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Role of Executive in Parliamentary Democracy The Executive ( the political executive) remains responsible and accountable to the Parliament. Parliament exercises political and financial control over the Executive and ensures administrative oversight over the executive. Subset of Parliament: In the parliamentary system the de facto head of the executive (Prime Minister) is not directly elected by the people, but he is the leader of the majority party in the Parliament. S/He chooses his own Cabinet which again, should be out of the Parliament only. Thus, in parliament democracy, the executive is a subset of the Legislature. The legislature is responsible for making the laws and the executive is responsible for enforcing the laws. In this case, the separation of power between the executive and legislature is not followed in a strict sense. Collective and Individual Responsibilities: The Executive is collectively responsible to the Parliament. It means that the term and tenure of the executive depends on the pleasure of the Lower House of Parliament. The House can introduce a no-confidence motion regarding the removal of the executive (government). The ministers, however, are individually responsible to the President and, ultimately, to the Council of Ministers. Administrative role: The executive's primary responsibility is to maintain internal peace and order, while also ensuring the country's safety from external aggression, encompassing all activities related to the state's well-being. The executive is also responsible for day-to-day administration. Financial role: The Executive has the authority to formulate the Budget, which is required to be presented annually to Parliament. The Executive has the freedom to determine expenditure levels, acquire funds for various purposes, and raise revenue to meet expenditures, leaving the entire financial initiative to the Government. Role of Parliament: Without the authority of Parliament, the executive, acting through its ministers, cannot raise funds through taxing, borrowing, or any other means. Money bills must originate and pass in the Lok Sabha, which has the exclusive authority to grant money in the form of taxes or loans and to sanction expenditure. Policy initiatives: The political executive, or the Council of Ministers, introduces bills in the house through its party members. The cabinet, the highest order of political executives, initiates and decides public policy concerning almost every sphere of government's activity. Further, delegated legislative functions are performed by the political and permanent executive. These are very important for policy making. Judicial role: The judicial functions are performed by the President of India with the aid and advice of his/her Council of Ministers. It includes the appointment of the judges of the Supreme Court and High Courts, and the power to grant pardon, reprieve, suspension, remission, or commutation of punishment or sentence of a court. Military Functions: The President of India with the Council of Ministers in aid and advice, is also vested with military powers
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BASIC STRUCTURE AND PROMINENT FUNCTIONS OF VERTEBRATE INTEGUMENT INTRODUCTION The integument or the outer cover of the body is commonly referred to as the skin. Together with its derivatives it makes up the integumentary system. It is continuous with the mucous membrane lining the mouth, eyelids, nostrils, rectum and the openings of the urino-genital ducts. The skin functions primarily to cover and protect the tissues lying beneath it. In other words, it forms the external protective covering of an animal. Forms interface between organism and external environment. Part that the predator sees first, and which offers the first line of defense. Abundantly supplied with sensory nerve endings, which are affected by environmental stimuli and play an important role in communication. General metabolism of the body, temperature regulation and water loss. Character of the skin and its derivatives shows variation in different regions of the body, in different individuals, in the same individual as age advances and in different groups of vertebrates. The type of environment whether aquatic or terrestrial is of importance in connection with these variations. The evolution of vertebrate integument is correlated with the transition of vertebrates from an aquatic to a terrestrial environment. Nevertheless, basic similarities exist in the integument of all vertebrates. INTEGUMENT PROPER In Annelids, Arthropods, integument consists of single layer of cells, the EPIDERMIS, together with an outer non-cellular CUTICLE, secreted by the cells. Annelids have a body covered with an external thin collagenous cuticle (never shed or molted). In Arthropods, the chitinous and rigid cuticle makes up the exoskeleton. Periodic shedding of this cuticle is termed Ecdysis. THE VERTEBRATE SKIN DIFFERS FROM INVERTEBRATE SKIN TWO LAYERS – Outer epidermis derived from ectoderm Inner dermis or corium of mesodermal origin. The relative amount of the two layers varies with the environment. EPIDERMIS – the epidermis is made of stratified epithelium (several layers of columnar epithelium cells). These cells are held together tightly by minute intercellular bridges found on the surface of cells. The innermost layer is stratum Malpighii or stratum germinativum placed over a thin basement membrane. These cells divide constantly to produce new cells. Move upwards, tend to become flattened, protoplasm becomes horny (keratinisation). In fishes and amphibians, this keratinised layer forms a cuticle, but in amniotes, it forms stratum corneum, of hard, horny, flat, cornified cells made largely of keratin, which is tough, waterproof and insoluble protein. It affords protection against mechanical injuries, fungal and bacterial attacks and prevents desiccation. In many Tetrapoda, this layer is shed periodically in pieces or all at once. No stratum corneum in cyclostomes and fishes (since they are fully aquatic) here the epidermis has mucous glands, secreting mucus to keep the skin slimy and protects it from bacteria. The epidermis has no blood vessels and is nourished by capillaries in the dermis. The epidermis rests on a thin basement membrane which separates it from the dermis Dermis has an outer loose layer and inner dense layer Made up of dense connective tissue having cells, muscles, blood vessels, lymph vessels, collagen and elastic fibres, and nerves. Amphibians and reptiles -collagen fibres at right angles in three planes Birds and mammals, they have an irregular arrangement. Substances pass by diffusion from the dermis to the epidermis. Skin contains pigment, if present in epidermis, it occurs as a diffuse substance or as granules. If in dermis, then in the form of granules in special branching cells called chromatophores. The pigment can either collect as a central ball making the skin lighter or spread out into all the branches making the skin darker, thus, chromatophores bring about colour variations. Chromatophores are of many kinds, Melanophores that contain brown to black pigment Lipophores or xanthophores which contain yellow red fatty pigments Iridocytes or guanophores contain crystals of guanine which reflect light. Under dermis, the skin has subcutaneous loose areolar tissue which separates the skin from the underlying muscles, it may contain fat and muscles, especially in mammals. Integument of Anamnia shows a decrease in thickness and also a decrease in the degree of ossification. These are of advantage in allowing greater mobility and in amphibians, they permit respiration by the skin. But in Amniota, the skin becomes progressively thicker to prevent loss of water and to retain body heat. STRUCTURE OF INTEGUMENT IN CYCLOSTOMATA Epidermis is multi-layered (stratified) but has no keratin. It has three types of unicellular gland cells: mucus glands (secrete mucus), club cells (scab-forming cells) and granular cells (unknown function). Below epidermis is the cutis formed of collagen and elastin fibres. Star- shaped pigment cells are also present in the cutis. STRUCTURE OF INTEGUMENT IN PISCES The epidermis has several layers of simple and thin cells, but there is no dead stratum corneum. The outermost cells are nucleated and living. The stratum Malpighii replenishes the outer layers of cells which have some keratin. Unicellular goblet or mucous gland cells are found in the epidermis, as in all aquatic animals. The mucous makes the skin slimy reducing friction between the body surface and water, protects the skin from bacteria and fungi and assists in the control of osmosis. Multicellular epidermal glands like poison glands and light producing organs may also be found. The epidermis rests on a delicate basement membrane. The dermis contains connective tissue, smooth muscles, blood vessels, nerves, lymph vessels and collagen fibres. The connective tissue fibres are generally not arranged at right angles but run parallel to the surface. Scales are embedded in the dermis and projected above the epidermal surface. The colours of fishes are due to chromatophores and iridocytes. STRUCTURE OF INTEGUMENT IN AMPHIBIA: The epidermis has several layers of cells, six to eight cells in thickness and is divisible into three layers: stratum corneum, stratum germinativum and a basal portion in contact with the basement membrane. The outermost layer is a stratum corneum, made of flattened, highly keratinised cells. Such a dead layer appears first in amphibians and is best formed in those which spend a considerable time on land. The stratum corneum is an adaptation to terrestrial life (protects body and prevents excessive loss of moisture). In ecdysis, stratum corneum is cast off in fragments or as a whole in some. (moulting / desquamation i.e., removal of unicellular sheet of stratum corneum). The dermis is relatively thin in amphibians, it is made of two layers - upper loose stratum spongiosum and a lower dense and compact stratum compactum. Connective tissue fibres run both vertically and horizontally. Blood vessels, lymph spaces, glands and nerves are abundant in the stratum spongiosum. There are two kinds of glands, multicellular mucous glands and poison glands in the dermis, but they are derivatives of the epidermis. Mucous gland produces mucus (slimy protective covering, helps in respiration). Amphibian skin is an important organ of respiration. Poison glands produce a mild but unpleasant poison which is protective. In the upper part of the dermis are chromatophores. (melanophores and lipophores) Ability of the skin for changing colour to blend with the environment is well developed. INTEGUMENT IN REPTILIA. The integument is thick and dry, it prevents any loss of water, it has almost no glands. The only glands present are scent glands for sexual activity. The epidermis has a well-developed stratum corneum well adapted to terrestrial life. The horny scales of reptiles are derived from this layer. Ecdysis is necessary to remove dead outer layers, hence scales are shed periodically in fragments or cast in a single slough as in snakes and some lizards Scales often form spines or crests. Below the epidermal scales are dermal bony plates or osteoderms in tortoises, crocodiles and some lizards (Heloderma). The dermis is thick and has an upper layer and a lower layer, upper layer has abundance of chromatophores in snakes and lizards. Lower layer has bundles of connective tissue in which collagen fibres lie at right angles. Leather of high commercial value can be prepared from the skin of many reptiles like lizards, snakes and crocodiles. Many lizards and snakes have elaborate colour patterns, they may be for concealment or as warning colours. There is marked colour change in certain lizards such as chameleon, the colour may change with the environment for concealment or it may change in courtship or threat. The ability of chameleons and some other animals to change colour is known as metachrosis. (metachromatism) In Calotes, chromatophores are controlled by the posterior lobe of pituitary whereas in chameleons they are controlled by the Autonomic Nervous System. INTEGUMENT IN BIRDS Thin, loose, dry and devoid of glands. There is only a uropygial gland at the base of the tail, its oil is used for preening (to clean and tidy its feathers with its beak) and waterproofing the feathers (aquatic birds) Epidermis is delicate except on shanks and feet where it is thick and forms epidermal scales. The rest of the body has a protective covering of epidermal feathers. The keratin producing powers of the epidermis are devoted to producing feathers and scales. The dermis is thin and has interlacing connective tissue fibres, abundant muscle fibres for moving feathers, blood vessels and nerves. The dermis has an upper and lower compact layer, between which is a vascular layer, the dermis also contains fat cells. The skin has no chromatophores. Pigment is found only in feathers and scales. Colour patterns in birds are vivid (concealment, recognition and sexual stimulation) Colours are produced partly by pigments and partly by reflection and refraction from the surface of the feathers. INTEGUMENT IN MAMMALS Skin is elastic and waterproof, much thicker than in other animals, especially the dermis is very thick and is used in making leather. Epidermis is thickest in mammals. Outer stratum corneum containing keratin, cells not dead as believed before. Below this is stratum lucidum (barrier layer), chemical called eleidin Below this stratum granulosum, darkly staining granules of keratohyalin Below this is stratum spinosum whose cells are held together by spiny intercellular bridges. Lastly stratum germinativum which rests on a basement membrane Dermis is best developed in mammals. Upper layer is papillary layer made up of elastic and collagen fibres with capillaries in-between, thrown into folds called dermal papillae, especially in areas of friction Greater lower part of dermis is reticular layer, having elastic and collagen fibres. In both layers there are blood vessels, nerves smooth muscles, certain glands tactile corpuscles and connective tissue fibres in all directions. Below dermis the subcutaneous tissue contains a layer of fat cells forming adipose tissue In the lowest layer of epidermis there are pigment granules, no pigment bearing chromatophores in mammaIs (in man, branching dendritic cells or melanoblasts) FUNCTIONS OF THE INTEGUMENT ▪ PROTECTION ▪ TEMPERATURE CONTROL ▪ FOOD STORAGE ▪ SECRETION ▪ EXCRETION ▪ SENSATION ▪ RESPIRATION ▪ LOCOMOTION ▪ DERMAL ENDOSKELETON ▪ SEXUAL SELECTION 1. Protection: The integument forms a covering of the body and is protective. It protects the body against entry of foreign bodies and against mechanical injuries. It protects the tissues against excessive loss of moisture, this is very important because both aquatic and terrestrial animals are dependent upon water in their bodies for various metabolic activities. The integument forms protective derivatives, such as scales, bony plates, layer of fat, feathers and hair which reduce the effect of injurious contacts. In some animals the skin shows protective colouration which makes the animals resemble their environment, thus, making them almost invisible to their enemies. Poison glands of toads, slippery skin of aquatic animals and an armour of spines of some mammals are protective devices of the integument. The skin forms a covering which prevents the passage of water and solutes in one of the following ways: (a) By formation of cuticle in Protochordata and embryos of fishes and amphibians, (b) By secreting a coat of mucus in fishes and aquatic amphibians, and (c) By formation of keratin layers in the epidermis of tetrapoda. Keratin is formed from the cytoplasm of degenerating cells of the epidermis which finally form a layer of horny stratum corneum. 2. Temperature Control: Heat is produced constantly by oxidation of food stuffs in tissues. This heat is distributed evenly by the circulating blood. The body heat is lost constantly with expired breath, with faeces and urine, and from the surface of the skin. The integument regulates heat and maintains a constant temperature in endothermal animals. In birds the heat is regulated by adjustment of feathers which retain a warm blanket of air, when feathers are held close to the body, they remove warm air and body cooled, when feathers are fluffed out, they keep the warm air enclosed. In mammals, constant evaporation of sweat regulates the body heat. In cold weather contraction of skin’s blood capillaries reduces the loss of body heat. In some animals, fat in the skin prevents loss of heat because it is a non-conductor of heat. 3. Food Storage: The skin stores fat in its layers as reserve food material which is used for nourishment in times of need. In whales and seals the fat of the skin forms a thick layer, called blubber which is not only reserve food but also maintains the body temperature. 4. Secretion: The skin acts as an organ of secretion. Glands of the skin are secretory. In aquatic forms there are secretory mucous glands whose secretions keep the skin moist and slippery. In mammals, sebaceous glands secrete oil which lubricates the skin and hairs. Mammary glands produce milk for nourishment of the young. In birds uropygial glands secrete oil for preening the feathers. Odours of scent glands attract the opposite sex. Lacrymal glands’ secretion wash the conjunctiva of eyeball in mammals. Ear wax (cerumen) secreted by the glands of auditory meatus greases the eardrums and avoids insects to enter the canal. 5. Excretion: The integument acts as an organ of excretion. Shedding of the corneal layer during ecdysis removes some waste substances. In mammals metabolic waste (salts, urea and water) is removed from the blood by means of sweat. Chloride secreting cells are found in gills of marine fishes. 6. Sensation: The skin is an important sense organ because it has various kinds of tactile cells and corpuscles which are sensory to touch, temperature changes, heat, cold, pressure and pain. 7. Respiration: In amphibians, the moist skin acts as an organ of respiration, in frogs the respiratory function of the skin is greater than that of the lungs. 8. Locomotion: Derivatives of the integument bring about locomotion in some animals, such as the fins of fishes aid in locomotion in water, the web of skin in the feet of frogs and aquatic birds aid in swimming, feathers of the wings and tail of birds are used for flying, and extensions of the integument forming “wings” of flying lizards, extinct pterodactyls, flying squirrels and bats. 9. Dermal Endoskeleton: The skin contributes to the endoskeleton. It forms the dermal bones of vertebrates and also forms parts of the teeth. Endoskeleton of head protects the brain and sense organs. In the body it protects the soft, tender viscera. 10. Sexual Selection: The skin acts as an organ of sexual selection. It provides the feathers of birds which often have brilliant colours which are for sexual attraction. Some integumentary glands of mammals produce odours far attracting the opposite sex. Antlers of male deer distinguish it from female. Besides the above functions, mammalian skin synthesizes the vitamin D with the help of Sebum of sebaceous glands. Brood pouches beneath skin in some fishes and amphibians protect unhatched eggs. Nasal glands of tetrapods, keep the nostrils free of dirt and water. Skin also has the power of absorption of oils, ointments, etc
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You place a RBC (0.9%) into a 5% sugar solution. Which statement below is false? The RBC is hypotonic to the 5% solution Which is an example of a sensor in a negative homeostatic feedback loop? Chemoreceptor in carotid body For membrane fluidity experiment, the part of the experiment that actually validated that the membrane was fluid was: The labeled antibodies of the human and mouse intermixing An example of primary active transport would be a protein requiring ATP to transport sodium ions across the plasma membrane. True If a red blood cell is put in a solution and it hemolyzes, then the solution is considered to be: Hypotonic If your body temperature goes too high you can denature enzymes in your body. True What does an integrator do in a homeostatic pathway? Measures the signal coming in to a set point and send a signal out to the body Which of the following represents stages of the cell division (mitosis) in the proper sequence? Prophase, metaphase, anaphase, telophase Which is not true for proteins? They are comprised of mostly cellulose What would be a disturbance for blood glucose homeostasis (normal blood glucose set point = 77mg/dL)? A permanent decrease in insulin production from the Islets of Langerhans Dr. Bio measures your total cholesterol and he reports back to you that your level is 300 mg/ 100 ml of plasma. You do what? Eat more oatmeal and flax to increase your HDL level. How do you make an unsaturated fatty acid? Perform a dehydration synthesis reaction on a saturated fatty acid Which is false for antioxidants? They speed up reactions in your body Which molecules do not dissolve in water? Non-polar Which molecule requires a transport protein to get through the plasma membrane (either channel or carrier protein)? Two of the answers are correct Interphase is considered to be part of normal cell division (mitosis). False What is the function of ATP? All of the answers are correct What are the three kinds of lipids? Triglycerides, phospholipids, and steroids When glycerol combines with 3 fatty acids to form a triglyceride (fat), which of the following chemical reactions has occurred? Dehydration Synthesis How can you alter a protein’s shape? More than one answer is correct If a red blood cell is put into a solution and it maintains its shape, then the solution is considered to be: Isotonic Which molecule requires some type of transport protein to get through the plasma membrane? Sodium Ion Cofactors are molecules that activate enzymes. Which is not a cofactor? Mercury The nitrogenous bases found in DNA have complementary paring. Which pair is correct? C-G Which is not true for meiosis? Results in a gamete that is 2N In the diagram below the two solutions are separated by a semi permeable membrane. In which direction will net movement of water occur? From side A to side B Which is not a component of a DNA molecule: Ribose Sugar Phospholipids are similar to fatty acids except for? Phospholipids have a phosphate group Which is not true for cells? They allow diffusion of all molecules If you combine a molecule of glucose and fructose, which statement is true? You have formed sucrose Which is true for enzymes? Activity will increase until the enzyme becomes saturated What method would you use to get glucose into a cell along/down it’s concentration gradient (from high to low)? Facilitated Diffusion Which is not considered an integrator in a negative homeostatic feedback loop? Pancreas Which phase of the cell cycle is where cytokinesis takes place? Telophase What vitamin do we produce by sitting in the sun; it aids in calcium absorption from the small intestine? Vitamin D Why is it important to think about ion dissociation in the body? All the above In what order do you use macromolecules for fuel? Carbohydrates, lipids, proteins Which is false for cholesterol? It can dissolve in water/blood You place a RBC (0.9%) into a 0.5% sugar solution. Which statement below is false? The RBC is hypertonic to the 0.5% solution Which is not a membrane protein function? Protein synthesis Ingesting (eating) excess hydrophilic vitamins, such as vitamin C, results in excess vitamin C being stored in your tissues. False Diffusion is: The movement of molecules from an area of high molecular concentration to an area of low molecular concentration across a selectively-permeable membrane The hormone responsible for glucose uptake/removal from the blood is: Insulin What method would you use to get sodium ions into a cell against sodium’s concentration gradient (from low to high concentration)? Active Transport Which phase of the cell cycle is where the cell is functioning normally or doing its job? Interphase Evidence for mitochondria once being bacteria that our cells engulfed is: It has it’s own DNA Ionic molecules (ie NA+, K+) can diffuse straight through the plasma membrane. True What is the difference between cis and trans fatty acids? Cis fatty acids have hydrogens on the same side of the carbon double bond and trans fatty acids do not Cofactors are molecules that activate enzymes. Where do we get cofactors from? Vitamins found in fruits and vegetables RNA has what nitrogenous base in place of thymine? Uracil Large polar molecules (ie glucose) can diffuse straight through the plasma membrane? False Which lipoprotein is comprised of more protein and less cholesterol so it scavenges for cholesterol in the blood? High density lipoprotein A normal human being has 46 chromosomes (23 pairs/2N/diploid) in each somatic cell (body cell). True The three main compounds digested by the digestive system are? Fats, carbohydrates, and proteins Meiosis is the process in which our sex cells go from 46 chromosomes to 23 single chromosomes. True The effector in any negative feedback loop is usually: An organ/tissue If a red blood cell is put into a solution and it crenates (shrinks), then the solution is considered to be: Hypertonic Which statement is false for glycogen? It is a disaccharide Enzymes aid in digestion by? Lowering the energy required to break food apart Nonpolar molecules (ie CO2) can diffuse straight through the plasma membrane
