On middle school as a mass casualty site

I recently read Paul Tough’s Whatever It Takes: Geoffrey Canada’s Quest to Change Harlem and America, a deservedly celebrated book. It describes that efforts by Canada (GC hereafter) to give children in Harlem the skills they need to compete with other American children. Impoverished children face adverse environments at every stage of development, so disadvantage starts early and is reinforced in each successive childhood setting. Therefore, GC wants to intervene prenatally and to create institutions to support kids at each stage. The book contains a thoughtful summary of the research supporting this view.

Viewed as a social program, this level of intensity of intervention is extraordinary. However, such “concerted cultivation” is entirely normative child rearing in the global upper middle class.

A principal theme of the book, however, is about a part of GC’s program that doesn’t work terribly well. GC also runs a middle school, which accepts kids who haven’t been participating in his early childhood programs and are therefore not well socialized into school culture. The kids in this school do not do well and even very hard work by the staff seemingly makes little impact. GC is torn between whether to continue the program or to concentrate his resources on young kids, for whom he can provide the cradle to grave support that upper class kids receive.

This is a hard moral choice. If GC discontinues the middle school, he can invest the resources in the younger kids, maximizing the marginal benefit of his limited budget. But this reduces the limited chances of the older kids still further. This runs against our moral intuitions, which say that middle school kids in need have the same claim on our help as younger children. Part of what makes the book compelling is watching GC struggle with this choice.

Of course, it makes little sense to blame GC, whatever choice he makes. What he is facing a kind of battlefield or mass casualty disaster triage decision, that is, a disaster in which it is not possible to provide care for all of the victims. In such situations, it is ethical to focus limited resources on those who are at high risk but have a high probability of survival conditional on receiving treatment.

But we should stop, take a breath, and appreciate how ghastly it is that the ethics of medical care in mass casualty situations seems also to fit allocation of care for a large population of American children. Consider how well this metaphor works, noting particularly that mass casualty is not really a metaphor. Look at the graph above, noting that the vertical axes are not on the same scale and tend to visually suppress the relative carnage among black males. Consider also that almost 30% of these young men will be displaced from the community to prison. What doesn’t work about the mass casualty metaphor is that the bodies do not fall suddenly or unexpectedly. Is that a relevant moral difference?

About Bill Gardner

A health care researcher and a child and quantitative psychologist by training. I am an American living in Canada and am Professor of Paediatrics, Obstetrics & Gynaecology, and Community Health & Epidemiology at Dalhousie University; and Professor of Pediatrics, Psychology, and Psychiatry at The Ohio State University. I also blog at The Incidental Economist (theincidentaleconomist.com) and you can follow me @Bill_Gardner on Twitter.
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