “I’m on this side, you’re on this side, and never the two shall meet.” We’re on the same side. We are shifting away from that, and it does make me nervous about the future. as What policy issues do you feel have not received adequate attention in this election cycle? mw The environment is pretty serious. You can have all the aspirational talk in the world, but if that’s all you have, eventually you won’t be able to talk anymore, because we won’t be able to breathe anymore, because we’ll have no clean air. People pooh-pooh the climate crisis in favor of a short-term focus on the economy, saying, “The economy matters most because people need to eat every day.” I agree, people do need to eat; that’s why I’m concerned about the environment. You can’t eat if you can’t breathe. The environment goes back to education for me as well, though, because it’s clear that in order to get a piece of meat in today’s economy, let alone solve the climate crisis, you need much better than a seventh-grade education. In fact, you probably need a college education. Sometimes you need more than a college education, or you need specialized training in an area that allows you to be able to compete just so you can live, let alone get a job that effects change. We really have to think about better access to all forms of education. I’ve always said, we are a country of inventors. We were able to invent this whole country, so we should be able to reinvent it. “There is supposed to be an ongoing debate; more than that, there is supposed to be an intense argument, because we’re talking about decisions that directly impact people’s lives.”
BUNDLES OF JOY
Rethinking how maternity care is paid for in the US
by maddy noh ’22 illustrator brenda rodriguez ’21
Approximately one-third of births in the US are C-sections, a strikingly high proportion compared to similarly developed countries. Yet despite their frequent occurrence, and contrary to popular belief, C-sections are riskier than vaginal births: Risks of blood loss, heightened chances of infection, and other complications are all part of the fine print of the procedure. And although it’s widely understood that there are situations in which C-sections are medically necessary, experts caution that they are often performed in the US even when they aren’t needed. In fact, the World Health Organization estimates that C-sections should only account for around 10 to 15 percent of births, which is far less than the current rate of 33 percent.
So why are C-sections performed so frequently? One reason may be the culture of risk aversion in US healthcare. Though C-sections are more complex than traditional births, the range of possible outcomes and complications is comparatively well-understood. Performing C-sections, then, can remove liability with regards to potential risks, such as the prolonged labor pains that are associated with a vaginal birth. Also, administrative burdens are often lower for C-sections: Studies have shown that the frequency of C-sections tends to increase during times when physicians may be in a rush, such as around lunchtime and toward the end of the day.
But perhaps the most significant factor contributing to high C-section rates is the financial incentive for healthcare providers. Since they are surgical procedures, C-sections are considered more labor- and time-intensive than standard deliveries, and as a result, physicians are paid on average 15 percent more for performing a C-section than a vaginal birth. As costs continue to rise, healthcare providers’ incentives to perform C-sections are also on the rise, even for low-risk pregnancies. The current tendency for doctors to overperform C-sections, whether for the sake of money or convenience, represents a perverse form of outcome-based medicine, in which healthcare professionals place far too little value on the well-being of mothers.
It’s clear that something must be done to address this threat to maternal healthcare. To reduce the number of C-sections, then, one worthwhile step may be removing the financial incentive for performing these often unnecessary and risky procedures. Insurance companies may be able to offer a solution through bundled payments.
In the context of maternal healthcare, bundled payment plans are fairly straightforward: Rather than paying for each action that a healthcare provider performs, bundled payments group all episodes of care during the entire term of pregnancy under one umbrella and set a limit on the amount of money allotted for the expected course of treatment. Providers also typically receive a bonus for not exceeding outlined treatment costs.
Without the financial incentive to perform C-sections—and with the added incentive of minimizing treatment costs in order to secure their bonus—doctors are encouraged to deliver better long-term maternal care. This includes watching for preemptive signs of latent medical conditions from the onset of pregnancy and, if they appear, treating them in the first- and second-trimesters. Such practices decrease the chance of eventually running into issues that may necessitate pricier, higher-risk procedures—such as C-sections—later on. As a result, bundled care payments present an effective solution that allows physicians to have more control over the decision-making process and encourages close examination through the entire period of obstetric care, not simply at the end.
Several states have already seen promising results in implementing their own rolled-out bundled payment programs. For example, in 2012, the Arkansas Health Care Payment Improvement Initiative (AHCPII) was implemented and adopted by the vast majority of
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Arkansas payers, including Medicaid and private insurance companies. AHCPII sets budget goals for both prenatal and postpartum care. Healthcare providers participating in the obstetric care receive incentive payments for delivering high-quality care without crossing over the threshold of intended costs. Within three years of its implementation, the program began to make progress toward its goals: It prompted a seven percent decrease in C-sections and a 3.8 percent decrease of state-wide perinatal spending.
Despite its known successes, concerns that bundled payments may swing the pendulum too far in the other direction and disincentivize C-sections to a dangerous degree still exist. In order to reduce total treatment costs, it’s a real possibility that payment schemes could prompt physicians to promote vaginal births even in complex cases where C-sections may be required. Without proper caution, therefore, financial incentives could again pose a threat to maternal health.
Yet programs are already finding ways to alleviate this concern. For example, bundled payment plans could allot money for treatment based on the complexity of each mothers’ case so that physicians feel comfortable spending more on expectant mothers with
serious medical conditions. North Carolina’s Pregnancy Medical Home (PMH) program implements this idea by requiring the majority of obstetric providers to assess each Medicaid-eligible pregnant patient’s risk for premature birth. This strategy works toward bringing C-section rates below 20 percent among a specific demographic of women on Medicaid, but it still ensures that higher-risk pregnancies receive the care they need.
From coast to coast, pilot programs of bundled care payments, funded through both public and private insurance ventures, have continued to yield similarly positive results. Nationally, health services organization Cigna introduced the first episode-of-care model in 2017. In this model, providers receive a bonus shared savings payment if they meet the agreed-upon cost and commit to quality standards, one of which includes reducing the rates of C-sections. On a smaller scale, a single California program spanning three hospitals yielded measurable success: It saw a 20 percent decrease in C-sections in those hospitals in less than a year and a total 33 percent decrease over six years.
While results have been promising and the possibility of further expansion of such programs seems optimistic, it is clear that widespread integration of bundled care presents unique challenges, especially in the US healthcare system. Without a national health insurance scheme, implementation of bundled payment programs has occurred in a piecemeal manner, and it will likely continue in this way. Since the efficacy of these strategies relies heavily on how well they can be accomplished through insurers’ policies, this obstetric care challenge is just one part of a larger debate over how healthcare should be paid for and by whom. Regardless of who is providing the service, however, discussions of how to manage prices prompt further questions relating to provider reimbursement criteria and costs. Overall, re-evaluating insurance-making policies at both commercial and state levels can help to re-establish the providers’ priorities as they relate to cost and quality while continuing to press for the removal of financial incentive for unnecessary C-sections.
Giving birth in the United States can and should be safer and more affordable. By implementing bundled payments to promote holistic care and discourage unnecessary C-sections, the insurance industry can make that happen.
Madeline Noh ’22 is an Anthropology and Public Health concentrator and a World Staff Writer at BPR.