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1. Hyperemesis Gravidarum/ Pernicious Vomiting Definition: Excessive nausea and vomiting during pregnancy, extending beyond week 12 or causing dehydration, ketonuria, and significant weight loss within the first 12 weeks. Incidence: 1 in 200-300 women Cause: Unknown, but may be associated with increased thyroid function and Helicobacter pylori infection. Signs and Symptoms: • Decreased urine output • Weight loss • Ketonuria • Dry mucous membranes • Poor skin turgor • Elevated hematocrit • Decreased sodium, potassium, and chloride levels • Polyneuritis (in some cases) Assessment: • Hemoglobin: Elevated hematocrit concentration (hemoconcentration) due to inability to retain fluids. • Electrolytes: Decreased sodium, potassium, and chloride levels due to low intake. • Acid-base Balance: Hypokalemic alkalosis (severe vomiting, prolonged period). • Neurological Examination: Polyneuritis due to B vitamin deficiency. Effects (if left untreated): • Intrauterine Growth Restriction (IUGR): Dehydration and inability to provide nutrients for fetal growth. • Preterm birth: Due to complications caused by the condition. • Prolonged hospitalization/home care: Resulting in social isolation. Therapeutic Management: • Fluid and Electrolyte Management: Monitor input and output, blood chemistry to prevent dehydration. • Nutritional Support: Withhold oral food and fluids (usually) and administer total parenteral nutrition (TPN). • Intravenous Fluid Replacement: 3000 ml Ringer's lactate with added vitamin B to increase hydration. • Antiemetic Medication: Metoclopramide (Reglan) to control vomiting. 2. Ectopic Pregnancy Definition: Implantation of a fertilized egg outside the uterine cavity (ovary, cervix, fallopian tube - most common). Incidence: Second most frequent cause of bleeding during the first trimester. Causes: • Obstruction of the fallopian tube: ◦ Adhesions (from previous infection like chronic salpingitis or pelvic inflammatory disease). ◦ Congenital malformations. ◦ Scars from tubal surgery. ◦ Uterine tumor pressing on the proximal end of the tube. ◦ Current use of an intrauterine device (IUD). Signs and Symptoms: • Missed period/amenorrhea. • Positive hCG test. • Sharp, stabbing pain in the lower abdominal quadrants and pelvic pain (at time of rupture). • Scant vaginal spotting/bleeding. • Rigid abdomen (from peritoneal irritation). • Leukocytosis (increased WBC count due to trauma). • Decreased blood pressure and increased pulse rate (signs of shock). • Cullen's sign (bluish tinge around the umbilicus). • Tender mass palpable in the cul-de-sac of Douglas (vaginal exam). • Falling hCG or serum progesterone level (suggesting the pregnancy has ended). • No gestational sac on ultrasound. Therapeutic Management: • Non-ruptured Ectopic Pregnancy: Oral administration of methotrexate followed by leucovorin. • Ruptured Ectopic Pregnancy (emergency): Laparoscopy to ligate bleeding vessels and remove or repair the damaged fallopian tube. 3. Hydatidiform Mole (H-mole)/ Gestational Trophoblastic Disease/ Molar Pregnancy Definition: A gestational anomaly of the placenta consisting of a bunch of clear vesicles resembling grapes. This neoplasm is formed from the swelling of the chorionic villi, resulting from a fertilized egg whose nucleus is lost, and the sperm nucleus duplicates, producing a diploid number 46XX. Incidence: Approximately 1 in every 1500 pregnancies. Risk Factors: • Low socioeconomic group (decreased protein intake). • Women under 18 or over 35 years old. • Women of Asian heritage. • Receiving clomiphene citrate (Clomid) for induced ovulation. Types of Molar Growth: • Complete/Classic H-mole: All trophoblastic villi swell and become cystic. No embryonic or fetal tissue present. High risk for malignancy. • Partial/Incomplete H-mole: Some of the villi form normally. Presence of fetal or embryonic tissue. Low risk for malignancy. Signs and Symptoms: • Uterus expands faster than normal. • No fetal heart sounds heard. • Serum or urine test for hCG strongly positive. • Early signs of preeclampsia. • Vaginal bleeding (dark-brown spotting or profuse fresh flow). • Discharge of fluid-filled vesicles. Diagnosis: • Ultrasound. • Chest x-ray (lung metastasis). • Amniocentesis (no fluid). • Hysteroscopy (via cervix). Management: • Evacuation of the mole: Dilation and curettage (D&C). • Blood transfusion. • Hysterectomy (in some cases). • Monitoring hCG levels: Every 2 weeks until normal. • Contraception: Reliable method for 12 months to prevent confusion with a new pregnancy. 4. Premature Cervical Dilatation/ Incompetent Cervix Definition: Premature dilation of the cervix, usually occurring around week 20, when the fetus is too immature to survive. Incidence: About 1% of pregnancies. Causes: • Increased maternal age. • Congenital structural defects. • Trauma to the cervix (cone biopsy, repeated D&C). Signs and Symptoms: • Painless dilation of the cervix. • Pink-stained vaginal discharge. • Increased pelvic pressure. • Rupture of membranes and discharge of amniotic fluid. Therapeutic Management: • Cervical cerclage: Surgical procedure to prevent loss of the child due to premature dilation. • Bed rest: After cerclage surgery, to decrease pressure on the sutures. 5. Abortion Definition: Termination of pregnancy before the fetus is viable (400-500 grams or 20-24 weeks gestation). Types of Abortion: • Spontaneous Abortion: Pregnancy interruption due to natural causes. ◦ Threatened: Mild cramping, vaginal spotting. ◦ Inevitable/Imminent: Profuse bleeding, uterine contractions, cervical dilation. ◦ Complete: All products of conception expelled spontaneously. ◦ Incomplete: Part of the conceptus expelled, some retained in the uterus. ◦ Missed: Fetus dies in utero but is not expelled. ◦ Habitual: 3 or more consecutive spontaneous abortions. • Induced Abortion: Deliberate termination of pregnancy in a controlled setting. Complications of Abortion: • Hemorrhage. • Infection (endometritis, parametritis, peritonitis, thrombophlebitis, septicemia). Management: • Bed rest. • Emotional support. • Sedation. • D&C: Surgical removal of retained products of conception. • Antibiotics. • Blood transfusion. 6. Placenta Previa Definition: The placenta is implanted in the lower uterine segment, covering the cervical os, obstructing the birth canal. Incidence: 5 per 1000 pregnancies. Signs and Symptoms: • Abrupt, painless vaginal bleeding (bright red). • Bleeding may stop or slow after the initial hemorrhage, but continue as spotting. Types: • Total: Placenta completely obstructs the cervical os. • Partial: Placenta partially obstructs the cervical os. • Marginal: Placenta edge approaches the cervical os. • Low-lying: Placenta implanted in the lower rather than the upper portion of the uterus. Therapeutic Management: • Immediate Care: Bed rest in a side-lying position. • Assessment: Monitor vital signs, bleeding, and fetal heart sounds. • Intravenous Therapy: Fluid replacement with large gauge catheter. • Delivery: Vaginal birth (safe for infant if previa is less than 30%). Cesarean section (safest for both mother and infant if previa is over 30%). 7. Abruptio Placenta/ Premature Separation of Placenta/ Accidental Hemorrhage/ Placental Abruption Definition: Separation of a normally implanted placenta after the 20th week of pregnancy, before birth of the fetus. Incidence: Most frequent cause of perinatal death. Causes: • Unknown. • Predisposing Factors: ◦ High parity. ◦ Advanced maternal age. ◦ Short umbilical cord. ◦ Chronic hypertensive disease. ◦ PIH. ◦ Trauma (automobile accident, intimate partner abuse). ◦ Cocaine or cigarette use. ◦ Thrombophilitic conditions (autoimmune antibodies). Classification: • Total/Complete: Concealed hemorrhage. • Partial: Concealed or apparent hemorrhage. Signs and Symptoms: • Sharp, stabbing pain in the uterine fundus. • Contractions accompanied by pain. • Uterine tenderness on palpation. • Heavy vaginal bleeding (may be concealed). • Signs of shock. • Tense, rigid uterus. • Disseminated Intravascular Coagulation (DIC). Therapeutic Management: • Fluid Replacement: IV fluids. • Oxygen: Limit fetal hypoxia. • Fetal Monitoring: External fetal heart rate monitoring. • Fibrinogen Determination: IV fibrinogen or cryoprecipitate. • Lateral Position: Prevent pressure on the vena cava. • Delivery: CS is the method of choice if birth is not imminent. 8. Premature Rupture of Membranes Definition: Rupture of the fetal membranes with loss of amniotic fluid during pregnancy before 37 weeks. Incidence: 5%-10% of pregnancies. Causes: • Unknown. • Associated with: Infection of the membranes (chorioamnionitis), vaginal infections (gonorrhea, streptococcus B, Chlamydia). Signs and Symptoms: • Sudden gush of clear fluid from the vagina with continued minimal leakage. • Nitrazine paper test: Amniotic fluid turns the paper blue (alkaline), urine remains yellow (acidic). • Microscopic examination: Amniotic fluid shows ferning, urine does not. • Ultrasound: Assess amniotic fluid index. • Signs of infection (increased WBC count, C-reactive protein, temperature, tenderness, odorous vaginal discharge). Therapeutic Management: • Bed Rest: To prevent further leakage and risk of infection. • Corticosteroids: To hasten fetal lung maturity. • Prophylactic Antibiotics: To reduce risk of infection. • Intravenous Penicillin/Ampicillin: If (+) for streptococcus B. • Induction of Labor: If fetus is mature and labor does not begin within 24 hours. 9. Pregnancy-Induced Hypertension (PIH)/ Toxemia Definition: Vasospasm occurring in both small and large arteries during pregnancy, causing elevated blood pressure, proteinuria, and edema. Incidence: Rarely occurs before 20 weeks of pregnancy. Risk Factors: • Multiple pregnancy. • Primiparas younger than 20 or older than 40. • Low socioeconomic background. • Five or more pregnancies. • Hydramnios. • Underlying diseases (heart disease, diabetes). • Rh incompatibility. • History of H-mole. Categories: • Gestational Hypertension: Blood pressure 140/90 or greater, without proteinuria or edema. • Preeclampsia: Blood pressure 140/90 or greater, with proteinuria and edema. • Eclampsia: Seizures or coma accompanied by preeclampsia. Therapeutic Management: • Preeclampsia: Bed rest, balanced diet, left lateral position. • Severe Preeclampsia: Hospitalization, diazepam, hydralazine, magnesium sulfate. • Eclampsia: Magnesium sulfate, diazepam, oxygen therapy, left lateral position
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CNS Stimulants ADHD Medications Amphetamine (Adderall, Dexedrine) Mechanism of Action: Stimulates excitatory neurons, increases dopamine & norepinephrine. Indications: ADHD, narcolepsy. Adverse Effects: Increased HR/BP, anxiety, tremor, insomnia, headache, decreased appetite, GI distress, dry mouth. Contraindications: Cardiac abnormalities, hypertension, anxiety, agitation, glaucoma, MAOI use (within 14 days). Nursing Implications: Administer 4-6 hours before bedtime. Take on an empty stomach. Monitor BP, pulse, weight, growth patterns in children. Avoid abrupt withdrawal. Methylphenidate (Ritalin, Concerta) Mechanism of Action: CNS stimulant affecting dopamine reuptake. Indications: ADHD, narcolepsy. Adverse Effects: Same as amphetamines. Nursing Implications: Same as amphetamines. Lisdexamfetamine (Vyvanse) Mechanism of Action: Converted into dextroamphetamine. Indications: ADHD, binge-eating disorder. Nursing Implications: Similar to amphetamines. Atomoxetine (Strattera) Mechanism of Action: Selective norepinephrine reuptake inhibitor. Indications: ADHD (children >6 and adults). Adverse Effects: Lower abuse potential, less insomnia, but Black Box Warning for suicidal thoughts. Nursing Implications: Monitor mental health for suicidal ideation. Narcolepsy Medications Modafinil (Provigil) Mechanism of Action: Low abuse potential stimulant. Indications: Narcolepsy, shift work sleep disorder. Nursing Implications: Monitor BP & mental health. Antimigraine Medications Rizatriptan (Maxalt), Sumatriptan (Imitrex) Mechanism of Action: Serotonin receptor agonist, causing vasoconstriction. Indications: Acute migraine treatment. Adverse Effects: Tingling, flushing, chest tightness, rebound headaches if overused. Contraindications: Cardiovascular disease, hypertension, glaucoma. Nursing Implications: Administer at first sign of migraine. Avoid triggers. Monitor cardiac history. Endocrine Medications Pituitary Medications Somatropin (Humotrope) Mechanism of Action: Growth hormone replacement. Indications: Growth failure (hypopituitarism, HIV wasting). Adverse Effects: Hyperglycemia, hypothyroidism, injection site reactions. Nursing Implications: Monitor growth, motor skills, thyroid, and glucose levels. Rotate injection sites. Octreotide (Sandostatin) Mechanism of Action: GH antagonist. Indications: Acromegaly, GH-producing tumors. Adverse Effects: GI distress, glucose changes, cardiac conduction issues. Nursing Implications: Monitor glucose, EKG, growth. ADH Medications Vasopressin (Pitressin) & Desmopressin (DDAVP) Mechanism of Action: Mimics ADH. Indications: Vasopressin: Hypotension, hemorrhage. Desmopressin: Diabetes insipidus, bedwetting. Adverse Effects: Increased BP, headache, GI distress. Nursing Implications: Monitor VS, urine output, cardiac status. Thyroid Medications Levothyroxine (Synthroid) Mechanism of Action: Synthetic T4. Indications: Hypothyroidism. Adverse Effects: Hyperthyroid symptoms. Nursing Implications: Administer before breakfast on an empty stomach. Monitor thyroid labs (TSH, T3, T4). Avoid iodine-rich foods, iron/calcium supplements. Propylthiouracil (PTU) Mechanism of Action: Inhibits thyroid hormone production. Indications: Hyperthyroidism, thyroid storm. Adverse Effects: GI distress, bone marrow suppression. Nursing Implications: Monitor thyroid levels & CBC. Avoid iodine-rich foods. Radioactive Iodine (I-131) Mechanism of Action: Destroys thyroid tissue. Indications: Hyperthyroidism, thyroid cancer. Adverse Effects: Radiation sickness, Pregnancy Category X. Nursing Implications: Radiation precautions: Avoid close contact, use separate utensils, increase fluids. Adrenal Medications Glucocorticoids Hydrocortisone (Solu-Cortef), Prednisone (Deltasone), Dexamethasone (Decadron), Methylprednisolone (Solu-Medrol) Mechanism of Action: Anti-inflammatory, immunosuppressant. Indications: Adrenal insufficiency, inflammatory/autoimmune diseases. Adverse Effects: Metabolic: Hyperglycemia, weight gain, Cushing’s syndrome. Musculoskeletal: Osteoporosis, muscle wasting. CV: Hypertension, edema. Neuro: Mood swings, insomnia. Nursing Implications: Administer in the morning with food. Taper off slowly to prevent adrenal crisis. Monitor glucose levels with long-term use. Avoid sick contacts due to immune suppression. Mineralocorticoids Fludrocortisone (Florinef) Mechanism of Action: Mimics aldosterone (Na & water retention). Indications: Addison’s disease, adrenal insufficiency. Adverse Effects: Hypertension, hypokalemia, edema. Nursing Implications: Monitor BP, electrolytes (Na, K). Immunosuppressants Cyclosporine (Sandimmune), Tacrolimus (Prograf) Mechanism of Action: Suppresses immune response. Indications: Organ transplant, autoimmune diseases. Adverse Effects: Increased risk for infections, nephrotoxicity, diabetes. Nursing Implications: Strict dosing schedule (same time every day). Avoid grapefruit juice & styrofoam cups. No live vaccines (MMR, Varicella, Smallpox). Report any signs of infection immediately. Lifespan Considerations Pediatrics: Monitor growth in children using ADHD meds & growth hormones. Pregnancy: Avoid radioactive iodine (I-131) & immunosuppressants. Elderly: Caution with stimulants & corticosteroids (risk of cardiac issues, osteoporosis). Patient Teaching CNS Stimulants: Avoid abrupt withdrawal. Monitor growth (children). Thyroid Meds: Take levothyroxine on an empty stomach. Avoid iodine-rich foods if on PTU. Corticosteroids: Taper off gradually. Monitor glucose, avoid infections. Immunosuppressants: No live vaccines. Strict dosing schedule. Insulins Rapid-acting Insulins (Insulin lispro - Humalog, Insulin aspart - Novolog) Mechanism of Action: Fast-acting insulin that mimics natural insulin secretion in response to meals. Indications: Type 1 or Type 2 Diabetes. Adverse Effects: Hypoglycemia, weight gain, lipodystrophy at injection sites. Nursing Implications: Must eat a meal after injection. Administer subcutaneously (SQ) or via infusion pump. Clear, colorless solution. Short-acting Insulin (Regular insulin - Humulin R) Mechanism of Action: Provides short-term glucose control. Indications: Type 1 & Type 2 Diabetes. Adverse Effects: Hypoglycemia, weight gain. Nursing Implications: Onset: 30-60 min, Peak: 2.5 hr, Duration: 6-10 hr. Can be administered IV, IM, or SQ. Clear, colorless solution. Intermediate-acting Insulin (NPH - Isophane insulin suspension) Mechanism of Action: Delayed onset but prolonged glucose control. Indications: Often combined with regular insulin for Type 1 & Type 2 Diabetes. Adverse Effects: Hypoglycemia, weight gain. Nursing Implications: Onset: 1-2 hr, Peak: 4-8 hr, Duration: 10-18 hr. Cloudy suspension, administered SQ. Usually given twice daily before meals. Long-acting Insulins (Insulin glargine - Lantus, Insulin detemir - Levemir) Mechanism of Action: Provides basal insulin coverage with no peak effect. Indications: Type 1 & Type 2 Diabetes. Adverse Effects: Hypoglycemia (less risk), weight gain. Nursing Implications: Onset: 1-2 hr, No peak, Duration: 24 hr. DO NOT mix with other insulins. Clear, colorless solution. Oral Antidiabetics Biguanides (Metformin - Glucophage) Mechanism of Action: Decreases hepatic glucose production & increases insulin sensitivity. Indications: First-line treatment for Type 2 Diabetes. Adverse Effects: GI discomfort, diarrhea, metallic taste, reduced B12 levels. Black Box Warning: Risk of lactic acidosis (especially in renal failure). Nursing Implications: Administer 30 min before meals. Hold if contrast dye is used (renal failure risk). Sulfonylureas (Glipizide - Glucotrol) Mechanism of Action: Stimulates pancreatic insulin release. Indications: Type 2 Diabetes (early stages). Adverse Effects: Hypoglycemia, weight gain, nausea. Contraindications: Sulfa allergy. Nursing Implications: Give 30 min before meals. Monitor for hypoglycemia. Glinides (Repaglinide - Prandin) Mechanism of Action: Increases insulin secretion from beta cells. Indications: Type 2 Diabetes (postprandial glucose control). Adverse Effects: Hypoglycemia, weight gain. Black Box Warning: May exacerbate heart failure. Nursing Implications: Take with each meal, skip if meal is skipped. Glitazones (Pioglitazone - Actos) Mechanism of Action: Improves insulin sensitivity. Indications: Type 2 Diabetes (often combined with metformin or sulfonylureas). Adverse Effects: Fluid retention, weight gain, fractures. Black Box Warning: May exacerbate heart failure. Nursing Implications: Weigh daily. Monitor for heart failure signs. Alpha-glucosidase Inhibitors (Acarbose - Precose) Mechanism of Action: Delays carbohydrate absorption. Indications: Type 2 Diabetes (postprandial glucose control). Adverse Effects: GI issues (flatulence, diarrhea). Contraindications: GI disorders (IBD, malabsorption). Nursing Implications: Take with first bite of meal. DPP-4 Inhibitors (Gliptins) (Sitagliptin - Januvia) Mechanism of Action: Enhances incretin hormone function. Indications: Adjunct to diet/exercise in Type 2 Diabetes. Adverse Effects: URI, headache, diarrhea. Nursing Implications: Take once daily, with or without food. SGLT-2 Inhibitors (Canagliflozin - Invokana) Mechanism of Action: Inhibits glucose reabsorption in kidneys. Indications: Type 2 Diabetes (weight loss benefit). Adverse Effects: UTIs, yeast infections, dehydration, ketoacidosis. Nursing Implications: Take once daily before breakfast. Injectable Non-Insulin Medications Amylin Agonists (Pramlintide - Symlin) Mechanism of Action: Slows gastric emptying, suppresses glucagon. Indications: Type 1 & Type 2 Diabetes. Adverse Effects: Nausea, vomiting, anorexia. Contraindications: Gastroparesis. Nursing Implications: Inject before meals. Take at least 1 hr before oral meds. Incretin Mimetics (Exenatide - Byetta) Mechanism of Action: Enhances insulin secretion. Indications: Type 2 Diabetes (used when oral meds fail). Adverse Effects: GI symptoms, weight loss, thyroid tumors (Black Box Warning). Nursing Implications: Administer SQ 1 hr before meals. Glucose-Elevating Agents Glucagon Indications: Severe hypoglycemia. Adverse Effects: Vomiting (turn patient on side). Nursing Implications: Used when patient cannot take oral glucose. Dextrose 50% in Water (D50W) Indications: Emergency treatment of hypoglycemia. Nursing Implications: Administer IV. Nonsteroidal Anti-Inflammatory Drugs (NSAIDs) Salicylates (Aspirin - ASA) Mechanism of Action: COX-1 & COX-2 inhibitor, antiplatelet. Indications: Pain, fever, inflammation, CV prevention. Adverse Effects: GI bleeding, Reye’s syndrome in children. Nursing Implications: Do not give to children with viral infections. Acetic Acid Derivative (Ketorolac - Toradol) Indications: Short-term pain management (up to 5 days). Adverse Effects: Renal impairment, GI distress. COX-2 Inhibitor (Celecoxib - Celebrex) Indications: Osteoarthritis, rheumatoid arthritis. Adverse Effects: CV risk (Black Box Warning). Contraindications: Sulfa allergy. Propionic Acid Derivatives (Ibuprofen, Naproxen) Indications: Pain, inflammation, fever. Adverse Effects: GI distress, bleeding risk. Antigout Medications Allopurinol (Zyloprim) Mechanism of Action: Reduces uric acid production. Indications: Chronic gout prevention. Adverse Effects: Stevens-Johnson syndrome. Nursing Implications: Take with food. Colchicine (Colcrys) Mechanism of Action: Reduces inflammatory response. Indications: Acute gout attack. Adverse Effects: GI distress, bleeding risk. Nursing Implications: Hydration (3L/day). Immunizations Active Immunizing Drugs Mechanism of Action: Stimulate the immune system to produce antibodies against specific pathogens, offering long-term immunity. Indications: Prevention of infectious diseases. Adverse Effects: Common: Soreness, fever, mild rash. Severe: Fever >103°F, encephalitis, convulsions, anaphylaxis. Contraindications: Immunocompromised patients, pregnancy (some vaccines), active infections. Nursing Implications: Assess medical history, immune status, and pregnancy. Administer vaccines at appropriate sites: Infants: Mid-lateral thigh. Older children/adults: Deltoid muscle. Use warm compresses, Tylenol for mild reactions. Report severe reactions to VAERS (Vaccine Adverse Event Reporting System). Examples of Active Immunizations: Diphtheria, tetanus toxoids, acellular pertussis (DTaP, Td): Prevents diphtheria, tetanus, and pertussis. Haemophilus influenzae type B (Hib): Prevents bacterial infections, especially in children. Hepatitis B vaccine: Prevents Hep B infection. Influenza vaccine: Annual vaccine for flu prevention. Measles, mumps, rubella (MMR): Prevents viral infections. Pneumococcal vaccine: Protects against pneumococcal infections (pneumonia, meningitis). Poliovirus vaccine (IPV): Prevents poliomyelitis. Rabies vaccine: Given for rabies exposure or pre-exposure prophylaxis. Human papillomavirus (HPV - Gardasil): Prevents HPV-related cancers. Herpes zoster (Zostavax, Shingrix): Protects against shingles. Varicella vaccine: Prevents chickenpox. Passive Immunizing Drugs Mechanism of Action: Provides preformed antibodies for immediate protection; temporary immunity. Indications: Post-exposure prophylaxis in high-risk patients. Examples: Hepatitis B immunoglobulin: Post-exposure protection for Hepatitis B. Immunoglobulin: General immune support. Rabies immunoglobulin: Post-exposure prophylaxis after animal bites. Tetanus immunoglobulin: Used in unvaccinated individuals exposed to tetanus. Dermatologic Medications Antibacterials Bacitracin Mechanism of Action: Inhibits bacterial cell wall synthesis. Indications: Minor skin infections. Adverse Effects: Burning, itching. Neomycin & Polymyxin B (Neosporin) Mechanism of Action: Broad-spectrum antibacterial. Indications: Minor wounds. Adverse Effects: Local irritation. Mupirocin (Bactroban) Indications: Topical: Treats impetigo (Staphylococcus, Streptococcus infections). Intranasal: Used for MRSA colonization. Adverse Effects: Burning, itching. Silver Sulfadiazine (Silvadene) Mechanism of Action: Acts on bacterial cell wall. Indications: Burn treatment (prevention of infection). Adverse Effects: Pain, burning, contraindicated in sulfa allergy. Antiacne Medications Benzoyl Peroxide Mechanism of Action: Releases oxygen, killing acne bacteria. Indications: Mild to moderate acne. Adverse Effects: Red, peeling skin, warmth. Tretinoin (Retin-A) Mechanism of Action: Vitamin A derivative, stimulates cell turnover. Indications: Acne, UV damage. Adverse Effects: Skin peeling, severe sunburn risk (use sunscreen). Isotretinoin (Accutane) Mechanism of Action: Sebaceous gland suppression. Indications: Severe cystic acne. Adverse Effects: Teratogenic (Pregnancy Category X), liver toxicity, mood changes. Black Box Warning: IPLEDGE Program (2 contraceptive methods required). Antifungals Clotrimazole (Lotrimin) Mechanism of Action: Inhibits fungal growth. Indications: Athlete’s foot, ringworm, yeast infections. Adverse Effects: Local irritation. Miconazole (Monistat) Mechanism of Action: Antifungal, some Gram-positive action. Indications: Yeast infections, jock itch, athlete’s foot. Adverse Effects: Burning, itching, pelvic cramps. Antivirals Acyclovir (Zovirax) Mechanism of Action: Inhibits viral DNA replication. Indications: Herpes simplex (HSV-1 & HSV-2), shingles. Adverse Effects: Stinging, rash. Miscellaneous Dermatologics Permethrin (Elimite) Mechanism of Action: Neurotoxic to lice/scabies. Indications: Head lice, scabies. Adverse Effects: Itching, burning. Ophthalmic Medications Cholinergic Drugs (Miotics) Acetylcholine (Miochol-E) Indications: Induces miosis (pupil constriction) during surgery. Adverse Effects: Eye discomfort, blurred vision. Pilocarpine (Pilocar) Mechanism of Action: Stimulates cholinergic receptors, reduces intraocular pressure. Indications: Glaucoma, ocular surgery. Adverse Effects: Blurred vision, tearing, reduced night vision. Beta-Adrenergic Blockers Timolol (Timoptic) Mechanism of Action: Reduces aqueous humor production & increases outflow. Indications: Glaucoma, ocular hypertension. Adverse Effects: Eye irritation, systemic effects possible (bradycardia, hypotension). Otic Medications Ofloxacin (Floxin Otic) Mechanism of Action: Fluoroquinolone antibiotic (bacterial DNA disruption). Indications: Otitis externa & media. Adverse Effects: Mild itching/pain. Carbamide Peroxide (Debrox) Mechanism of Action: Softens & breaks down earwax. Indications: Earwax removal. Adverse Effects: Ear irritation. Nursing Considerations Lifespan Considerations Pediatrics: Infants: Thigh for vaccines, avoid aspirin (Reye’s syndrome risk). Monitor growth with long-term corticosteroids. Pregnancy: Avoid live vaccines (MMR, varicella, HPV, Zoster). Avoid isotretinoin (teratogenic). Elderly: Caution with ophthalmic beta-blockers (can cause systemic effects). Monitor renal function with fluoroquinolones (ototoxicity risk). Patient Teaching Vaccines: Keep records, report reactions. Use Tylenol, not aspirin for fever. Dermatologics: Apply with gloves, wash hands before & after. Sunscreen required with tretinoin & isotretinoin. Ophthalmic/Otic: Apply pressure to inner canthus after eye drops (reduce systemic absorption). Hold ear up & back (adults), down & back (children) for otic drops
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Primary adrenal insufficiency = problem at level of adrenal glands Causes? Addison’s disease Pathophys? Autoimmune destruction of the adrenal glands Associated with hyperpigmentation POMC is precursor to both ACTH and MSH PAI → lack of negative feedback → high ACTH Lab findings? ACTH high Aldosterone low Destruction of zona glomerulosa Renin high Hypotension → RAAS activation Electrolytes Na+ low, K+ high CBC Eosinophils high Pathophys? Glucocorticoids → eosinophil apoptosis. Lack of glucocorticoids cause eosinophilia. Dx? Cosyntropin testing → no rise in cortisol Adrenal glands aren’t working, so no response to ACTH. Tx? prednisone/hydrocortisone/dexamethasone + fludrocortisone (mineralocorticoid) Stress-dose steroids for surgery, serious illness, etc. Secondary adrenal insufficiency = problem at level of pituitary, reduced ACTH release Causes? MC is prolonged steroid use → ACTH suppression Sheehan’s syndrome (infarction of pituitary) pregnancy Pituitary tumors (ACTH-producing tumor) Lab findings? ACTH low Anterior pituitary is being inhibited Aldosterone normal Zona glomerulosa under control of RAAS system Renin normal Electrolytes Na+ & K+ unaffected (Aldosterone levels are normal) CBC Neutrophilia due to demargination (if pt was recently taking steroids) Dx? Cosyntropin testing → rise in cortisol Adrenal gland is functional Tx? Glucocorticoids Do not need to replace mineralocorticoids since adrenals are functional and aldosterone is under RAAS control Stress-dose steroids for surgery, serious illness, etc. AI with a history of nuchal rigidity and purpuric skin lesions → Waterhouse-Friedrichson syndrome Pathophys? AI 2/2 hemorrhagic infarction of the adrenal glands in the context of Neisseria meningitidis infection Adrenal synthesis enzymes If the enzyme starts with 1 → HTN (high mineralocorticoids) and hypokalemia If the second # is 1 → virilization (high androgens) E.g. 11-beta hydroxylase deficiency → HTN & virilization E.g. 21 hydroxylase deficiency → virilization only E.g. 17-alpha hydroxylase deficiency → HTN only B12 deficiency Where does B12 come from? Animal products VS folic from plants Physiology R factor in saliva binds to B12 and protects it from acidity in the stomach. R factor protector -B12 travels to the duodenum. Parietal cells produce intrinsic factor, which travels to the duodenum. Pancreatic enzymes cleave B12 from R factor and B12 then binds IF. B12-IF complex is reabsorbed in the terminal ileum Reabsorption where? Terminal ileum Causes of B12 deficiency Extreme vegan Pernicious anemia Pancreatic enzyme deficiency Cystic Fibrosis Can’t cleave B12 from R factor Crohn’s Affects terminal ileum Lab markers Homocysteine HIGH MethlyManoicAcid HIGH Presentation? Megaloblastic anemia Subacute combined degeneration (of dorsal columns + lateral corticospinal tract) Peripheral neuropathy Dx of pernicious anemia? anti-IF Ab Folate deficiency Where does folate come from? Leafy things Causes of folate deficiency Poor diet (e.g. alcoholics, elderly) Phenytoin Lab markers Homocysteine HIGH MMA normal Presentation? Megaloblastic anemia Prophylaxis in HIV+ patients CD4 < 200 → PCP TMP-SMX, inhaled pentamidine, dapsone, atovaquone CD4 < 100 → Toxoplasm Treat: TMP-SMX CD4 < 50 → MAC Treat: Azithromycin If live in endemic area, CD4 < 250 → Coccidioides Immitis E.g. Arizona, Nevada, Texas, California Treat: Itraconazole If live in endemic area, CD4 < 150 → Histoplasma Capsulatum E.g. Kentucky, Ohio, Missouri Treat: Itraconazole Diabetes insipidus Dx? Water deprivation test Measure serum osmolality & urine osmolality Deprive pt of water Remeasure serum osmolality & urine osmolality If urine osmolality doesn’t go up → suspect DI Central DI → deficiency of ADH Pathophys? Supraoptic nucleus not making enough ADH Dx? Give desmopressin → urine osmolality increases significantly Nephrogenic DI → kidneys are not responding to ADH Dx? Give desmopressin → urine osmolality doesn’t change much Tx? Hydrochlorothiazide Unless 2/2 lithium, use amiloride or triametere Causes? Lithium SSRIs Carbamazepine Demeclocycline Tx of normovolemic hypernatremia? D5W to correct free water deficit Divine says NS, but most other resources I found said correct free water deficit Tx of hypovolemic hypernatremia? Give NS first until normal volume, then give D5W Consequence of correcting hypernatremia too rapidly? Cerebral edema Osteoarthritis Presentation? Old person with joint pain that gets worse throughout the day Risk Factr? Obesity vs decreases osteoporosis Imaging findings? Joint space narrowing Subchondral sclerosis Subchondral cysts Osteophytes Arthrocentesis findings? <2000 cells Tx? 1st line acetaminophen 2nd line NSAID (e.g. naproxen) 3rd line joint replacement surgery Returned from a business conference 1 week ago + Fever + Nonproductive cough + Abdominal pain + Hyponatremia → Legionella Dx? Urine antigen Tx? FQ or macrolide MaCroLide mnemonic = Mycoplasma, Chlamydia, Legionella What are the common causes of atypical PNA? Mycoplasma, Legionella, Chlamydia MC cause? Mycoplasma CXR findings? Interstitial infiltrates HY associations C. Psittaci → birds C. Burnetii → cows, goats, sheet Mycoplasma → college student w/ walking pneumonia Midsystolic click heard best at the apex. → mitral valve prolapse “Stenosnap & Proclick” Risk Factor? Connective tissue disease Marfarn Ehlers-Danlos ADPKD bilateral renal masses Classic demographic? Young woman psychiatric Pathophys? Myxomatous degeneration MVP vs aortic dissection: cystic medial necrosis Exam maneuvers Anything that increase amount of blood in LV → murmur softer Increase preload Increase afterload Anything that decreases amount of blood in LV → murmur louder Dx? Echo Scaly, itchy skin with yellowish crusting in the winter. → seborrheic dermatitis Tx? Topical antifungals e.g. ketoconazole or selenium sulfide shampoo Classic disease distribution? Hair → e.g. cradle cap Eyebrows Episodic/intermittent HTN + HA → pheochromocytoma Genetic disease associations MEN2A MEN2B VHL in brain (hemangioma) NF-1 growth in skin Pathophys? Catecholamine-secreting tumor Location? Adrenal medulla Posterior mediastinum Organ of Zuckerkandl (chromaffin cells along the aorta) Dx? 1st step: urine metanephrines If elevated → CT abdomen If nothing found on CT → MIBG scan Tx? Alpha blocker (e.g. phenoxybenzamine, phenotaline) THEN beta blocker Most common cause of a Lower GI Bleed in the elderly → diverticulosis Dx? Colonoscopy or barium enema Recall that you acutely do a CT scan for diverticulitis, then 6 weeks later colonoscopy to r/o cancer Ppx? Eat fiber Megaloblastic anemias Blood smear findings? Hypersegmented neutrophils MCV > 100 Classic patient demographic with folate deficiency? Alcoholics Elderly person with poor nutrition Folate synthesis inhibitors Pt with molar pregnancy → methotrexate Pulmonary issue? Pulmonary fibrosis HIV+ pt with ring-enhancing lesions → pyrimethamine-sulfadiazine Pyrimethamine inhibits DHFR AIDS pt on ppx for toxo → TMP-SMX TMP inhibits DHFR Use of leucovorin? Rescue bone marrow in setting of methotrexate toxicity Mechanism? Folinic acid analog CMV presentations Esophagitis → linear ulcers Colitis → post-transplant pt Retinitis → HIV pt with CD4 < 50 Congenital CMV → periventricular calcifications + hearing loss calcifications elsewhere → toxo Histology? Owl’s eye intranuclear inclusions Tx? Gancicyclovir Resistance? UL97 kinase mutation Tx for resistance? foscarnet CD4 < 200 + severe peripheral edema + frothy urine. → FSGS in HIV pt Variant classic in HIV+ pts? Collapsing variant Tx? Steroids + cyclophosphamide + ACE-I Indinavir AE? Kidney stones triad of fever, rash, and eosinophiluria → acute interstitial nephritis Drugs cause? Penicillins Tx? Stop the drug! Can add steroids if severe Vitamin D metabolism Liver converts Vit D to calcidiol (25OH-Vit D). Calcidiol goes to kidney. Alpha-1 hydroxylase converts calcidiol to calcitriol (1,25-OH Vit D). Common causes of Vitamin D deficiency CKD → 1-alpha hydroxyalse deficiency Liver disease → can’t make calcidiol CF → malabsorption Crohn’s → malabsorption Osteomalacia vs Rickets Osteomalacia in adults Rickets in kids Tx? Calcium + vit D Lab findings? Ca++ low Phos low Low in liver disease High in kidney disease (kidneys can’t get rid of phos) PTH high (2ary hyperpara) vs liver dx PTH low Alk phos Aspiration pneumonia Risk Factor? Alcoholism Dementia Neuromuscular problems (e.g. MG, ALS) Bugs? Anaerobes foul smelling Bacteroides FUsobacterium Peptostreptococcus Klebsiella → currant jelly sputum alcoholic Tx? Clindamycin CURB-65 criteria Purpose? Who to admit Cutoff? 2+ → hospitalize C = confusion U = uremia (BUN > 20) R = RR > 30 B = BP < 90/60 Age > 65 Drugs commonly used in PNA treatment Ceftriaxone Levofloxacin fluoroquinolone Macrolides - great for atypical PNA Pharmacological management of pulmonary arterial HTN Endothelin antagonists Bosentan ambrisentan PDE-5 inhibitors Sildenafil Tadalafil Prostacyclin analogs Iloprost Epoprostenol Treprostinil Causes? Young female → idiopathic PAH Mutation? BMPR2 55 yo F presents with a 5 week history of a rash on her forehead. PE reveals scaly macules with a sandpaper texture. → actinic keratosis Risk Factor? Sun exposure Tx? Topical 5-FU Possible dangerous sequelae? Squamous cell carcinoma Most likely disease sequelae? Resolution 1ary hyperparathyroidism 2ary hyperparathyroidism 3ary hyperparathyroidism Autonomous PTH production Causes? Adenoma Parathyroid hyperplasia PTH high Ca++ high Phos low Low Ca++ → PTH production Causes? CKD PTH high Ca++ low Phos high PTH production despite normalized of Ca++ levels Causes? CKD s/p transplant PTH high Ca++ high Phos low Tx? Parathyroidectomy (remove 3.5 glands) Cinacalcet (CSR modulator) Hypercalcemia Presentation? bones, stones, groans, psychic overtones Tx? 1st step: Normal Saline Hypercalcemia of malignancy → bisphosphonates EKG finding? Shortened QT Periumbilical pain that migrates to the right lower quadrant. → appendicitis PE findings? McBurney’s point tenderness Psoas sign (flex hip pain) Obturator sign (pain with internal rotation of hip) Rovsing’s sign (palpation of LLQ → pain in RLQ) Dx? CT scan Pregnant → US Kid → US Tx? Surgery Classic drug and viral causes of aplastic anemia. Drugs? Carbamazepine Chloramphenicol Viral? Parvovirus B19 (single stranded DNA virus) Fanconi anemia Pathophys? Problems with DNA repair Fanconi anemia vs Fanconi syndrome Fanconi anemia → cytopenias + thumb anomalies + short stature + cafe-au-lait spots Fanconi syndrome → type 2 RTA (proximal) CD4 count of 94 + MRI revealing ring enhancing lesions in the cortex → toxoplasmosis Tx? Pyrimethamine-sulfadiazine Rescue agent for pt who becomes leukopenic with treatment? leucovorin Who should get steroids? Increased ICP For PCP pneumonia: O2 sat < 92 PaO2 < 70 A-a gradient > 35 Ppx? TMP-SMX for CD4 < 100 Congenital toxo Hydrocephalus Chorioretinitis Intracranial calcifications Classic methods of transmission? handling cat litter Lupus nephritis Associated autoantibody? anti-dsDNA Classic “immunologic” description? “Full house” pattern Tx? Steroids + cyclophosphamide Osteoporosis Screening population? women > 65 Screening modality? DEXA scan Dx? T-score < -2.5 Risk Factor? Postmenopauseal Low BMI Smoking Alcohol Preventive strategies? Weight bearing exercise Smoking cessation Reduce alcohol consumption Tx? 1st line: bisphosphonates + Ca/Vit D supplementation Raloxifene (SERM) Agonist in bone Blocker Antagonist in breast Classic locations of osteoporotic fractures Vertebral compression fracture Hip fracture Name the PNA Red currant jelly sputum. → Klebsiella Rust colored sputum. → Strep pneumo PNA in an alcoholic. → Klebsiella Post viral PNA with a cavitary CXR lesion. → Staph aureus PNA in a patient that has chronically been on a ventilator. → Pseudomonas MC cause of Community Acquired Pneumonia. → Strep pneumo Pharmacological management of MRSA. Vancomycin Clindamycin Linezolid Ceftaroline (5th gen cephalosporin) Tigecycline, tertracycline Pharmacological management of Pseudomonas. Ceftazidime (only 3rd gen cephalosporin) Cefepime (4th gen cephalosporin) Pip-tazo Fluoroquinolones Carbapenems Aztreonam Aminoglycosides JVD and exercise intolerance in a patient with a recent history of an URI. → dilated cardiomyopathy 2/2 viral myocarditis MC cause? Coxsackie B VS Coxsackie A: Hand foot mouth dx Drug causes myocarditis Clozapine Anthracyclines Prevention? Dexrazoxane (iron chelator) Trastuzumab reversible tx for breast cancer Classic cause in a patient with recent history of travel to S. America? Chagas T. Cruzi Potential sequelae? Achalasia Dilated cardiomyopathy Megacolon (2/2 degeneration of myenteric plexus) Massive skin sloughing (45% BSA) in a patient that was recently started on a gout medication? TEN Dx? <10% BSA → SJS >30% BSA → TEN Tx? STOP the drug IVF Topical abx to prevention infection Tetany and a prolonged QT interval in a patient with recent surgical treatment of follicular thyroid carcinoma. → hypocalcemia due to removal of parathyroids Recurrent viral infections + QT prolongation + tetany → DiGeorge syndrome Pathophys? Failure of development of 3rd/4th pharyngeal pouches Trousseau and Chvostek signs. Trousseau → inflation of BP cuff causes carpopedal spasm Chvostek → taping on cheek causes facial muscle spasm Hypocalcemia that is refractory to repletion → consider hypomagnesemia Electrolyte/drug causes of prolonged QT intervals Electrolytes? Hypocalcemia Hypomagnesemia Hypokalemia Drugs? Macrolides FloroQunlones Haloperidol Ondensatron Methadone Hypoalbuminemia and Ca balance Hypoalbumenia → decrease in total body Ca++, no change in ionized Ca++ Drop of 1 in albumin → add 0.8 to Ca++ Abdominal pain radiating to the back → acute pancreatitis Causes? #1 = Gallstones #2 = Alcohol Hypertriglyceridemia Hypercalcemia Scorpion sting Handlebar injuries Lab markers? Lipase - most sensitive Amylase Physical exam signs in pancreatitis. Cullen’s sign = periumbilical ecchymosis Grey Turner sign = flank ecchymosis Tx? NPO + IVF + pain control Meperidine is a good agent because it doesn’t cause sphincter of Oddi spasms Management of gallstone pancreatitis Dx? US then ERCP Tx? DELAYED cholecystectomy What if the patient becomes severely hypoxic with a CXR revealing a “white out” lung? ARDS noncardiogenic pulm edema PCWP? <18 mmHg NORMAL 20 yo M with red urine in the morning + hepatic vein thrombosis + CBC findings of hemolytic anemia. → paroxysmal nocturnal hemoglobinuria Pathophys? Defect in GPI anchors, which attach CD55 and CD59 to cell (they prevent complement from destroying RBC) Sleep → hypoventilation → mild respiratory acidosis → activation of complement cascade Gene mutation? PIGA Dx? Flow cytometry Tx? Eculizumab (terminal complement inhibitor) Vaccine required? pnemococal Neisseria meningitidis Chronic diarrhea and malabsorption in a HIV+ patient + detection of acid fast oocysts in stool. → cryptosporidium parvum Acid-fast organisms Cryptosporidium TB MAC Nocardia Dx? Stool O&P Tx? Nitazoxanide Route of transmission? Contaminated water Muddy brown casts on urinalysis in a patient with recent CT contrast administration (or Gentamicin administration for a life threatening gram -ve infection) → Acute Tubular Necrosis Woman with morning joint stiffness > 1 hr → Rhematoid Arthritis. Antibodies? Rheum Factor (IgM against IgG) anti-CCP - more specific HLA? DR4 Pathophys? IgM constant region activates complement → inflammation → formation of pannus (hypertrophied synovium) → damage to cartilage and bone Caplan syndrome = RA + pneumoconiosis Felty syndrome = RA + neutropenia + splenomegaly (“RANS”) Classic hand/finger findings/distribution? MCP & PIP joints of hands (DIP joints spared) Imaging findings? Symmetric joint space narrowing Tx? Methotrexate (DMARDs) If no response → TNF alpha inhibitor (e.g. infliximab) Required testing prior to starting methotrexate? PFTs Required testing prior to starting infliximab? TB Hep B/Hep C Differentiating Strep pharyngitis from Infectious Mononucleosis LND distribution Anterior cervical → Strep Posterior cervical → Mono Disease onset Acute → Strep Over weeks → Mono Organ involvement Splenomegaly → Mono Pt with sore throat takes amoxicillin and gets rash → mono NOT allergic rxn! CENTOR criteria C = absence of Cough E = tonsillar Exudates N = nodes/anterior cervical lymphadenopathy T = temp (fever) OR <15 → +1 >=45 → -1 Using CENTOR score 0/1 → don’t test, don’t treat 2/3 → rapid antigen test Positive → treat Negative → throat culture 4/5 → treat empirically Tx of Strep pharyngitis? Amoxillcin If PCN allergic → azithromycin Potential sequelae of Strep pharyngitis RF - preventable with abx PSGN Endocarditis MC cause of endocarditis? IVDU Bug? Staph aureus Valve? tricuspid Prosthetic valve endocarditis Bug? Staph epidermidis Endocarditis after dental procedure? Viridans group streptococci Strep viridans, Strep mitis, Strep mutans, Strep sanguineous Patient with malar rash and echo showing vegetations on both sides of the mitral valve → Libman-Sacks endocarditis Presentation? Fever + night sweats + new murmur Splinter hemorrhages Roth spots (retinal hemorrhages) Painless Janeway lesions + painful Osler nodes (immune phenomenon) Dx? 1st step: blood cultures TEE Tx? Abx that include Staph aureus coverage (e.g. vancomycin) for WEEKS Bugs implicated in culture negative endocarditis HACEK H = haemophilus A = actinobacillus C = cardiobacterium E = eikenella K = kingella Coxiella burnetii Blood cultures in a patient with endocarditis reveal S. Bovis (or S. Gallolyticus bacteremia). NBS? Colonoscopy Who needs antibiotic prophylaxis? Hx endocarditis Prosthetic valve Unrepaired cyanotic congenital dz Heart transplant with valve dysfunction Erythematous salmon colored patch with silvery scale on the elbows and knees. → psoriasis Tx? Topical steroids If this patient presents with joint pain (especially in the fingers)? Psoriatic arthritis Imaging? Pencil-and-cup deformity Tx? NSAIDs T of 104 + tachycardia + new onset Afib in a patient with a history of Graves disease. → thyroid storm Lab findings? TSH low T3/T4 high Tx? 1st step: propranolol 2nd step: PTU Then: Prednisone Potassium iodide (Lugul’s solution) Wolff-Chaikoff effect → large amounts of iodine inhibit thyroid hormone synthesis Biopsy revealing tennis racket shaped structures in cells of immune origin. → Langerhans cell histiocytosis Electron microscopy? Birbeck granules (tennis rackets) Marker? S100 Small bowel obstruction in a HIV patient with purple macules on the face, arms, and lower extremities. → Kaposi’s sarcoma Bug? HHV8 Tx? HAART Pathophys of vascular lesions? Overexpression of VEGF Fever + rash + eosinophiluria 10 days after a patient started an antistaphylococcal penicillin. → acute interstitial nephritis Tx? STOP drug + steroids SLE SOAP BRAIN MD S = serositis O = oral ulcers A = arthritis P = photosensitivity B = blood disorders (cytopenias) R = renal A = ANA/anti-dsDNA I = immunologic N = neurologic findings M = malar rash D = discoid rash Type 2 vs 3 HSRs in lupus Type 2 → cytopenias Type 3 → all other manifestations Lupus Ab? ANA anti-dsDNA anti-Smith Lupus nephritis → full house pattern on IF Antiphospholipid antibody syndrome → recurrent pregnancy losses Pathophys? Thrombosis of the uteroplacental arteries. MC cause of death in lupus patients? What I’ve read recently: CV disease Per Divine: Treated → infection Untreated → renal dz Also 40x risk MI Endocarditis in lupus pt? Libman-Sacks endocarditis Neonatal 3rd degree heart block → neonatal lupus Maternal autoimmune dz? Sjogren’s SLE Ab? anti-SSA/anti-Ro anti-SSB/anti-La Tx? Steroids Cyclophosphamide Hydroxychloroquine → good for skin lesions Pulmonary abscesses Bugs? Staph Anaerobes Klebsiella RF? Alcoholism Elderly Post-viral pneumonia MC location of aspiration pneumonia? Superior segment of RLL Chest pain worsened by deep inspiration and relieved by sitting up in a patient with a recent MI or elevated creatinine or URI or RA/SLE. → pericarditis EKG findings? Diffuse ST elevations + PR depression PE finding? Friction rub (“scratchy sound on auscultation”) A few days after MI → fibrinous pericarditis Weeks after MI → Dressler’s Tx? NSAIDS Consider adding on colchicine Cardiac tamponade Beck’s triad = hypotension + JVD + muffled heart sounds EKG findings? Electrical alternans Type of shock? Obstructive cardiogenic (Amboss) CO low SVR high PCWP high Tx? Pericardiocentesis or pericardial Pearly lesion with telangiectasias on the ear in a farmer. → Basal Cell Carcinoma MC type skin cancer Location? Upper lip Dx? Biopsy Tx? Mohs surgery Cold intolerance in a 35 yo white F → hypothyroidism MC cause? Hashimoto’s Histology? lymphoid follicles w/ active germinal centers Lab findings? TSH high T3/T4 low Ab? anti-TPO Anti-thyroglobulin HLA? DR3/DR5 Tx? Levothyroxine Future complication? thyroid lymphoma Massive hematemesis in a patient with a history of chronic liver disease. → ruptured varices Pathophys? L gastric vein has anastomosis with azygos veins. Increased portal pressure → backward flow from L gastric veins to azygous vein (which empties into SVC). Acute tx? IVF + octreotide + ceftriaxone/cipro + EGD w/ ligation/banding Do NOT give a beta blocker for acute tx Prophalaxsis? Beta blocker + spironolactone Other manifestations of elevated portal pressures Caput medusa Internal hemorrhoids Tx for cirrhotic coagulopathies? FFP If uremia → give desmopressin Note: Desmopressin = ADH analog → so, it can cause AE of hyponatremia 2/2 SIADH Hemophilia A Pathophys? deficiency of factor 8 Inheritance? XLR Coag labs? Bleeding time normal PTT HIGH b/c clotting problem PT normal Hemophilia B Pathophys? deficiency of factor 9 Inheritance? XLR Coag labs? Bleeding time normal PTT HIGH PT normal Hemophilia C Pathophys? deficiency of factor 11 Inheritance? AR Coag labs? Bleeding time normal PTT HIGH PT normal Bernard Soulier Syndrome Pathophys? Deficiency of GpIb Coag labs? Bleeding time HIGH PTT normal PT normal Glanzmann Thrombasthenia Pathophys? Deficiency of GpIIbIIIa Coag labs? Bleeding time HIGH PTT normal PT normal Von Willebrand’s disease Pathophys? Deficiency of vWF Inheritance? AD Coag labs? Bleeding time HIGH PTT HIGH vWF is a protecting group for factor 8 PT normal ITP Pathophys? Ab against GpIIbIIIa Classic pt? Pt with SLE Tx? Observation Steroids IVIG Splenectomy TTP Pathophys? Deficiency in ADAMTS13 enzyme → cannot cleave vWF multimers → activation of platelets → thrombosis → thrombocytopenia Presentation? microangiopathic hemolytic anemia + thrombocytopenia + renal failure + fever + neurologic problems Tx? Plasma exchange transfusion****** HUS Bugs? Shigella or E. coli O157:H7 Presentation? Fever+ microangiopathic hemolytic anemia + thrombocytopenia + renal failure + neurologic Platelet deficiency vs coagulation factor bleeds Platelet deficiency → mucosal bleeds, petechiae, heavy menses Coag factor deficiency bleeds → hemarthrosis Why do patients with CKD develop coagulopathy? Uremia → platelet dysfunction Tx? Desmopressin Note: Desmopressin = ADH analog → so, it can cause AE of hyponatremia 2/2 SIADH Exercising caution with transfusion in patients with Bernard Soulier syndrome Do NOT give transfusion that includes platelets They can have an anaphylactic rxn to GpIb (since they don’t have GpIb) Oropharyngeal candidiasis. RF? HIV Chronic ICS use TNF inhibitor Micro finding? Germ tubes at 37 C Tx oral candidiasis? Nystatin swish-and-swallow Tx invasive candidiasis? Amphotericin B Prevention of Amphotericin B toxicity? Liposomal formulation Pleural effusions Light’s criteria (must meet all 3 to be considered transudative!) LDH < 2/3 ULN LOW Pleural LDH/serum LDH < 0.6 LOW Pleural protein/serum protein < 0.5 LOW Causes of transudative effusion CHF Cirrhosis Nephrotic syndrome Note: Per UW 2021: Mechanism of transudate effusion? Decreased pulmonary artery oncotic pressure, e.g. hypoalbuminemia in nephrotic syndrome Increased pulmonary capillary hydrostatic pressure, e.g. volume overload in heart failure Causes of exudative effusion Malignancy Cancer Parapneumonic effusion Tb Note: Per UW 2021: Mechanism of exudate effusion? Inflammatory increased in vascular permeability of membrane (increased flow of interstitial edema into pleural space) Unique cause of both transudative & exudative effusions? PE Classic Pleural Effusion findings? Decreased breath sounds Dullness to percussion Decreased tactile fremitus Tx? Chest tube Chylothorax = lymph in the pleural space Pathophys? Obstruction of thoracic duct or injury to the thoracic duct Pleural fluid findings? High Triglycerides Holosystolic murmur heard best at the apex with radiation to the axilla in a patient with a recent MI. → mitral regurg 2/2 papillary muscle rupture Dx? Echo Why widely split S2? Aortic valve is closing earlier (LV is emptying into both aorta & LA) Maneuvers that increase intensity Increase preload (putting more blood in that can be regurgitated) Increase afterload Decubitus ulcers RF? Elderly Paraplegic Fecal/urinary incontinence Poor nutrition Staging Stage 1 = non-blanchable erythema Tx? Repositioning q2hrs Stage 2 = loss of epidermis + partial loss of dermis Tx? Occlusive dressing superficial Stage 3 = involves entire dermis, extending to subQ fat Does NOT extend past fascia Tx? Surgical debridement Stage 4 = muscle/tendon/bose exposed Tx? Surgical debridement General tx strategies? Repositioning + good nutritional support Marjolin’s ulcer = non-healing wound that is actually squamous cell carcinoma T1DM Pathophys? Autoimmune destruction of pancreas Ab? anti-GAD 65 (glutamic acid decarboxylase) anti-IA2 (islet tyrosine phosphatase 2) Islet cell autoantibodies Insulin autoantibodies Dx? A1c > 6.5% (twice) Fasting BG >= 126 (twice) Oral glucose tolerance test >= 200 (twice) Sxs of DM + random glucose > 200 Tx? Long-acting insulin + mealtime insulin Long-acting Glargine Detemir Rapid-acting Lispro Aspart Glulisine 3 HY complications Nephropathy Retinopathy & cataracts Neuropathy Chronic DM care A1c q3 months Foot exam annually Eye exam annually Microalbumin:Cr ratio annually Nephroprotection in DM? ACE-I GI bleed algorithm 1st step: ABCs + 2 large-bore IVs + IVFs 2nd step: NG lavage Clear fluid → go deeper Blood → UGIB → upper endoscopy Bilious fluid → have ruled out UGIB → proceed to colonoscopy See source → intervene as needed See nothing → CT angiography for large bleed Tagged RBC scan for smaller bleed Antiplatelet Pharmacology Aspirin Mechanism? Irreversibly inhibits COX-1 and COX-2 Clopidogrel/ticlopidine = P2Y12 (ADP receptor) blockers Mechanism? Inhibit platelet activation Abciximab/eptifibatide/tirofiban = GpIIbIIIa receptor blockers Mechanism? Inhibit platelet aggregation Ristocetin cofactor assay Issues with adhesion step → abnormal result Abnormal ristocetin cofactor assays: Von Willebrand disease Bernard Soulier disease Normal ristocetin cofactor assay: Glanzmann Thrombasthenia Von Willebrand disease effects on PTT? Increased Pathophys? vWF is a protecting group for Factor 8. Treatment of VWD? Desmopressin Mechanism? Increases release of vWF from Weibel-Palade bodies of endothelial cells Note: Desmopressin = ADH analog → so, it can cause AE of hyponatremia 2/2 SIADH HSV1 vs HSV2. Oral herpes → HSV1 Genital herpes → HSV2 Dx? PCR (most up-to-date) Tzanck smear (outdated, not very sensitive, nonspecific) → intranuclear inclusions Brain area affected by HSV encephalitis? Temporal lobes CSF findings in HSV encephalitis? RBCs******* Tx herpes encephalitis? Acyclovir AE? Crystal nephropathy Can’t see, can’t pee, can’t climb a tree. → reactive arthritis HLA? B27 Classic bug? Chlamydia Tx? steroids Need abx? Only if ongoing infection Can’t see, can’t pee, can’t hear a bee → Alport syndrome Inheritance? X-linked dominant Tx of NG & CT NG → treat empirically for both → ceftriaxone + azithro/doxy CT → azithro/doxy Hypovolemic Septic Neurogenic Cardiogenic CO low PCWP low SVR high*** CO high PCWP normal SVR low Tx? norepi CO low SVR low CO low PCWP high*** SVR high*** Tx anaphylactic shock? epinephrine Melanomas ABCDE A = asymmetry B = irregular borders C = color variation D = diameter > 6 mm E = evolving Dx? Full-thickness biopsy Excisional for small lesions Punch for larger lesions Most important prognostic factor → Breslow depth DM pharmacology Lactic acidosis → metformin Decreases hepatic gluconeogenesis → metformin Hold before CT w/ contrast → metformin Weight gain → sulfonylureas & TZDs (-glitizones) Diarrhea → acarbose & migliton Inhibits disaccharidases (can’t reabsorb disaccharides) Recurrent UTIs → SGLT-2 inhibitors Weight loss → GLP-1 agonists (e.g. liraglutide, exenatide) & DPP4 inhibitors (-gliptins) Contraindicated in pt with HF → TZDs PPAR-gamma receptor found in kidney → water retention Contraindication in pt with MTC → GLP-1 agonists Biggest risk of hypoglycemia? Sulfonylureas RF esophageal adenocarcinoma Barrett’s esophagus RF esophageal squamous cell carcinoma Smoking Drinking Achalasia Location esophageal adenocarcinoma? Lower 1/3 Location esophageal squamous cell carcinoma? Upper 2/3 MC US? Adenocarcinoma MC worldwide? Squamous cell carcinoma Presentation? Dysphagia to solids → dysphagia to liquids Dx? EGD Staging? CT scan or esophageal US Factor V Leiden Pathophys? Resistance to protein C Dx? Activated Protein C resistance assay Patient needs super large doses of heparin to record any changes in PTT → AT-III deficiency Recall that heparin is a AT-III activator 35 yo with a hypercoagulable disorder that does not correct with mixing studies. → antiphospholipid antibody disorder Anaphylaxis in a patient with a long history of Hemophilia A → Ab against factor 8 that cause type 1 HSR with transfusion Hx of hemophilia, diagnosed 5 years ago. Before you would give them factor 8 concentrate and PTT would normalize. Now they’re requirizing larger doses of factor 8 to normalize PTT. → inhibitor formation (antibodies against clotting factors) Skin necrosis with Warfarin → protein C/S deficiency Prothrombin G20210 mutation → overproduction of factor II Rash in dermatomal distribution → VZV infection Contraindications to VZV vaccination? Pregnant woman Kid < 1 year Severe immunosuppression (e.g. HIV with CD4 < 200) Tx? Acyclovir If resistant, foscarnet Tzanck smear findings? Intranuclear inclusions Shingles vaccination guidelines? Adults over 60 #1 cause of ESRD in the US → DM nephropathy Histology? Kimmelsteil-Wilson nodules #2 cause of ESRD in the US → hypertensive nephropathy Pt with BP 240/150. How fast should you lower BP? 25% in first 24 hrs Drugs for hypertensive emergencies? Nicardipine Clevidipine Nitroprusside AE? Cyanide poisoning Tx? Amyl nitrate + thiosulfate OR hydroxocobalamin Labelol Renal protective medications in patients with DKD or hypertensive nephropathy? ACE-I Anemia + Cranial Nerve deficits + Thick bones + Carbonic Anhydrase 2 deficiency + Increased TRAP + Increased Alkaline Phosphatase. → osteopetrosis Pathophys? Carbonic anhydrase is defective → osteoclasts cannot produce acid to resorb bone Tx? IFN-gamma Osteoclasts are a specialized macrophage IFN-gamma is an activator of macrophages Clinical diagnostic criteria for Chronic Bronchitis Diagnostic criteria? 2 years 3 months/year of chronic cough PFT findings FEV1 low FEV1/FVC ratio low RV high TLC high Which PFT market can differentiate CB from emphysema? DLCO DLCO normal → CB DLCO low → emphysema ****** Tx acute exacerbation? Abx + bronchodilators + corticosteroids (“ABCs”) Prevention? Stop smoking! Afib #1 RF? Mitral stenosis #1 RF MS? Rheumatic fever #1 RF CAD and AAA: smoking #1 RF stroke and aortic dissection: HTN MC arrhythmia in hyperthyroidism → Afib MC site of ectopic foci in Afib → pulmonary veins EKG findings? “Irregularly irregular” + no P waves Location of emboli formation? LA appendage Who should be cardioverted back to sinus rhythm? New onset (<48 hrs) Afib Anticoagulated for 3 weeks + TEE negative for clot Afib that’s refractory to medical therapy Afib & HDUS Q on T phenomenon? Depolarization during T wave (repolarization) can cause QT prolongation → Torsades → death Prevention? SYNCHRONIZED cardioversion Tx? Rate control Beta blockers ND-CCB (e.g. verapamil, diltiazem) Rhythmic control Amiodarone Reducing stroke risk in Afib? Anticoagulation for CHA2DS2VASc score >= 2 Anticoagulation options Valvular cause (e.g. MS) → warfarin Any other cause → warfarin or NOAC (apixiban) Reversal of AC Warfarin → Vit K, four-factor PCC Heparin → protamine sulfate Dabigatran → idarucizumab Crusty, scaly, ulcerating lesion with heaped up borders → squamous cell carcinoma Classic location? Below Lower lip Precursor lesion? Actinic keratosis What if it arises in a scar or chronic wound? Marjolin ulcer Hypothermia + hypercapnia + non pitting edema + hyponatremia + HR of 35 + hypotension in a patient with a history of papillary thyroid cancer → myxedema coma Tx? Levothyroxine + steroids Lab findings? TSH high T3/T4 low LDL high Acute onset “dermatologic” breakout in a patient with a recent history of weight loss and epigastric pain. → Leser–Trélat sign associated with visceral malignancy pancreatic cancer Lymph node associations Supraclavicular → Virchow’s node Periumbilical → Sister Mary Joseph What are mets to the ovaries called? Kruckenberg tumor Classic bug associated with gastric cancer? H. pylori (MALToma) Classic histological finding in the diffuse type of gastric cancer? Signet ring cells RBCs without central pallor + elevated MCHC + anemia. → hereditary spherocytosis Inheritance? AD Pathophys? Deficiency of spectrin, ankyrin, or band 3.2 Intravascular or extravascular hemolysis? Extravascular (RBCs bound by IgG, attacked by splenic macrophages) Dx? Osmotic fragility test Eosin-5-maleimide Acidified glycerol lysis test Tx? Splenectomy Post-splenectomy preventative care? Strep pneumo Hinflue vaccine Neisseria Septic shock Hemodynamic parameters CO high SVR low PCWP normal MvO2 high Tx? IVF + norepi + broad-spectrum abx (cover MRSA + Pseudomonas) E.g. vanc + pip-tazo E.g
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It was no ordinary Sunday morning when presidential candidate Barack Obama stepped to the podium at the Apostolic Church of God in Chicago. It was Father’s Day. Hundreds of enthusiastic con- gregants packed the pews at the overwhelmingly black church eager to hear what the first black Democratic nominee for president of the United States had to say. The message was a familiar one: black men should be better fathers. Too many are absent from their homes. For those in the audience, Obama’s speech was an old tune sung by an exciting new perform- er. His message of personal responsibility, particularly as it relates to fatherhood, was anything but new; it had been delivered countless times by black ministers in churches across America. The message had also been delivered on a national stage by celebrities such as Bill Cosby and Sidney Poitier. And the message had been delivered with great pas- sion by Louis Farrakhan, who more than a decade earlier summoned one million black men to Washington, DC, for a day of “atonement” and recommitment to their families and communities. The mainstream media, however, treated the event as big news, and many pundits seemed surprised that the black congregants actually applauded the message. For them, it was remarkable that black people nodded in approval when Obama said: “If we are honest with our- selves, we’ll admit that too many fathers are missing—missing from Alexander, M. (2010). The new jim crow : Mass incarceration in the age of colorblindness. New Press, The. Created from towson on 2025-01-28 20:58:43. 222 T HE N E W J IM C ROW Copyright © 2010. New Press, The. All rights reserved. too many lives and too many homes. Too many fathers are MIA. Too many fathers are AWOL. They have abandoned their responsibilities. They’re acting like boys instead of men. And the foundations of our families are weaker because of it. You and I know this is true every- where, but nowhere is this more true than in the African American community.” The media did not ask—and Obama did not tell—where the missing fathers might be found. The following day, social critic and sociologist Michael Eric Dyson published a critique of Obama’s speech in Time magazine. He pointed out that the stereotype of black men being poor fathers may well be false. Research by Boston College social psychologist Rebekah Levine Coley found that black fathers not living at home are more likely to keep in contact with their children than fathers of any other ethnic or racial group. Dyson chided Obama for evoking a black stereotype for political gain, pointing out that “Obama’s words may have been spoken to black folk, but they were aimed at those whites still on the fence about whom to send to the White House.”1 Dyson’s critique was a fair one, but like other media commentators, he remained silent about where all the absent black fathers could be found. He identi- fied numerous social problems plaguing black families, such as high levels of unemployment, discriminatory mortgage practices, and the gutting of early-childhood learning programs. Not a word was said about prisons. The public discourse regarding “missing black fathers” closely par- allels the debate about the lack of eligible black men for marriage. The majority of black women are unmarried today, including 70 percent of professional black women.2 “Where have all the black men gone?” is a common refrain heard among black women frustrated in their efforts to find life partners. The sense that black men have disappeared is rooted in reality. The U.S. Census Bureau reported in 2002 that there are nearly 3 million Alexander, M. (2010). The new jim crow : Mass incarceration in the age of colorblindness. New Press, The. Created from towson on 2025-01-28 20:58:43. Copyright © 2010. New Press, The. All rights reserved. T HE N E W J IM C ROW 223 more black adult women than men in black communities across the United States, a gender gap of 26 percent.3 In many urban areas, the gap is far worse, rising to more than 37 percent in places like New York City. The comparable disparity for whites in the United States is 8 percent.4 Although a million black men can be found in prisons and jails, public acknowledgment of the role of the criminal justice system in “disappearing” black men is surprisingly rare. Even in the black media—which is generally more willing to raise and tackle issues related to criminal justice—an eerie silence can often be found.5 Ebony magazine, for example, ran an article in December 2006 enti- tled “Where Have the Black Men Gone?” The author posed the popular question but never answered it.6 He suggested we will find our black men when we rediscover God, family, and self-respect. A more cynical approach was taken by Tyra Banks, the popular talk show host, who devoted a show in May 2008 to the recurring question, “Where Have All the Good Black Men Gone?” She wondered aloud whether black women are unable to find “good black men” because too many of them are gay or dating white women. No mention was made of the War on Drugs or mass incarceration. The fact that Barack Obama can give a speech on Father’s Day dedi- cated to the subject of fathers who are “AWOL” without ever acknowl- edging that the majority of young black men in many large urban areas are currently under the control of the criminal justice system is dis- turbing, to say the least. What is more problematic, though, is that hardly anyone in the mainstream media noticed the oversight. One might not expect serious analysis from Tyra Banks, but shouldn’t we expect a bit more from The New York Times and CNN? Hundreds of thousands of black men are unable to be good fathers for their chil- dren, not because of a lack of commitment or desire but because they are warehoused in prisons, locked in cages. They did not walk out on their families voluntarily; they were taken away in handcuffs, often due to a massive federal program known as the War on Drugs. Alexander, M. (2010). The new jim crow : Mass incarceration in the age of colorblindness. New Press, The. Created from towson on 2025-01-28 20:58:43. Copyright © 2010. New Press, The. All rights reserved. 22 4 T HE N E W J IM C ROW More African American adults are under correctional control today—in prison or jail, on probation or parole—than were enslaved in 1850, a decade before the Civil War began.7 The mass incarceration of people of color is a big part of the reason that a black child born today is less likely to be raised by both parents than a black child born during slavery.8 The absence of black fathers from families across America is not simply a function of laziness, immaturity, or too much time watching Sports Center. Thousands of black men have disap- peared into prisons and jails, locked away for drug crimes that are largely ignored when committed by whites. The clock has been turned back on racial progress in America, though scarcely anyone seems to notice. All eyes are fixed on people like Barack Obama and Oprah Winfrey, who have defied the odds and risen to power, fame, and fortune. For those left behind, especially those within prison walls, the celebration of racial triumph in America must seem a tad premature. More black men are imprisoned today than at any other moment in our nation’s history. More are disenfran- chised today than in 1870, the year the Fifteenth Amendment was rati- fied prohibiting laws that explicitly deny the right to vote on the basis of race.9 Young black men today may be just as likely to suffer dis- crimination in employment, housing, public benefits, and jury service as a black man in the Jim Crow era—discrimination that is perfectly legal, because it is based on one’s criminal record. This is the new normal, the new racial equilibrium. The launching of the War on Drugs and the initial construction of the new system required the expenditure of tremendous political initiative and resources. Media campaigns were waged; politicians blasted “soft” judges and enacted harsh sentencing laws; poor people of color were vilified. The system now, however, requires very little maintenance or justification. In fact, if you are white and middle class, you might not even realize the drug war is still going on. Most high school and college students today have no recollection of the political Alexander, M. (2010). The new jim crow : Mass incarceration in the age of colorblindness. New Press, The. Created from towson on 2025-01-28 20:58:43. T HE N E W J IM C ROW 225 and media frenzy surrounding the drug war in the early years. They were young children when the war was declared, or not even born yet. Crack is out; terrorism is in. Today, the political fanfare and the vehement, racialized rhetoric regarding crime and drugs are no longer necessary. Mass incarceration has been normalized, and all of the racial stereotypes and assumptions that gave rise to the system are now embraced (or at least internalized) by people of all colors, from all walks of life, and in every major politi- cal party. We may wonder aloud, “where have the black men gone?” but deep down we already know. It is simply taken for granted that, in cities like Baltimore and Chicago, the vast majority of young black men are currently under the control of the criminal justice system or branded criminals for life. This extraordinary circumstance— unheard of in the rest of the world—is treated here in America as a basic fact of life, as normal as separate water fountains were just a half century ago. Copyright © 2010. New Press, The. All rights reserved. States of Denial The claim that we really know where all the black men have gone may inspire considerable doubt. If we know, why do we feign ignorance? Could it be that most people really don’t know? Is it possible that the roundup, lockdown, and exclusion of black men en masse from the body politic has occurred largely unnoticed? The answer is yes and no. Much has been written about the ways in which people manage to deny, even to themselves, that extraordinary atrocities, racial oppres- sion, and other forms of human suffering have occurred or are occur- ring. Criminologist Stanley Cohen wrote perhaps the most important book on the subject, States of Denial. The book examines how individ- uals and institutions—victims, perpetrators, and bystanders—know about yet deny the occurrence of oppressive acts. They see only what they want to see and wear blinders to avoid seeing the rest. This has Alexander, M. (2010). The new jim crow : Mass incarceration in the age of colorblindness. New Press, The. Created from towson on 2025-01-28 20:58:43. 226 T HE N E W J IM C ROW Copyright © 2010. New Press, The. All rights reserved. been true about slavery, genocide, torture, and every form of systemic oppression. Cohen emphasizes that denial, though deplorable, is complicated. It is not simply a matter of refusing to acknowledge an obvious, though uncomfortable, truth. Many people “know” and “not-know” the truth about human suffering at the same time. In his words, “Denial may be neither a matter of telling the truth nor intentionally telling a lie. There seem to be states of mind, or even whole cultures, in which we know and don’t know at the same time.”10 Today, most Americans know and don’t know the truth about mass incarceration. For more than three decades, images of black men in handcuffs have been a regular staple of the evening news. We know that large numbers of black men have been locked in cages. In fact, it is precisely because we know that black and brown people are far more likely to be imprisoned that we, as a nation, have not cared too much about it. We tell ourselves they “deserve” their fate, even though we know—and don’t know—that whites are just as likely to commit many crimes, especially drug crimes. We know that people released from prison face a lifetime of discrimination, scorn, and exclusion, and yet we claim not to know that an undercaste exists. We know and we don’t know at the same time. Upon reflection, it is relatively easy to understand how Americans come to deny the evils of mass incarceration. Denial is facilitated by persistent racial segregation in housing and schools, by political dema- goguery, by racialized media imagery, and by the ease of changing one’s perception of reality simply by changing television channels. There is little reason to doubt the prevailing “common sense” that black and brown men have been locked up en masse merely in response to crime rates when one’s sources of information are mainstream media outlets. In many respects, the reality of mass incarceration is easier to avoid knowing than the injustices and sufferings associated with slavery or Jim Crow. Those confined to prisons are out of sight and out of mind; Alexander, M. (2010). The new jim crow : Mass incarceration in the age of colorblindness. New Press, The. Created from towson on 2025-01-28 20:58:43. Copyright © 2010. New Press, The. All rights reserved. T HE N E W J IM C ROW 227 once released, they are typically confined to ghettos. Most Americans only come to “know” about the people cycling in and out of prisons through fictional police dramas, music videos, gangsta rap, and “true” accounts of ghetto experience on the evening news. These racialized narratives tend to confirm and reinforce the prevailing public con- sensus that we need not care about “those people”; they deserve what they get. Of all the reasons that we fail to know the truth about mass incar- ceration, though, one stands out: a profound misunderstanding regarding how racial oppression actually works. If someone were to visit the United States from another country (or another planet) and ask, “is the U.S. criminal justice system some kind of tool of racial control?” most Americans would swiftly deny it. Numerous reasons would leap to mind why that could not possibly be the case. The visi- tor would be told that crime rates, black culture, or bad schools were to blame. “The system is not run by a bunch of racists,” the apologist would explain. “It’s run by people who are trying to fight crime.” That response is predictable because most people assume that racism, and racial systems generally, are fundamentally a function of attitudes. Because mass incarceration is officially colorblind, it seems inconceiv- able that the system could function much like a racial caste system. The widespread and mistaken belief that racial animus is necessary for the creation and maintenance of racialized systems of social con- trol is the most important reason that we, as a nation, have remained in deep denial. The misunderstanding is not surprising. As a society, our collec- tive understanding of racism has been powerfully influenced by the shocking images of the Jim Crow era and the struggle for civil rights. When we think of racism we think of Governor Wallace of Alabama blocking the schoolhouse door; we think of water hoses, lynchings, racial epithets, and “whites only” signs. These images make it easy to forget that many wonderful, good-hearted white people who were Alexander, M. (2010). The new jim crow : Mass incarceration in the age of colorblindness. New Press, The. Created from towson on 2025-01-28 20:58:43. 228 T HE N E W J IM C ROW Copyright © 2010. New Press, The. All rights reserved. generous to others, respectful of their neighbors, and even kind to their black maids, gardeners, or shoe shiners—and wished them well—nevertheless went to the polls and voted for racial segrega- tion. Many whites who supported Jim Crow justified it on paternalist grounds, actually believing they were doing blacks a favor or believ- ing the time was not yet “right” for equality. The disturbing images from the Jim Crow era also make it easy to forget that many African Americans were complicit in the Jim Crow system, profiting from it directly or indirectly or keeping their objections quiet out of fear of the repercussions. Our understanding of racism is therefore shaped by the most extreme expressions of individual bigotry, not by the way in which it functions naturally, almost invisibly (and sometimes with genuinely benign intent), when it is embedded in the structure of a social system. The unfortunate reality we must face is that racism manifests itself not only in individual attitudes and stereotypes, but also in the basic structure of society. Academics have developed complicated theories and obscure jargon in an effort to describe what is now referred to as structural racism, yet the concept is fairly straightforward. One the- orist, Iris Marion Young, relying on a famous “birdcage” metaphor, explains it this way: if one thinks about racism by examining only one wire of the cage, or one form of disadvantage, it is difficult to under- stand how and why the bird is trapped. Only a large number of wires arranged in a specific way, and connected to one another, serve to enclose the bird and to ensure that it cannot escape.11 What is particularly important to keep in mind is that any given wire of the cage may or may not be specifically developed for the pur- pose of trapping the bird, yet it still operates (together with the other wires) to restrict its freedom. By the same token, not every aspect of a racial caste system needs to be developed for the specific purpose of controlling black people in order for it to operate (together with Alexander, M. (2010). The new jim crow : Mass incarceration in the age of colorblindness. New Press, The. Created from towson on 2025-01-28 20:58:43. Copyright © 2010. New Press, The. All rights reserved. T HE N E W J IM C ROW 229 other laws, institutions, and practices) to trap them at the bottom of a racial hierarchy. In the system of mass incarceration, a wide variety of laws, institutions, and practices— ranging from racial profiling to biased sentencing policies, political disenfranchisement, and legal- ized employment discrimination—trap African Americans in a virtual (and literal) cage. Fortunately, as Marilyn Frye has noted, every birdcage has a door, and every birdcage can be broken and can corrode.12 What is most con- cerning about the new racial caste system, however, is that it may prove to be more durable than its predecessors. Because this new system is not explicitly based on race, it is easier to defend on seemingly neutral grounds. And while all previous methods of control have blamed the victim in one way or another, the current system invites observers to imagine that those who are trapped in the system were free to avoid second-class status or permanent banishment from society simply by choosing not to commit crimes. It is far more convenient to imagine that a majority of young African American men in urban areas freely chose a life of crime than to accept the real possibility that their lives were structured in a way that virtually guaranteed their early admis- sion into a system from which they can never escape. Most people are willing to acknowledge the existence of the cage but insist that a door has been left open. One way of understanding our current system of mass incarcera- tion is to think of it as a birdcage with a locked door. It is a set of structural arrangements that locks a racially distinct group into a subordinate political, social, and economic position, effectively creat- ing a second-class citizenship. Those trapped within the system are not merely disadvantaged in the sense that they are competing on an unequal playing field or face additional hurdles to political or eco- nomic success; rather, the system itself is structured to lock them into a subordinate position. Alexander, M. (2010). The new jim crow : Mass incarceration in the age of colorblindness. New Press, The. Created from towson on 2025-01-28 20:58:43. 230 T HE N E W J IM C ROW How It Works Copyright © 2010. New Press, The. All rights reserved. Precisely how the system of mass incarceration works to trap African Americans in a virtual (and literal) cage can best be understood by viewing the system as a whole. In earlier chapters, we considered vari- ous wires of the cage in isolation; here, we put the pieces together, step back, and view the cage in its entirety. Only when we view the cage from a distance can we disengage from the maze of rationalizations that are offered for each wire and see how the entire apparatus oper- ates to keep African Americans perpetually trapped. This, in brief, is how the system works: the War on Drugs is a vehicle through which extraordinary numbers of black men are forced into the cage. The entrapment occurs in three distinct phases, each of which has been explored earlier, but a brief review is useful here. The first stage is the roundup. Vast numbers of people are swept into the crimi- nal justice system by the police, who conduct drug operations primar- ily in poor communities of color. They are rewarded in cash—through drug forfeiture laws and federal grant programs—for rounding up as many people as possible, and they operate unconstrained by constitu- tional rules of procedure that once were considered inviolate. Police can stop, interrogate, and search anyone they choose for drug investi- gations, provided they get “consent.” Because there is no meaningful check on the exercise of police discretion, racial biases are granted free rein. In fact, police are allowed to rely on race as a factor in selecting whom to stop and search (even though people of color are no more likely to be guilty of drug crimes than whites)—effectively guarantee- ing that those who are swept into the system are primarily black and brown. The conviction marks the beginning of the second phase: the peri- od of formal control. Once arrested, defendants are generally denied meaningful legal representation and pressured to plead guilty whether they are or not. Prosecutors are free to “load up” defendants with extra Alexander, M. (2010). The new jim crow : Mass incarceration in the age of colorblindness. New Press, The. Created from towson on 2025-01-28 20:58:43. Copyright © 2010. New Press, The. All rights reserved. T HE N E W J IM C ROW 231 charges, and their decisions cannot be challenged for racial bias. Once convicted, due to the drug war’s harsh sentencing laws, people con- victed of drug offenses in the United States spend more time under the criminal justice system’s formal control—in jail or prison, on probation or parole—than people anywhere else in the world. While under formal control, virtually every aspect of one’s life is regulated and monitored by the system, and any form of resistance or disobedience is subject to swift sanction. This period of control may last a lifetime, even for those convicted of extremely minor, nonviolent offenses, but the vast majority of those swept into the system are eventually released. They are transferred from their prison cells to a much larger, invisible cage. The final stage has been dubbed by some advocates as the “period of invisible punishment.”13 This term, first coined by Jeremy Travis, is meant to describe the unique set of criminal sanctions that are imposed on individuals after they step outside the prison gates, a form of punishment that operates largely outside of public view and takes effect outside the traditional sentencing framework. These sanctions are imposed by operation of law rather than decisions of a sentencing judge, yet they often have a greater impact on one’s life course than the months or years one actually spends behind bars. These laws oper- ate collectively to ensure that the vast majority of people convicted of crimes will never integrate into mainstream, white society. They will be discriminated against, legally, for the rest of their lives—denied employment, housing, education, and public benefits. Unable to sur- mount these obstacles, most will eventually return to prison and then be released again, caught in a closed circuit of perpetual marginality. In recent years, advocates and politicians have called for greater resources devoted to the problem of “prisoner re-entry,” in view of the unprecedented numbers of people who are released from prison and returned to their communities every year. While the terminology is well intentioned, it utterly fails to convey the gravity of the situa- tion facing people upon their release from prison. People who have Alexander, M. (2010). The new jim crow : Mass incarceration in the age of colorblindness. New Press, The. Created from towson on 2025-01-28 20:58:43. 232 T HE N E W J IM C ROW been convicted of felonies almost never truly re-enter the society they inhabited prior to their conviction. Instead, they enter a separate soci- ety, a world hidden from public view, governed by a set of oppressive and discriminatory rules and laws that do not apply to everyone else. They become members of an undercaste—an enormous population of predominately black and brown people who, because of the drug war, are denied basic rights and privileges of American citizenship and are permanently relegated to an inferior status. This is the final phase, and there is no going back. Copyright © 2010. New Press, The. All rights reserved. Nothing New? Some might argue that as disturbing as this system appears to be, there is nothing particularly new about mass incarceration; it is merely a continuation of past drug wars and biased law enforcement practices. Racial bias in our criminal justice system is simply an old problem that has gotten worse, and the social excommunication of “criminals” has a long history; it is not a recent invention. There is some merit to this argument. Race has always influenced the administration of justice in the Unit- ed States. Since the day the first prison opened, people of color have been disproportionately represented behind bars. In fact, the very first person admitted to a U.S. penitentiary was a “light skinned Negro in excellent health,” described by an observer as “one who was born of a degraded and depressed race, and had never experienced anything but indifference and harshness.”14 Biased police practices are also nothing new, a recurring theme of African American experience since blacks were targeted by the police as suspected runaway slaves. And every drug war that has ever been waged in the United States—including alcohol prohibition—has been tainted or driven by racial bias.15 Even postconviction penalties have a long history. The American colonies passed laws barring people convicted of crimes from a wide variety of Alexander, M. (2010). The new jim crow : Mass incarceration in the age of colorblindness. New Press, The. Created from towson on 2025-01-28 20:58:43. Copyright © 2010. New Press, The. All rights reserved. T HE N E W J IM C ROW 233 jobs and benefits, automatically dissolving their marriages and deny- ing them the right to enter contracts. These legislatures were follow- ing a long tradition, dating back to ancient Greece, of treating those convicted of crimes as less than full citizens. Although many collateral sanctions were repealed by the late 1970s, arguably the drug war sim- ply revived and expanded a tradition that has ancient roots, a tradition independent of the legacy of American slavery. In view of this history and considering the lack of originality in many of the tactics and practices employed in the era of mass incar- ceration, there is good reason to believe that the latest drug war is just another drug war corrupted by racial and ethnic bias. But this view is correct only to a point. In the past, the criminal justice system, as punitive as it may have been during various wars on crime and drugs, affected only a rela- tively small percentage of the population. Because civil penalties and sanctions imposed on people with criminal records applied only to a few, they never operated as a comprehensive system of control over any racially or ethnically defined population. Racial minorities were always overrepresented in the criminal justice system, but as sociol- ogists have noted, until the mid- 1980s, the system was marginal to communities of color. While young minority men with little school- ing have always had relatively high rates of incarceration, “before the 1980s the penal system was not a dominant presence in the disadvan- taged neighborhoods.”16 Today, the War on Drugs has given birth to a system of mass incar- ceration that governs not just a small fraction of a racial or ethnic minority but entire communities of color. In ghetto communities, near- ly everyone is either directly or indirectly subject to the new caste sys- tem. The system serves to redefine the terms of the relationship of poor people of color and their communities to mainstream, white society, ensuring their subordinate and marginal status. The criminal and civil sanctions that were once reserved for a tiny minority are now used to Alexander, M. (2010). The new jim crow : Mass incarceration in the age of colorblindness. New Press, The. Created from towson on 2025-01-28 20:58:43. Copyright © 2010. New Press, The. All rights reserved. 234 T HE N E W J IM C ROW control and oppress a racially defined majority in many communities, and the systematic manner in which the control is achieved reflects not just a difference in scale. The nature of the criminal justice system has changed. It is no longer concerned primarily with the prevention and punishment of crime, but rather with the management and control of the dispossessed. Prior drug wars were ancillary to the prevailing caste system. This time the drug war is the system of control. If you doubt that this is the case, consider the effect of the war on the ground, in specific locales. Take Chicago, Illinois, for example. Chicago is widely considered to be one of America’s most diverse and vibrant cities. It has boasted black mayors, black police chiefs, black legislators, and is home to the nation’s first black president. It has a thriving economy, a growing Latino community, and a substantial black middle class. Yet as the Chicago Urban League reported in 2002, there is another story to be told.17 If Martin Luther King Jr. were to return miraculously to Chicago, some forty years after bringing his Freedom Movement to the city, he would be saddened to discover that the same issues on which he origi- nally focused still produce stark patterns of racial inequality, segrega- tion, and poverty. He would also be struck by the dramatically elevated significance of one particular institutional force in the perpetuation and deepening of those patterns: the criminal justice system. In the few short decades since King’s death, a new regime of racially disparate mass incarceration has emerged in Chicago and become the primary mechanism for racial oppression and the denial of equal opportunity. In Chicago, like the rest of the country, the War on Drugs is an engine of mass incarceration, as well as a major cause of gross racial disparities throughout the system. About 90 percent of those sentenced to prison for a drug offense in Illinois are African American.18 White drug users and dealers are rarely arrested, and when they are, they are treated more favorably at every stage of the criminal justice process, including plea bargaining and sentencing.19 Whites are consistently Alexander, M. (2010). The new jim crow : Mass incarceration in the age of colorblindness. New Press, The. Created from towson on 2025-01-28 20:58:43. Copyright © 2010. New Press, The. All rights reserved. T HE N E W J IM C ROW 235 more likely to avoid prison and felony charges, even when they are repeatedly caught with drugs.20 Black people, by contrast, are routine- ly labeled felons and released into a permanent racial undercaste. The total population of black males in Chicago with a felony record (inside and outside prisons) is equivalent to 55 percent of the black adult male population and an astonishing 80 percent of the adult black male workforce in the Chicago area.21 This stunning develop- ment reflects the dramatic increase in the number and race of those sent to prison for drug crimes. From the Chicago region alone, the number of those annually sent to prison for drug crimes increased almost 2,000 percent, from 469 in 1985 to 8,755 in 2005.22 That figure, of course, does not include the thousands who avoid prison but are arrested, convicted, and sentenced to jail or probation. They, too, have criminal records that will follow them for life. More than 70 percent of all criminal cases in the Chicago area involve a class D felony drug possession charge, the lowest-level felony charge.23 Those who do go to prison find little freedom upon release. When people are released from Illinois prisons, they are given as little as $10 in “gate money” and a bus ticket to anywhere in the United States. Most return to impoverished neighborhoods in the Chicago area, bringing few resources and bearing the stigma of their prison record.24 In Chicago, as in most cities across the country, people with criminal records are banned or severely restricted from employment in a large number of professions, job categories, and fields by professional licensing statutes, rules, and practices that discriminate against poten- tial employees with felony records. According to a study conducted by the DePaul University College of Law in 2000, of the then–ninety-eight occupations requiring licenses in Illinois, fifty-seven placed stipula- tions and/or restrictions on applicants with a criminal record.25 Even when not barred by law from holding specific jobs, formerly incarcer- ated and convicted people in Chicago find it extraordinarily difficult to find employers who will hire them, regardless of the nature of their Alexander, M. (2010). The new jim crow : Mass incarceration in the age of colorblindness. New Press, The. Created from towson on 2025-01-28 20:58:43. 236 T HE N E W J IM C ROW conviction. They are also routinely denied public housing and wel- fare benefits, and they find it increasingly difficult to obtain education, especially now that funding for public education has been hard-hit, due to exploding prison budgets. The impact of the new caste system is most tragically felt among the young. In Chicago (as in other cities across the United States), young black men are more likely to go to prison than to college.26 As of June 2001, there were nearly twenty thousand more black men in the Illi- nois state prison system than enrolled in the state’s public universi- ties.27 In fact, there were more black men in the state’s correctional facilities that year just on drug charges than the total number of black men enrolled in undergraduate degree programs in state universities.28 To put the crisis in even sharper focus, consider this: just 992 black men received a bachelor’s degree from Illinois state universities in 1999, while roughly 7,000 black men were released from the state pris- on system the following year just for drug offenses.29 The young men who go to prison rather than college face a lifetime of closed doors, discrimination, and ostracism. Their plight is not what we hear about on the evening news, however. Sadly, like the racial caste systems that preceded it, the system of mass incarceration now seems normal and natural to most, a regrettable necessity. Copyright © 2010. New Press, The. All rights reserved. Mapping the Parallels Those cycling in and out of Illinois prisons today are members of America’s new racial undercaste. The United States has almost always had a racial undercaste—a group defined wholly or largely by race that is permanently locked out of mainstream, white society by law, custom, and practice. The reasons and justifications change over time, as each new caste system reflects and adapts to changes in the social, political, and economic context. What is most striking about the design of the current caste system, though, is how closely it resembles Alexander, M. (2010). The new jim crow : Mass incarceration in the age of colorblindness. New Press, The. Created from towson on 2025-01-28 20:58:43. Copyright © 2010. New Press, The. All rights reserved. T HE N E W J IM C ROW 237 its predecessor. There are important differences between mass incar- ceration and Jim Crow, to be sure—many of which will be discussed later—but when we step back and view the system as a whole, there is a profound sense of déjà vu. There is a familiar stigma and shame. There is an elaborate system of control, complete with political disen- franchisement and legalized discrimination in every major realm of economic and social life. And there is the production of racial meaning and racial boundaries. Many of these parallels have been discussed at some length in ear- lier chapters; others have yet to be explored. Listed below are several of the most obvious similarities between Jim Crow and mass incar- ceration, followed by a discussion of a few parallels that have not been discussed so far. Let’s begin with the historical parallels. Historical parallels. Jim Crow and mass incarceration have similar political origins. As described in chapter 1, both caste systems were born, in part, due to a desire among white elites to exploit the resent- ments, vulnerabilities, and racial biases of poor and working- class whites for political or economic gain. Segregation laws were proposed as part of a deliberate and strategic effort to deflect anger and hos- tility that had been brewing against the white elite away from them and toward African Americans. The birth of mass incarceration can be traced to a similar political dynamic. Conservatives in the 1970s and 1980s sought to appeal to the racial biases and economic vul- nerabilities of poor and working- class whites through racially coded rhetoric on crime and welfare. In both cases, the racial opportunists offered few, if any, economic reforms to address the legitimate eco- nomic anxieties of poor and working- class whites, proposing instead a crackdown on the racially defined “others.” In the early years of Jim Crow, conservative white elites competed with each other by passing ever more stringent and oppressive Jim Crow legislation. A century later, politicians in the early years of the drug war competed with each other to prove who could be tougher on crime by passing ever harsher Alexander, M. (2010). The new jim crow : Mass incarceration in the age of colorblindness. New Press, The. Created from towson on 2025-01-28 20:58:43. Copyright © 2010. New Press, The. All rights reserved. 238 T HE N E W J IM C ROW drug laws—a thinly veiled effort to appeal to poor and working-class whites who, once again, proved they were willing to forego economic and structural reform in exchange for an apparent effort to put blacks back “in their place.”30 Legalized discrimination. The most obvious parallel between Jim Crow and mass incarceration is legalized discrimination. During Black History Month, Americans congratulate themselves for having put an end to discrimination against African Americans in employment, housing, public benefits, and public accommodations. Schoolchildren wonder out loud how discrimination could ever have been legal in this great land of ours. Rarely are they told that it is still legal. Many of the forms of discrimination that relegated African Americans to an inferior caste during Jim Crow continue to apply to huge segments of the black population today—provided they are first labeled felons. If they are branded felons by the time they reach the age of twenty-one (as many of them are), they are subject to legalized discrimination for their entire adult lives. The forms of discrimination that apply to peo- ple labeled criminals, described in some detail in chapter 4, mean that, once people are released from jail or prison, they enter a parallel social universe—much like Jim Crow—in which discrimination in nearly every aspect of social, political, and economic life is perfectly legal. Large majorities of black men in cities across the United States are once again subject to legalized discrimination effectively barring them from full integration into mainstream, white society. Mass incarcera- tion has nullified many of the gains of the Civil Rights Movement, put- ting millions of black men back in a position reminiscent of Jim Crow. Political disenfranchisement. During the Jim Crow era, African Americans were denied the right to vote through poll taxes, literacy tests, grandfather clauses, and felon disenfranchisement laws, even though the Fifteenth Amendment to the U.S. Constitution specifi- cally provides that “the right of citizens of the United States to vote shall not be denied . . . on account of race, color, or previous con- Alexander, M. (2010). The new jim crow : Mass incarceration in the age of colorblindness. New Press, The. Created from towson on 2025-01-28 20:58:43. Copyright © 2010. New Press, The. All rights reserved. T HE N E W J IM C ROW 239 dition of servitude.” Formally race- neutral devices were adopted to achieve the goal of an all- white electorate without violating the terms of the Fifteenth Amendment. The devices worked quite well. Because African Americans were poor, they frequently could not pay poll taxes. And because they had been denied access to education, they could not pass literacy tests. Grandfather clauses allowed whites to vote even if they couldn’t meet the requirements, as long as their ancestors had been able to vote. Finally, because blacks were dispro- portionately charged with felonies—in fact, some crimes were spe- cifically defined as felonies with the goal of eliminating blacks from the electorate— felon disenfranchisement laws effectively suppressed the black vote as well.31 Following the collapse of Jim Crow, all of the race-neutral devic- es for excluding blacks from the electorate were eliminated through litigation or legislation, except felon disenfranchisement laws. Some courts have found that these laws have “lost their discriminatory taint” because they have been amended since the collapse of Jim Crow; other courts have allowed the laws to stand because overt racial bias is absent from the legislative record.32 The failure of our legal system to eradicate all of the tactics adopted during the Jim Crow era to suppress the black vote has major implications today. Felon disenfranchisement laws have been more effective in eliminating black voters in the age of mass incarceration than they were during Jim Crow. Less than two decades after the War on Drugs began, one in seven black men nation- ally had lost the right to vote, and as many as one in four in those states with the highest African American disenfranchisement rate.33 These figures may understate the impact of felon disenfranchisement, because they do not take into account the millions of people who can- not vote in states that require people with felony convictions to pay fines or fees before their voting rights can be restored—the new poll tax. As legal scholar Pamela Karlan has observed, “felony disenfran- chisement has decimated the potential black electorate.”34 Alexander, M. (2010). The new jim crow : Mass incarceration in the age of colorblindness. New Press, The. Created from towson on 2025-01-28 20:58:43. Copyright © 2010. New Press, The. All rights reserved. 2 40 T HE N E W J IM C ROW It is worthy of note, however, that the exclusion of black voters from polling booths is not the only way in which black political power has been suppressed. Another dimension of disenfranchisement echoes not so much Jim Crow as slavery. Under the usual-residence rule, the Census Bureau counts imprisoned individuals as residents of the jurisdiction in which they are incarcerated. Because most new prison construction occurs in predominately white, rural areas, these com- munities benefit from inflated population totals at the expense of the urban, overwhelmingly minority communities from which people in prison frequently come.35 This has enormous consequences for the redistricting process. White rural communities that house prisons wind up with more people in state legislatures representing them, while poor communities of color lose representatives because it appears their population has declined. This policy is disturbingly reminiscent of the three-fifths clause in the original Constitution, which enhanced the political clout of slaveholding states by including 60 percent of slaves in the population base for calculating Congressional seats and elec- toral votes, even though they could not vote. Exclusion from juries. Another clear parallel between mass incar- ceration and Jim Crow is the systematic exclusion of blacks from juries. One hallmark of the Jim Crow era was all-white juries trying black defendants in the South. Although the exclusion of jurors on the basis of race has been illegal since 1880, as a practical matter, the removal of prospective black jurors through race-based peremptory strikes was sanctioned by the Supreme Court until 1985, when the Court ruled in Batson v. Kentucky that racially biased strikes violate the equal protection clause of the Fourteenth Amendment.36 Today defendants face a situation highly similar to the one they faced a cen- tury ago. As described in chapter 3, a formal prohibition against race- based peremptory strikes does exist; as a practical matter, however, the Court has tolerated the systematic exclusion of blacks from juries by allowing lower courts to accept “silly” and even “superstitious” reasons Alexander, M. (2010). The new jim crow : Mass incarceration in the age of colorblindness. New Press, The. Created from towson on 2025-01-28 20:58:43. Copyright © 2010. New Press, The. All rights reserved. T HE N E W J IM C ROW 2 41 for striking black jurors.37 To make matters worse, a large percentage of black men (about 30 percent) are automatically excluded from jury service because they have been labeled felons.38 The combined effect of race-based peremptory strikes and the automatic exclusion of people with felonies from juries has put black defendants in a familiar place— in a courtroom in shackles, facing an all-white jury. Closing the courthouse doors. The parallels between mass incar- ceration and Jim Crow extend all the way to the U.S. Supreme Court. Over the years, the Supreme Court has followed a fairly consistent pat- tern in responding to racial caste systems, first protecting them and then, after dramatic shifts in the political and social climate, disman- tling these systems of control and some of their vestiges. In Dred Scott v. Sanford, the Supreme Court immunized the institution of slavery from legal challenge on the grounds that African Americans were not citizens, and in Plessy v. Ferguson, the Court established the doctrine of “separate but equal”—a legal fiction that protected the Jim Crow system from judicial scrutiny for racial bias. Currently, McCleskey v. Kemp and its progeny serve much the same function as Dred Scott and Plessy. In McCleskey, the Supreme Court demonstrated that it is once again in protection mode—firmly com- mitted to the prevailing system of control. As chapter 3 demonstrat- ed, the Court has closed the courthouse doors to claims of racial bias at every stage of the criminal justice process, from stops and searches to plea bargaining and sentencing. Mass incarceration is now off- limits to challenges on the grounds of racial bias, much as its pre- decessors were in their time. The new racial caste system operates unimpeded by the Fourteenth Amendment and federal civil rights legislation—laws designed to topple earlier systems of control. The Supreme Court’s famous proclamation in 1857—“[the black man] has no rights which the white man is bound to respect”—remains true to a significant degree today, so long as the black man has been labeled a felon.39 Alexander, M. (2010). The new jim crow : Mass incarceration in the age of colorblindness. New Press, The. Created from towson on 2025-01-28 20:58:43. Copyright © 2010. New Press, The. All rights reserved. 2 42 T HE N E W J IM C ROW Racial segregation. Although the parallels listed above should be enough to give anyone pause, there are a number of other, less obvi- ous, similarities between mass incarceration and Jim Crow that have not been explored in earlier chapters. The creation and maintenance of racial segregation is one example. As we know, Jim Crow laws mandat- ed residential segregation, and blacks were relegated to the worst parts of town. Roads literally stopped at the border of many black neigh- borhoods, shifting from pavement to dirt. Water, sewer systems, and other public services that supported the white areas of town frequently did not extend to the black areas. The extreme poverty that plagued blacks due to their legally sanctioned inferior status was largely invis- ible to whites—so long as whites remained in their own neighbor- hoods, which they were inclined to do. Racial segregation rendered black experience largely invisible to whites, making it easier for whites to maintain racial stereotypes about black values and culture. It also made it easier to deny or ignore their suffering. Mass incarceration functions similarly. It achieves racial segregation by segregating people in prison—the majority of whom are black and brown—from mainstream society. They are kept behind bars, typical- ly more than a hundred miles from home.40 Even prisons—the actu- al buildings—are a rare sight for many Americans, as they are often located far from population centers. Although rural counties contain only 20 percent of the U.S. population, 60 percent of new prison con- struction occurs there.41 Incarcerated people are thus hidden from public view—out of sight, out of mind. In a sense, imprisonment is a far more extreme form of physical and residential segregation than Jim Crow segregation. Rather than merely shunting black people to the other side of town or corralling them in ghettos, mass incarcera- tion locks them in cages. Bars and walls keep hundreds of thousands of black and brown people away from mainstream society—a form of apartheid unlike any the world has ever seen. Prisons, however, are not the only vehicle for racial segregation. Seg- Alexander, M. (2010). The new jim crow : Mass incarceration in the age of colorblindness. New Press, The. Created from towson on 2025-01-28 20:58:43. Copyright © 2010. New Press, The. All rights reserved. T HE N E W J IM C ROW 2 43 regation is also created and perpetuated by the flood of people who return to ghetto communities from prisons each year. Because the drug war has been waged almost exclusively in poor communities of color, when people convicted of drug crimes are released, they are gener- ally returned to racially segregated ghetto communities—the places they call home. In many cities, the re- entry phenomenon is highly concentrated in a small number of neighborhoods. According to one study, during a twelve-year period, the number of people returning from prison back home to “core counties”—those counties that con- tain the inner city of a metropolitan area— tripled.42 The effects are felt throughout the United States. In interviews with one hundred residents of two Tallahassee, Florida, communities, researchers found that nearly every one of them had experienced or expected to experi- ence the return of a family member from prison.43 Similarly, a survey of families living in the Robert Taylor Homes in Chicago found that the majority of residents either had a family member in prison or expected one to return from prison within the next two years.44 Fully 70 percent of men between the ages of eighteen and forty-five in the impoverished and overwhelmingly black North Lawndale neighborhood on Chica- go’s West Side are saddled for life with a criminal record.45 The majority (60 percent) were incarcerated for drug offenses.46 These neighbor- hoods are a minefield for people on parole, for a standard condition of parole is a promise not to associate with anyone who has a felony conviction. As Paula Wolff, a senior executive at Chicago Metropolis 2020 observes, in these ghetto neighborhoods, “It is hard for a parolee to walk to the corner store to get a carton of milk without being subject to a parole violation.” 47 By contrast, whites—even poor whites—are far less likely to be imprisoned for drug offenses. And when they are released from prison, they rarely find themselves in the ghetto. The white poor have a vastly different experience in America than do poor people of color, as they are rarely relegated to racially segregated urban areas characterized by Alexander, M. (2010). The new jim crow : Mass incarceration in the age of colorblindness. New Press, The. Created from towson on 2025-01-28 20:58:43. Copyright © 2010. New Press, The. All rights reserved. 2 4 4 T HE N E W J IM C ROW intense poverty. In New York City, one study found that 70 percent of the city’s poor black and Latino residents live in high-poverty neigh- borhoods, whereas 70 percent of the city’s poor whites live in nonpov- erty neighborhoods—communities that have significant resources, including jobs, schools, banks, and grocery stores.48 Nationwide, nearly seven out of eight people living in high-poverty urban areas are members of a minority group.49 Mass incarceration thus perpetuates and deepens pre-existing pat- terns of racial segregation and isolation, not just by removing people of color from society and putting them in prisons, but by dumping them back into ghettos upon their release. Youth of color who might have escaped their ghetto communities—or helped to transform them—if they had been given a fair shot in life and not been labeled felons— instead find themselves trapped in a closed circuit of perpetual mar- ginality, circulating between ghetto and prison.50 The racially segregated, poverty-stricken ghettos that exist in inner- city communities across America would not exist today but for racially biased government policies for which there has never been meaningful redress.51 Yet every year, hundreds of thousands of poor people of col- or who have been targeted by the War on Drugs are forced to return to these racially segregated communities—neighborhoods still crippled by the legacy of an earlier system of control. As a practical matter, they have no other choice. In this way, mass incarceration, like its predeces- sor Jim Crow, creates and maintains racial segregation. Symbolic production of race. Arguably the most important parallel between mass incarceration and Jim Crow is that both have served to define the meaning and significance of race in America. Indeed, a prima- ry function of any racial caste system is to define the meaning of race in its time. Slavery defined what it meant to be black (a slave), and Jim Crow defined what it meant to be black (a second-class citizen). Today mass incarceration defines the meaning of blackness in America: black people, especially black men, are criminals. That is what it means to be black. Alexander, M. (2010). The new jim crow : Mass incarceration in the age of colorblindness. New Press, The. Created from towson on 2025-01-28 20:58:43. Copyright © 2010. New Press, The. All rights reserved. T HE N E W J IM C ROW 2 45 The temptation is to insist that black men “choose” to be criminals; the system does not make them criminals, at least not in the way that slavery made blacks slaves or Jim Crow made them second- class citi- zens. The myth of choice here is seductive, but it should be resisted. African Americans are not significantly more likely to use or sell pro- hibited drugs than whites, but they are made criminals at drastically higher rates for precisely the same conduct. In fact, studies suggest that white professionals may be the most likely of any group to have engaged in illegal drug activity in their lifetime, yet they are the least likely to be made criminals.52 The prevalence of illegal drug activity among all racial and ethnic groups creates a situation in which, due to limited law enforcement resources and political constraints, some people are made criminals while others are not. Black people have been made criminals by the War on Drugs to a degree that dwarfs its effect on other racial and ethnic groups, especially whites. And the process of making them criminals has produced racial stigma. Every racial caste system in the United States has produced racial stigma. Mass incarceration is no exception. Racial stigma is produced by defining negatively what it means to be black. The stigma of race was once the shame of the slave; then it was the shame of the second- class citizen; today the stigma of race is the shame of the criminal. As described in chapter 4, many people labeled criminals describe an existential angst associated with their pariah status, an angst that casts a shadow over every aspect of their identity and social experi- ence. The shame and stigma are not limited to the individual; they extend to family members and friends—even whole communities are stigmatized by the presence of those caught and thus tainted by the system. Those stigmatized by convictions often adopt coping strategies African Americans once employed during the Jim Crow era, including lying about their own criminal history or the status of their family members in an attempt to “pass” as someone who will be welcomed by mainstream society. Alexander, M. (2010). The new jim crow : Mass incarceration in the age of colorblindness. New Press, The. Created from towson on 2025-01-28 20:58:43. Copyright © 2010. New Press, The. All rights reserved. 2 46 T HE N E W J IM C ROW The critical point here is that, for black men, the stigma of being a “criminal” in the era of mass incarceration is fundamentally a racial stigma. This is not to say stigma is absent for white people convicted of crimes; it is present and powerful. Rather, the point is that the stigma of criminality for whites is different—it is a nonracial stigma. An experiment may help to illustrate how and why this is the case. Say the following to nearly anyone and watch the reaction: “We really need to do something about the problem of white crime.” Laughter is a likely response. The term white crime is nonsensical in the era of mass incarceration, unless one is really referring to white-collar crime, in which case the term is understood to mean the types of crimes that seemingly respectable white people commit in the comfort of fancy offices. Because the term white crime lacks social meaning, the term white criminal is also perplexing. In that formulation, white seems to qualify the term criminal—as if to say, “he’s a criminal but not that kind of criminal.” Or, he’s not a real criminal—i.e., not what we mean by criminal today. In the era of mass incarceration, what it means to be a criminal in our collective consciousness has become conflated with what it means to be black, so the term white criminal is confounding, while the term black criminal is nearly redundant. Recall the study discussed in chap- ter 3 that revealed that when survey respondents were asked to picture a drug criminal, nearly everyone pictured someone who was black. This phenomenon helps to explain why studies indicate that white people with a criminal record may actually have an easier time gaining employment than African Americans without a criminal record.53 To be a black man is to be thought of as a criminal, and to be a black crim- inal is to be despicable—a social pariah. To be a white criminal is not easy, by any means, but as a white criminal you are not a racial outcast, though you may face many forms of social and economic exclusion. Whiteness mitigates crime, whereas blackness defines the criminal. As we have seen in earlier chapters, the conflation of blackness with Alexander, M. (2010). The new jim crow : Mass incarceration in the age of colorblindness. New Press, The. Created from towson on 2025-01-28 20:58:43. Copyright © 2010. New Press, The. All rights reserved. T HE N E W J IM C ROW 2 47 crime did not happen organically; rather, it was constructed by politi- cal and media elites as part of the broad project known as the War on Drugs. This conflation served to provide a legitimate outlet to the expression of antiblack resentment and animus—a convenient release valve now that explicit forms of racial bias are strictly condemned. In the era of colorblindness, it is no longer permissible to hate blacks, but we can hate criminals. Indeed, we are encouraged to do so. As writer John Edgar Wideman points out, “It’s respectable to tar and feather criminals, to advocate locking them up and throwing away the key. It’s not racist to be against crime, even though the archetypal criminal in the media and the public imagination almost always wears Willie Horton’s face.”54 It is precisely because our criminal justice system provides a vehicle for the expression of conscious and unconscious antiblack sentiment that the prison label is experienced as a racial stigma. The stigma exists whether or not one has been formally branded a criminal, yet another parallel to Jim Crow. Just as African Ameri- cans in the North were stigmatized by the Jim Crow system even if they were not subject to its formal control, black men today are stig- matized by mass incarceration—and the social construction of the “criminalblackman”—whether they have ever been to prison or not. For those who have been branded, the branding serves to intensify and deepen the racial stigma, as they are constantly reminded in virtually every contact they have with public agencies, as well as with private employers and landlords, that they are the new “untouchables.” In this way, the stigma of race has become the stigma of criminal- ity. Throughout the criminal justice system, as well as in our schools and public spaces, young + black + male is equated with reasonable suspicion, justifying the arrest, interrogation, search, and detention of thousands of African Americans every year, as well as their exclusion from employment and housing and the denial of educational oppor- tunity. Because black youth are viewed as criminals, they face severe Alexander, M. (2010). The new jim crow : Mass incarceration in the age of colorblindness. New Press, The. Created from towson on 2025-01-28 20:58:43. Copyright © 2010. New Press, The. All rights reserved. 2 48 T HE N E W J IM C ROW employment discrimination and are also “pushed out” of schools through racially biased school discipline policies.55 For black youth, the experience of being “made black” often begins with the first police stop, interrogation, search, or arrest. The experi- ence carries social meaning—this is what it means to be black. The story of one’s “first time” may be repeated to family or friends, but for ghetto youth, almost no one imagines that the first time will be the last. The experience is understood to define the terms of one’s relationship not only to the state but to society at large. This reality can be frustrating for those who strive to help ghetto youth “turn their lives around.” James Forman Jr., the cofounder of the See Forever charter school for juveniles arrested or convicted in Washington, DC, made this point when describing how random and degrading stops and searches of ghetto youth “tell kids that they are pariahs, that no matter how hard they study, they will remain potential suspects.” One student com- plained to him, “We can be perfect, perfect, doing everything right and still they treat us like dogs. No, worse than dogs, because criminals are treated worse than dogs.” Another student asked him pointedly, “How can you tell us we can be anything when they treat us like we’re nothing?”56 The process of marking black youth as black criminals is essen- tial to the functioning of mass incarceration as a racial caste system. For the system to succeed—that is, for it to achieve the political goals described in chapter 1—black people must be labeled criminals before they are formally subject to control. The criminal label is essential, for forms of explicit racial exclusion are not only prohibited but widely condemned. Thus black youth must be made—labeled—criminals. This process of being made a criminal is, to a large extent, the process of “becoming” black. As Wideman explains, when “to be a man of color of a certain economic class and milieu is equivalent in the public eye to being a criminal,” being processed by the criminal justice sys- tem is tantamount to being made black, and “doing time” behind bars Alexander, M. (2010). The new jim crow : Mass incarceration in the age of colorblindness. New Press, The. Created from towson on 2025-01-28 20:58:43. T HE N E W J IM C ROW 2 49 is at the same time “marking race.”57 At its core, then, mass incarcera- tion, like Jim Crow, is a “race-making institution.” It serves to define the meaning and significance of race in America. Copyright © 2010. New Press, The. All rights reserved. The Limits of the Analogy Saying that mass incarceration is the New Jim Crow can leave a misim- pression. The parallels between the two systems of control are striking, to say the least—in both, we find racial opportunism by politicians, legalized discrimination, political disenfranchisement, exclusion of blacks from juries, stigmatization, the closing of courthouse doors, racial segregation, and the symbolic production of race—yet there are important differences. Just as Jim Crow, as a system of racial control, was dramatically different from slavery, mass incarceration is different from its predecessor. In fact, if one were to draft a list of the differences between slavery and Jim Crow, the list might well be longer than the list of similarities. The same goes for Jim Crow and mass incarceration. Each system of control has been unique—well adapted to the circum- stances of its time. If we fail to appreciate the differences, we will be hindered in our ability to meet the challenges created by the current moment. At the same time, though, we must be careful not to assume that differences exist when they do not, or to exaggerate the ones that do. Some differences may appear on the surface to be major, but on close analysis they prove less significant. An example of a difference that is less significant than it may initial- ly appear is the “fact” that Jim Crow was explicitly race-based, whereas mass incarceration is not. This statement initially appears self-evident, but it is partially mistaken. Although it is common to think of Jim Crow as an explicitly race-based system, in fact a number of the key policies were officially colorblind. As previously noted, poll taxes, lit- eracy tests, and felon disenfranchisement laws were all formally race- neutral practices that were employed in order to avoid the prohibition Alexander, M. (2010). The new jim crow : Mass incarceration in the age of colorblindness. New Press, The. Created from towson on 2025-01-28 20:58:43. Copyright © 2010. New Press, The. All rights reserved. 250 T HE N E W J IM C ROW on race discrimination in voting contained in the Fifteenth Amend- ment. These laws operated to create an all-white electorate because they excluded African Americans from the franchise but were not gen- erally applied to whites. Poll workers had the discretion to charge a poll tax or administer a literacy test, or not, and they exercised their discretion in a racially discriminatory manner. Laws that said noth- ing about race operated to discriminate because those charged with enforcement were granted tremendous discretion, and they exercised that discretion in a highly discriminatory manner. The same is true in the drug war. Laws prohibiting the use and sale of drugs are facially race neutral, but they are enforced in a highly discriminatory fashion. The decision to wage the drug war primarily in black and brown communities rather than white ones and to target African Americans but not whites on freeways and train stations has had precisely the same effect as the literacy and poll taxes of an ear- lier era. A facially race-neutral system of laws has operated to create a racial caste system. Other differences between Jim Crow and mass incarceration are actually more significant than they may initially appear. An example relates to the role of racial stigma in our society. As discussed in chap- ter 4, during Jim Crow, racial stigma contributed to racial solidarity in the black community. Racial stigma today, however—that is, the stigma of black criminality—has turned the black community against itself, destroyed networks of mutual support, and created a silence about the new caste system among many of the people most affected by it.58 The implications of this difference are profound. Racial stigma today makes collective action extremely difficult—sometimes impos- sible—whereas racial stigma during Jim Crow contained the seeds of revolt. Described below are a number of the other important differences between Jim Crow and mass incarceration. Listing all of the differ- ences here is impractical, so instead we will focus on a few of the major Alexander, M. (2010). The new jim crow : Mass incarceration in the age of colorblindness. New Press, The. Created from towson on 2025-01-28 20:58:43. Copyright © 2010. New Press, The. All rights reserved. T HE N E W J IM C ROW 251 differences that are most frequently cited in defense of mass incar- ceration, including the absence of overt racial hostility, the inclusion of whites in the system of control, and African American support for some “get tough” policies and drug war tactics. Absence of racial hostility. First, let’s consider the absence of overt racial hostility among politicians who support harsh drug laws and the law enforcement officials charged with enforcing them. The absence of overt racial hostility is a significant difference from Jim Crow, but it can be exaggerated. Mass incarceration, like Jim Crow, was born of racial opportunism—an effort by white elites to exploit the racial hostilities, resentments, and insecurities of poor and working- class whites. Moreover, racial hostility and racial violence have not alto- gether disappeared, given that complaints of racial slurs and brutality by the police and prison guards are fairly common. Some scholars and commentators have pointed out that the racial violence once associat- ed with brutal slave masters or the Ku Klux Klan has been replaced, to some extent, by violence perpetrated by the state. Racial violence has been rationalized, legitimated, and channeled through our criminal justice system; it is expressed as police brutality, solitary confinement, and the discriminatory and arbitrary imposition of the death penalty.59 But even granting that some African Americans may fear the police today as much as their grandparents feared the Klan (as a wallet can be mistaken for a gun) and that the penal system may be as brutal in many respects as Jim Crow (or slavery), the absence of racial hostility in the public discourse and the steep decline in vigilante racial vio- lence are no small matter. It is also significant that the “whites only” signs are gone and that children of all colors can drink from the same water fountains, swim in the same pools, and play on the same play- grounds. Black children today can even dream of being president of the United States. Those who claim that mass incarceration is “just like” Jim Crow make a serious mistake. Things have changed. The fact that a clear Alexander, M. (2010). The new jim crow : Mass incarceration in the age of colorblindness. New Press, The. Created from towson on 2025-01-28 20:58:43. Copyright © 2010. New Press, The. All rights reserved. 252 T HE N E W J IM C ROW majority of Americans were telling pollsters in the early 1980s—when the drug war was kicking off—that they opposed race discrimination in nearly all its forms should not be dismissed lightly.60 Arguably some respondents may have been telling pollsters what they thought was appropriate rather than what they actually believed, but there is no reason to believe that most of them were lying. It is more likely that most Americans by the early 1980s had come to reject segregationist thinking and values, and not only did not want to be thought of as rac- ist but did not want to be racist. This difference in public attitudes has important implications for reform efforts. Claims that mass incarceration is analogous to Jim Crow will fall on deaf ears and alienate potential allies if advocates fail to make clear that the claim is not meant to suggest or imply that supporters of the current system are racist in the way Americans have come to understand that term. Race plays a major role—indeed, a defin- ing role—in the current system, but not because of what is commonly understood as old-fashioned, hostile bigotry. This system of control depends far more on racial indifference (defined as a lack of compassion and caring about race and people belonging to certain racial groups) than racial hostility—a feature it actually shares with its predecessors. All racial caste systems, not just mass incarceration, have been sup- ported by racial indifference. As noted earlier, many whites during the Jim Crow era sincerely believed that African Americans were inferior, and that segregation was a sensible system for managing a society com- prised of fundamentally different and unequal people. The sincerity of many people’s bigoted racial beliefs is what led Martin Luther King Jr. to declare, “Nothing in all the world is more dangerous than sincere ignorance and conscientious stupidity.” The notion that all racial caste systems are necessarily predicated on a desire to harm other racial groups, and that racial hostility is the essence of racism, is fundamentally misguided. Even slavery does not conform to this limited understanding of racism and racial caste. Not Alexander, M. (2010). The new jim crow : Mass incarceration in the age of colorblindness. New Press, The. Created from towson on 2025-01-28 20:58:43. Copyright © 2010. New Press, The. All rights reserved. T HE N E W J IM C ROW 253 all plantation owners supported the institution of slavery because of a sadistic desire to harm blacks; most wanted to get rich, and black slav- ery was the most efficient means to that end. Every plantation own- er, however, was willing to use brutality and violence to force black people into servitude, and every American— whether they lived in the North or South—knew that slavery could not be maintained without terror and the deliberate infliction of pain and suffering. The institu- tion of slavery did not require plantation owners or countless bystand- ers to be filled with racial hostility; so long as plantation owners and a critical mass of white Americans remained indifferent to the suffering inflicted on black slaves, the racial caste system could endure. Indeed, it lasted for centuries. Preoccupation with the role of racial hostility in earlier caste systems can blind us to the ways in which every caste system, including mass incarceration, has been supported by racial indifference—a lack of care and compassion for people of other races. Racial animus is a predictable and recurring feature of racial caste sys- tems, but it is not necessary for the system to function if there is wide- spread racial indifference. White victims of racial caste. We now turn to another important difference between mass incarceration and Jim Crow: the direct harm to whites caused by the current caste system. Whites never had to sit at the back of the bus during Jim Crow, but today a white man may find himself in prison for a drug offense, sharing a cell with a black man. The direct harm caused to whites caused by mass incarceration seems to distinguish it from Jim Crow; yet, like many of the other differences, this one requires some qualification. Some whites were directly harmed by Jim Crow. For example, a white woman who fell in love with a black man and hoped to spend the rest of her life with him was directly harmed by anti- miscegenation laws. The laws were intended for her benefit—to protect her from the corrupting influence of the black man and the “tragedy” of mulatto children—but she was directly harmed nonetheless. Alexander, M. (2010). The new jim crow : Mass incarceration in the age of colorblindness. New Press, The. Created from towson on 2025-01-28 20:58:43. Copyright © 2010. New Press, The. All rights reserved. 25 4 T HE N E W J IM C ROW Still, it seems obvious that mass incarceration directly harms far more whites than Jim Crow ever did. For some, this fact alone may be reason enough to reject the analogy. An “interracial racial caste system” may seem like an oxymoron. What kind of racial caste system includes white people within its control? The answer: a racial caste system in the age of colorblindness. If 100 percent of the people arrested and convicted for drug offenses were African American, the situation would provoke outrage among the majority of Americans who consider themselves nonracist and who know very well that Latinos, Asian Americans, and whites also commit drug crimes. We, as a nation, seem comfortable with 90 percent of the people arrested and convicted of drug offenses in some states being African American, but if the figure were 100 percent, the veil of color- blindness would be lost. We could no longer tell ourselves stories about why 90 percent might be a reasonable figure; nor could we continue to assume that good reasons exist for extreme racial disparities in the drug war, even if we are unable to think of such reasons ourselves. In short, the inclusion of some whites in the system of control is essen- tial to preserving the image of a colorblind criminal justice system and maintaining our self-image as fair and unbiased people. Because most Americans, including those within law enforcement, want to believe they are nonracist, the suffering in the drug war crosses the color line. Of course, the fact that white people are harmed by the drug war does not mean they are the real targets, the designated enemy. The harm white people suffer in the drug war is much like the harm Iraqi civilians suffer in U.S. military actions targeting presumed terrorists or insurgents. In any war, a tremendous amount of collateral damage is inevitable. Black and brown people are the principal targets in this war; white people are collateral damage. Saying that white people are collateral damage may sound callous, but it reflects a particular reality. Mass incarceration as we know it would not exist today but for the racialization of crime in the media Alexander, M. (2010). The new jim crow : Mass incarceration in the age of colorblindness. New Press, The. Created from towson on 2025-01-28 20:58:43. Copyright © 2010. New Press, The. All rights reserved. T HE N E W J IM C ROW 255 and political discourse. The War on Drugs was declared as part of a political ploy to capitalize on white racial resentment against Afri- can Americans, and the Reagan administration used the emergence of crack and its related violence as an opportunity to build a racial- ized public consensus in support of an all-out war—a consensus that almost certainly would not have been formed if the primary users and dealers of crack had been white. Economist Glenn Loury made this observation in his book The Anatomy of Racial Inequality. He noted that it is nearly impossible to imagine anything remotely similar to mass incarceration happening to young white men. Can we envision a system that would enforce drug laws almost exclusively among young white men and largely ignore drug crime among young black men? Can we imagine large majorities of young white men being rounded up for minor drug offens- es, placed under the control of the criminal justice system, labeled felons, and then subjected to a lifetime of discrimination, scorn, and exclusion? Can we imagine this happening while most black men landed decent jobs or trotted off to college? No, we cannot. If such a thing occurred, “it would occasion a most profound reflection about what had gone wrong, not only with THEM, but with US.” 61 It would never be dismissed with the thought that white men were simply reap- ing what they have sown. The criminalization of white men would disturb us to the core. So the critical questions are: “What disturbs us? What is dissonant? What seems anomalous? What is contrary to expectation?” 62 Or more to the point: Whom do we care about? An answer to the last question may be found by considering the dras- tically different manner in which we, as a nation, responded to drunk driving in the mid-1980s, as compared to crack cocaine. During the 1980s, at the same time crack was making headlines, a broad-based, grassroots movement was under way to address the widespread and sometimes fatal problem of drunk driving. Unlike the drug war, which was initiated by political elites long before ordinary people identified it Alexander, M. (2010). The new jim crow : Mass incarceration in the age of colorblindness. New Press, The. Created from towson on 2025-01-28 20:58:43. Copyright © 2010. New Press, The. All rights reserved. 256 T HE N E W J IM C ROW as an issue of extraordinary concern, the movement to crack down on drunk drivers was a bottom-up movement, led most notably by moth- ers whose families were shattered by deaths caused by drunk driving. Media coverage of the movement peaked in 1988, when a drunk driver traveling the wrong way on Interstate 71 in Kentucky caused a head-on collision with a school bus. Twenty-seven people died and dozens more were injured in the ensuing fire. The tragic accident, known as the Carrollton bus disaster, was one of the worst in U.S. his- tory. In the aftermath, several parents of the victims became actively involved in Mothers Against Drunk Driving (MADD), and one became its national president. Throughout the 1980s, drunk driving was a regular topic in the media, and the term designated driver became part of the American lexicon. At the close of the decade, drunk drivers were responsible for approximately 22,000 deaths annually, while overall alcohol-related deaths were close to 100,000 a year. By contrast, during the same time period, there were no prevalence statistics at all on crack, much less crack-related deaths. In fact, the number of deaths related to all illegal drugs combined was tiny compared to the number of deaths caused by drunk drivers. The total of all drug-related deaths due to AIDS, drug overdose, or the violence associated with the illegal drug trade was estimated at 21,000 annually—less than the number of deaths directly caused by drunk drivers, and a small fraction of the number of alcohol- related deaths that occur every year.63 In response to growing concern—fueled by advocacy groups such as MADD and by the media coverage of drunk-driving fatalities— most states adopted tougher laws to punish drunk driving. Numer- ous states now have some type of mandatory sentencing for this offense—typically two days in jail for a first offense and two to ten days for a second offense.64 Possession of a tiny amount of crack cocaine, on the other hand, carries a mandatory minimum sentence of five years in federal prison. Alexander, M. (2010). The new jim crow : Mass incarceration in the age of colorblindness. New Press, The. Created from towson on 2025-01-28 20:58:43. Copyright © 2010. New Press, The. All rights reserved. T HE N E W J IM C ROW 257 The vastly different sentences afforded drunk drivers and people convicted of drug offenses speaks volumes regarding who is viewed as disposable—someone to be purged from the body politic—and who is not. Drunk drivers are predominantly white and male. White men comprised 78 percent of the arrests for this offense in 1990 when new mandatory minimums governing drunk driving were being adopted.65 They are generally charged with misdemeanors and typically receive sentences involving fines, license suspension, and community service. Although drunk driving carries a far greater risk of violent death than the use or sale of illegal drugs, the societal response to drunk drivers has generally emphasized keeping the person functional and in society, while attempting to respond to the dangerous behavior through treat- ment and counseling.66 People charged with drug offenses, though, are disproportionately poor people of color. They are typically charged with felonies and sentenced to prison. Another clue that mass incarceration, as we know it, would not exist but for the race of the imagined enemy can be found in the history of drug-law enforcement in the United States. Yale historian David Musto and other scholars have documented a disturbing, though unsurprising, pattern: punishment becomes more severe when drug use is associated with people of color but softens when it is associated with whites.67 The history of marijuana policy is a good example. In the early 1900s, marijuana was perceived—rightly or wrongly—as a drug used by blacks and Mexican Americans, leading to the Boggs Act of the 1950s, penalizing first-time possession of marijuana with a sentence of two to five years in prison.68 In the 1960s, though, when marijuana became associated with the white middle class and college kids, commissions were promptly created to study whether marijuana was really as harmful as once thought. By 1970, the Comprehensive Drug Abuse Prevention and Control Act differentiated marijuana from other narcotics and lowered federal penalties.69 The same drug that had been considered fearsome twenty years earlier, when associated Alexander, M. (2010). The new jim crow : Mass incarceration in the age of colorblindness. New Press, The. Created from towson on 2025-01-28 20:58:43. Copyright © 2010. New Press, The. All rights reserved. 258 T HE N E W J IM C ROW with African Americans and Latinos, was refashioned as a relatively harmless drug when associated with whites. In view of the nation’s treatment of predominately white drunk driv- ers and drug users and dealers, it is extremely difficult to imagine that our nation would have declared all-out war on drugs if the enemy had been defined in the public imagination as white. It was the confla- tion of blackness and crime in the media and political discourse that made the drug war and the sudden, massive expansion of our prison system possible. White drug “criminals” are collateral damage in the War on Drugs because they have been harmed by a war declared with blacks in mind. While this circumstance is horribly unfortunate for them, it does create important opportunities for a multiracial, bottom- up resistance movement, one in which people of all races can claim a clear stake. For the first time in our nation’s history, it may become readily apparent to whites how they, too, can be harmed by antiblack racism—a fact that, until now, has been difficult for many to grasp. Black support for “get tough” policies. Yet another notable differ- ence between Jim Crow and mass incarceration is that many African Americans seem to support the current system of control, while most believe the same could not be said of Jim Crow. It is frequently argued in defense of mass incarceration that African Americans want more police and more prisons because crime is so bad in some ghetto com- munities. It is wrong, these defenders claim, for the tactics of mass incarceration—such as the concentration of law enforcement in poor communities of color, the stop-and-frisk programs that have prolif- erated nationwide, evictions of people and their families from pub- lic housing, and the drug sweeps of ghetto neighborhoods—to be characterized as racially discriminatory, because those programs and policies have been adopted for the benefit of African American com- munities and are supported by many ghetto residents.70 Ignoring ram- pant crime in ghetto communities would be racially discriminatory, they say; responding forcefully to it is not. Alexander, M. (2010). The new jim crow : Mass incarceration in the age of colorblindness. New Press, The. Created from towson on 2025-01-28 20:58:43. Copyright © 2010. New Press, The. All rights reserved. T HE N E W J IM C ROW 259 This argument, on the surface, seems relatively straightforward, but there are actually many layers to it, some of which are quite problem- atic. To begin with, the argument implies that most African Americans prefer harsh criminal justice policies to other forms of governmen- tal intervention, such as job creation, economic development, educa- tional reform, and restorative justice programs, as long-term solutions to problems associated with crime. There is little evidence to support that claim. In fact, surveys consistently show that African Americans are generally less supportive of harsh criminal justice policies than whites, even though blacks are far more likely to be victims of crime.71 This pattern is particularly striking given that less educated people tend to be more punitive and blacks on average are less educated than whites.72 The notion that African Americans support “get tough” approaches to crime is further complicated by the fact that “crime” is not a generic category. There are many different types of crime, and violent crime tends to provoke the most visceral and punitive response. Yet as we have seen in chapter 2, the drug war has not been aimed at rooting out the most violent drug traffickers, or so-called kingpins. The vast majority of those arrested for drug crimes are not charged with seri- ous offenses, and most of the people in state prison on drug charges have no history of violence or significant selling activity. Those who are “kingpins” are often able to buy their freedom by forfeiting their assets, snitching on other dealers, or becoming paid government infor- mants. Thus, to the extent that some African Americans support harsh policies aimed at people who commit violent crimes, they cannot be said to support the War on Drugs, which has been waged primarily against people who have allegedly committed nonviolent, low-level drug crimes in communities of color. The one thing that is clear from the survey data and ethnographic research is that African Americans in ghetto communities experience an intense “dual frustration” regarding crime and law enforcement. As Alexander, M. (2010). The new jim crow : Mass incarceration in the age of colorblindness. New Press, The. Created from towson on 2025-01-28 20:58:43. 260 T HE N E W J IM C ROW Copyright © 2010. New Press, The. All rights reserved. Glenn Loury explained more than a decade ago, when violent crime rates were making headlines, “The young black men wreaking havoc in the ghetto are still ‘our youngsters’ in the eyes of many of the decent poor and working-class black people who sometimes are their vic- tims.”73 Throughout the black community, there is widespread aware- ness that black ghetto youth have few, if any, realistic options, and therefore dealing drugs can be an irresistible temptation. Suburban white youth may deal drugs to their friends and acquaintances as a form of recreation and extra cash, but for impoverished black youth, drug sales—though rarely lucrative—are often a means of survival, a means of helping to feed and clothe themselves and their families. The fact that this “career” path leads almost inevitably to jail is often understood as an unfortunate fact of life, part of what it means to be poor and black in America. Women, in particular, express complicated, conflicted views about crime, because they love their sons, husbands, and partners and under- stand their plight as current and future members of the racial under- caste. At the same time, though, they abhor gangs and the violence associated with inner-city life. One commentator explained, “African American women in poor neighborhoods are torn. They worry about their young sons getting involved in gang activity. They worry about their sons possibly selling or using drugs. They worry about their chil- dren getting caught in the crossfire of warring gangs. . . . These moth- ers want better crime and law enforcement. Yet, they understand that increased levels of law enforcement potentially saddle their children with a felony conviction—a mark that can ensure economic and social marginalization.”74 Given the dilemma facing poor black communities, it is inaccurate to say that black people “support” mass incarceration or “get tough” poli- cies. The fact that some black people endorse harsh responses to crime is best understood as a form of complicity with mass incarceration— not support for it. This complicity is perfectly understandable, for Alexander, M. (2010). The new jim crow : Mass incarceration in the age of colorblindness. New Press, The. Created from towson on 2025-01-28 20:58:43. T HE N E W J IM C ROW 261 Copyright © 2010. New Press, The. All rights reserved. the threat posed by crime— particularly violent crime—is real, not imagined. Although African Americans do not engage in drug crime at significantly higher rates than whites, black men do have much higher rates of violent crime, and violent crime is concentrated in ghetto communities. Studies have shown that joblessness—not race or black culture— explains the high rates of violent crime in poor black communities. When researchers have controlled for joblessness, dif- ferences in violent crime rates between young black and white men disappear.75 Regardless, the reality for poor blacks trapped in ghettos remains the same: they must live in a state of perpetual insecurity and fear. It is perfectly understandable, then, that some African Americans would be complicit with the system of mass incarceration, even if they oppose, as a matter of social policy, the creation of racially isolated ghettos and the subsequent transfer of black youth from underfunded, crumbling schools to brand-new, high-tech prisons. In the era of mass incarceration, poor African Americans are not given the option of great schools, community investment, and job training. Instead, they are offered police and prisons. If the only choice that is offered blacks is rampant crime or more prisons, the predictable (and understand- able) answer will be “more prisons.” The predicament African Americans find themselves in today is not altogether different from the situation they faced during Jim Crow. Jim Crow, as oppressive as it was, offered a measure of security for blacks who were willing to play by its rules. Those who flouted the rules or resisted them risked the terror of the Klan. Cooperation with the Jim Crow system often seemed far more likely to increase or maintain one’s security than any alternative. That reality helps to explain why African American leaders such as Booker T. Washington urged blacks to focus on improving themselves rather than on challenging racial discrimination. It is also why the Civil Rights Movement initially met significant resistance among some African Americans in the South. Civil rights advocates strenuously argued that it was the mentality Alexander, M. (2010). The new jim crow : Mass incarceration in the age of colorblindness. New Press, The. Created from towson on 2025-01-28 20:58:43. 262 T HE N E W J IM C ROW Copyright © 2010. New Press, The. All rights reserved. and ideology that gave rise to Jim Crow that was the real source of the danger experienced by blacks. Of course they were right. But it is understandable why some blacks believed their immediate safety and security could best be protected by cooperation with the prevailing caste system. The fact that black people during Jim Crow were often complicit with the system of control did not mean they supported racial oppression. Disagreements within the African American community about how best to respond to systems of control—and even disagreements about what is, and is not, discriminatory—have a long history. The notion that black people have always been united in opposition to American caste systems is sheer myth. Following slavery, for exam- ple, there were some African Americans who supported disenfran- chisement because they believed that black people were not yet “ready” for the vote. Former slaves, it was argued, were too illiterate to exercise the vote responsibly, and were ill-prepared for the duties of public office. This sentiment could even be found among black politicians such as Isaiah T. Montgomery, who argued in 1890 that voting rights should be denied to black people because enfranchise- ment should only be extended to literate men. In the same vein, a fierce debate raged between Booker T. Washington and W.E.B. Du Bois about whether—and to what extent—racial bias and discrim- ination were responsible for the plight of the Negro and ought to be challenged. Du Bois praised and embraced Washington’s empha- sis on “thrift, patience, and industrial training for the masses,” but sharply disagreed with his public acceptance of segregation, dis- enfranchisement, and legalized discrimination. In Du Bois’s view, Washington’s public statements arguing that poor education and bad choices were responsible for the plight of former slaves ignored the damage wrought by caste and threatened to rationalize the entire system. In Du Bois’s words: Alexander, M. (2010). The new jim crow : Mass incarceration in the age of colorblindness. New Press, The. Created from towson on 2025-01-28 20:58:43. T HE N E W J IM C ROW [T] he distinct impression left by Mr. Washington’s pro- paganda is, first, that the South is justified in its present attitude toward the Negro because of the Negro’s degrada- tion; second, that the prime cause of the Negro’s failure to rise more quickly is his wrong education in the past; and, thirdly, that his future rise depends primarily on his own efforts. Each of these propositions is a dangerous half- truth. . . . [Washington’s] doctrine has tended to make the whites, North and South, shift the burden of the Negro problem to the Negro’s shoulders and stand aside as criti- cal and rather pessimistic spectators; when in fact the bur- den belongs to the nation, and the hands of none of us are clean if we bend not our energies to righting these great wrongs.76 263 Copyright © 2010. New Press, The. All rights reserved. Today, a similar debate rages in black communities about the under- lying causes of mass incarceration. While some argue that it is attribut- able primarily to racial bias and discrimination, others maintain that it is due to poor education, unraveling morals, and a lack of thrift and perseverance among the urban poor. Just as former slaves were viewed (even among some African Americans) as unworthy of full citizenship due to their lack of education and good morals, today similar argu- ments can be heard from black people across the political spectrum who believe that reform efforts should be focused on moral uplift and education for ghetto dwellers, rather than challenging the system of mass incarceration itself. Scholars, activists, and community members who argue that mor- al uplift and education provide the best solution to black criminal- ity and the phenomenon of mass incarceration have been influenced by what Evelyn Brooks Higginbotham has called the “politics of respectability”—a politics that was born in the nineteenth century Alexander, M. (2010). The new jim crow : Mass incarceration in the age of colorblindness. New Press, The. Created from towson on 2025-01-28 20:58:43. Copyright © 2010. New Press, The. All rights reserved. 264 T HE N E W J IM C ROW and matured in the Jim Crow era.77 This political strategy is predicated on the notion that the goal of racial equality can only be obtained if black people are able to successfully prove to whites that they are worthy of equal treatment, dignity, and respect. Supporters of the politics of respectability believe that African Americans, if they hope to be accepted by whites, must conduct themselves in a fashion that elicits respect and sympathy rather than fear and anger from other races. They must demonstrate through words and deeds their ability to live by and aspire to the same moral codes as the white middle class, even while they are being discriminated against wrongly.78 The basic theory underlying this strategy is that white Americans will abandon discriminatory practices if and when it becomes apparent that black people aren’t inferior after all. The politics of respectability made sense to many black reform- ers during the Jim Crow era, since African Americans had no vote, could not change policy, and lived under the constant threat of the Klan. Back then, the only thing black people could control was their own behavior. Many believed they simply had no choice, no realis- tic option, but to cooperate with the caste system while conducting themselves in a such a dignified and respectable manner that it would eventually become obvious to whites that their bigotry was misplaced. This strategy worked to some extent for a segment of the African American community, particularly those who had access to educa- tion and relative privilege. But a much larger segment—those who were uneducated and desperately poor—found themselves unable, as one historian put it, “to conform to the gender roles, public behav- ior, and economic activity deemed legitimate by bourgeois America but which the forces of Jim Crow sought to prevent black people from achieving.”79 In many cases, the relatively privileged black elite turned against the black urban poor, condemning them and distancing them- selves, while at the same time presenting themselves as legitimate spokespeople for the disadvantaged. It was a pattern that would repeat Alexander, M. (2010). The new jim crow : Mass incarceration in the age of colorblindness. New Press, The. Created from towson on 2025-01-28 20:58:43. Copyright © 2010. New Press, The. All rights reserved. T HE N E W J IM C ROW 265 itself in cities throughout the United States, as black communities found themselves embroiled in deep conflict over goals and strategies pursued by the black elite. What happened in Atlanta in the wake of the New Deal is a case in point. During Jim Crow, all black people in Atlanta were bound together by the racial caste system, but there was a significant group of African Americans who were well educated and had influence in the halls of power. Numerous black colleges were located in Atlanta, and the city was home to the South’s largest population of college- educated African Americans. Members of this relatively elite group believed they could prove their respectability to white Americans and often blamed less educated blacks for sabotaging their quest for racial equality, espe- cially when they committed crimes or failed to conform to white, middle- class norms of dress, cleanliness, and behavior. In the view of these black elites, a “poverty complex” plagued the black poor, one that made them politically apathetic and content with broken-down, overcrowded, and dirty living conditions.80 For decades, black elites engaged in private rescue efforts to make black communities tidy, clean, and respectable in a futile effort to gain white approval.81 Eventually, these rescue efforts gave way to black endorsement of harmful policies aimed at the urban poor. In the 1930s and ear- ly 1940s, President Franklin D. Roosevelt began to roll out the New Deal—a massive public works and investment program designed to lift the nation out of a severe depression. Almost immediately, black elites recognized the opportunity for the individual and collective advance- ment of Negroes who could present themselves favorably to whites. Some black Atlantans were brought from the margins into the sphere of opportunity by New Deal programs, but most were left behind. As historian Karen Ferguson observes, “when [black reformers] had the opportunity to determine the recipients of New Deal largesse, they did not choose the ‘mudsills’ of the black working class but rather the more prosperous elements who were more able to be respectable Alexander, M. (2010). The new jim crow : Mass incarceration in the age of colorblindness. New Press, The. Created from towson on 2025-01-28 20:58:43. 266 T HE N E W J IM C ROW Copyright © 2010. New Press, The. All rights reserved. according to the reformers’ vision.”82 Far from prioritizing the needs of the least advantaged, many black reformers began aggressively pursu- ing policy reforms that would benefit the black elite to the detriment of the poorest segments of the black community. Some of the most discriminatory federal programs of the New Deal era, including the slum-clearance program, received strong support from African Ameri- can bureaucrats and reformers who presented themselves as speaking for the black community as a whole.83 Although many poor African Americans rejected the philosophies, tactics, and strategies of the black elite, ultimately moral uplift ideol- ogy became the new common sense. Not just in Atlanta but in cities nationwide, the tensions and debates between black reformers strug- gling to improve and uplift the “slum dwellers” and those committed to challenging discrimination and Jim Crow directly played out over and over again. Black elites found they had much to gain by position- ing themselves as “race managers,” and many poor African Americans became persuaded that perhaps their degraded status was, after all, their own fault. Given this history, it should come as no surprise that today some black mayors, politicians, and lobbyists—as well as preachers, teach- ers, barbers, and ordinary folk—endorse “get tough” tactics and spend more time chastising the urban poor for their behavior than seeking meaningful policy solutions to the appalling conditions in which they are forced to live and raise their children. The fact that many African Americans endorse aspects of the current caste system and insist that the problems of the urban poor can be best explained by their behav- ior, culture, and attitude does not, in any meaningful way, distinguish mass incarceration from its predecessors. To the contrary, these atti- tudes and arguments have their roots in the struggles to end slavery and Jim Crow. Many African Americans today believe that uplift ideology worked in the past and ought to work again—forgetting that ultimately it took a major movement to end the last caste system, not simply good Alexander, M. (2010). The new jim crow : Mass incarceration in the age of colorblindness. New Press, The. Created from towson on 2025-01-28 20:58:43. Copyright © 2010. New Press, The. All rights reserved. T HE N E W J IM C ROW 267 behavior. Many black people are confused—and the black commu- nity itself is divided— about how best to understand and respond to mass incarceration. A seemingly colorblind system has emerged that locks millions of African Americans into a permanent undercaste, and it appears that those who are trapped within it could have avoided it simply by not committing crimes. Isn’t the answer not to challenge the system but to try to avoid it? Shouldn’t the focus be on improving ourselves, rather than challenging a biased system? Familiar questions are asked decades after the end of the old Jim Crow. Once again, com- plicity with the prevailing system of control may seem like the only option. Parents and schoolteachers counsel black children that, if they ever hope to escape this system and avoid prison time, they must be on their best behavior, raise their arms and spread their legs for the police without complaint, stay in failing schools, pull up their pants, and refuse all forms of illegal work and moneymaking activity, even if jobs in the legal economy are impossible to find. Girls are told not to have children until they are married to a “good” black man who can help provide for a family with a legal job. They are told to wait and wait for Mr. Right even if that means, in a jobless ghetto, never having children at all. When black youth find it difficult or impossible to live up to these standards—or when they fail, stumble, and make mistakes, as all humans do— shame and blame is heaped upon them. If only they had made different choices, they’re told sternly, they wouldn’t be sitting in a jail cell; they’d be graduating from college. Never mind that white children on the other side of town who made precisely the same choices— often for less compelling reasons—are in fact going to college. The genius of the current caste system, and what most distinguishes it from its predecessors, is that it appears voluntary. People choose to commit crimes, and that’s why they are locked up or locked out, we are told. This feature makes the politics of responsibility particularly Alexander, M. (2010). The new jim crow : Mass incarceration in the age of colorblindness. New Press, The. Created from towson on 2025-01-28 20:58:43. 268 T HE N E W J IM C ROW Copyright © 2010. New Press, The. All rights reserved. tempting, as it appears the system can be avoided with good behavior. But herein lies the trap. All people make mistakes. All of us are sinners. All of us are criminals. All of us violate the law at some point in our lives. In fact, if the worst thing you have ever done is speed ten miles over the speed limit on the freeway, you have put yourself and others at more risk of harm than someone smoking marijuana in the privacy of his or her living room. Yet there are people in the United States serving life sentences for first-time drug offenses, something virtually unheard of anywhere else in the world. The notion that a vast gulf exists between “criminals” and those of us who have never served time in prison is a fiction created by the racial ideology that birthed mass incarceration, namely that there is something fundamentally wrong and morally inferior about “them.” The reality, though, is that all of us have done wrong. As noted earlier, studies suggest that most Americans violate drug laws in their lifetime. Indeed, most of us break the law not once but repeatedly throughout our lives. Yet only some of us will be arrested, charged, convicted of a crime, branded a criminal or felon, and ushered into a permanent undercaste. Who becomes a social pariah and excommunicated from civil society and who trots off to college bears scant relationship to the morality of crimes committed. Who is more blameworthy: the young black kid who hustles on the street corner, selling weed to help his momma pay the rent? Or the college kid who deals drugs out of his dorm room so that he’ll have cash to finance his spring break? Who should we fear? The kid in the ’hood who joined a gang and now car- ries a gun for security, because his neighborhood is frightening and unsafe? Or the suburban high school student who has a drinking prob- lem but keeps getting behind the wheel? Our racially biased system of mass incarceration exploits the fact that all people break the law and make mistakes at various points in their lives and with varying degrees of justification. Screwing up—failing to live by one’s highest ideals and values—is part of what makes us human. Alexander, M. (2010). The new jim crow : Mass incarceration in the age of colorblindness. New Press, The. Created from towson on 2025-01-28 20:58:43. T HE N E W J IM C ROW 269 Urging the urban poor—or anyone—to live up to their highest ide- als and values is a good thing, as it demonstrates confidence in the ability of all people to stretch, grow, and evolve. Even in the most dire circumstances, we all have power and agency, the ability to choose what we think and how we respond to the circumstances of our lives. Moreover, we all have duties and responsibilities to each other, not the least of which is to do no harm. We ought never excuse violence or tolerate behavior that jeopardizes the safety and security of others. Just as all people—no matter who they are or what they have done— ought to be regarded as having basic human rights to work, housing, educa- tion, and food, residents of all communities have a basic human right to safety and security. The intuition underlying moral- uplift strategies is fundamentally sound: our communities will never thrive if we fail to respect ourselves and one another. As a liberation strategy, however, the politics of responsibility is doomed to fail—not because there is something especially wrong with those locked in ghettos or prisons today, but because there is noth- ing special about them. They are merely human. They will continue to make mistakes and break the law for reasons that may or may not be justified; and as long as they do so, this system of mass incarcera- tion will continue to function well. Generations of black men will con- tinue to be lost— rounded up for crimes that go ignored on the other side of town and ushered into a permanent second-class status. It may seem at first blush that cooperating with the system while urging good behavior is the only option available, but in reality it is not a liberation strategy at all. Copyright © 2010. New Press, The. All rights reserved. Fork in the Road Du Bois got it right a century ago: “the burden belongs to the nation, and the hands of none of us are clean if we bend not our energies to righting these great wrongs.” The reality is that, just a few decades after Alexander, M. (2010). The new jim crow : Mass incarceration in the age of colorblindness. New Press, The. Created from towson on 2025-01-28 20:58:43. Copyright © 2010. New Press, The. All rights reserved. 270 T HE N E W J IM C ROW the collapse of one caste system, we constructed another. Our nation declared a war on people trapped in racially segregated ghettos—just at the moment their economies had collapsed—rather than provid- ing community investment, quality education, and job training when work disappeared. Of course those communities are suffering from serious crime and dysfunction today. Did we expect otherwise? Did we think that, miraculously, they would thrive? And now, having waged this war for decades, we claim some blacks “support” mass incarcera- tion, as though they would rather have their young men warehoused in prison than going off to college. As political theorist Tommie Shelby has observed, “Individuals are forced to make choices in an environ- ment they did not choose. They would surely prefer to have a broader array of good opportunities. The question we should be asking—not instead of but in addition to questions about penal policy—is whether the denizens of the ghetto are entitled to a better set of options, and if so, whose responsibility it is to provide them.”84 Clearly a much better set of options could be provided to African Americans—and poor people of all colors—today. As historian Lerone Bennett Jr. eloquently reminds us, “a nation is a choice.” We could choose to be a nation that extends care, compassion, and concern to those who are locked up and locked out or headed for prison before they are old enough to vote. We could seek for them the same oppor- tunities we seek for our own children; we could treat them like one of “us.” We could do that. Or we could choose to be a nation that shames and blames its most vulnerable, affixes badges of dishonor upon them at young ages, and then relegates them to a permanent second-class status for life. That is the path we have chosen, and it leads to a famil- iar place. We faced a fork in the road one decade after Martin Luther King Jr. and Malcolm X were laid to rest. As described in chapter 1, dur- ing the late 1970s, jobs had suddenly disappeared from urban areas across America, and unemployment rates had skyrocketed. In 1954, Alexander, M. (2010). The new jim crow : Mass incarceration in the age of colorblindness. New Press, The. Created from towson on 2025-01-28 20:58:43. Copyright © 2010. New Press, The. All rights reserved. T HE N E W J IM C ROW 271 black and white youth unemployment rates in America were equal, with blacks actually having a slightly higher rate of employment in the age group sixteen to nineteen. By 1984, however, the black unemploy- ment rate had nearly quadrupled, while the white rate had increased only marginally.85 This was not due to a major change in black values, behavior, or culture; this dramatic shift was the result of deindustrial- ization, globalization, and technological advancement. Urban factories shut down as our nation transitioned to a service economy. Suddenly African Americans were trapped in jobless ghettos, desperate for work. The economic collapse of inner-city black communities could have inspired a national outpouring of compassion and support. A new War on Poverty could have been launched. Economic stimulus packages could have sailed through Congress to bail out those trapped in jobless ghettos through no fault of their own. Education, job training, public transportation, and relocation assistance could have been provided, so that youth of color would have been able to survive the rough tran- sition to a new global economy and secure jobs in distant suburbs. Constructive interventions would have been good not only for African Americans trapped in ghettos, but also for blue-collar workers of all colors, many of whom were suffering too, if less severely. A wave of compassion and concern could have flooded poor and working-class communities in honor of the late Martin Luther King Jr. All of this could have happened, but it didn’t. Instead our nation declared a War on Drugs. The collapse of inner-city economies coincided with the conser- vative backlash against the Civil Rights Movement, resulting in the perfect storm. Almost overnight, black men found themselves unnec- essary to the American economy and demonized by mainstream soci- ety. No longer needed to pick cotton in the fields or labor in factories, lower-class black men were hauled off to prison in droves. They were vilified in the media and condemned for their condition as part of a well-orchestrated political campaign to build a new white, Republican Alexander, M. (2010). The new jim crow : Mass incarceration in the age of colorblindness. New Press, The. Created from towson on 2025-01-28 20:58:43. Copyright © 2010. New Press, The. All rights reserved. 272 T HE N E W J IM C ROW majority in the South. Decades later, curious onlookers in the grips of denial would wonder aloud, “Where have all the black men gone?” No one has made this point better than sociologist Loïc Wacquant. Wacquant has written extensively about the cyclical nature of racial caste in America. He emphasizes that the one thing that makes the current penal apparatus strikingly different from previous racial caste systems is that “it does not carry out the positive economic mission of recruitment and disciplining of the workforce.”86 Instead it serves only to warehouse poor black and brown people for increasingly lengthy periods of time, often until old age. The new system does not seek primarily to benefit unfairly from black labor, as earlier caste systems have, but instead views African Americans as largely irrelevant and unnecessary to the newly structured economy—an economy that is no longer driven by unskilled labor. It is fair to say that we have witnessed an evolution in the Unit- ed States from a racial caste system based entirely on exploitation (slavery), to one based largely on subordination (Jim Crow), to one defined by marginalization (mass incarceration). While marginaliza- tion may sound far preferable to exploitation, it may prove to be even more dangerous. Extreme marginalization, as we have seen through- out world history, poses the risk of extermination. Tragedies such as the Holocaust in Germany or ethnic cleansing in Bosnia are traceable to the extreme marginalization and stigmatization of racial and ethnic groups. As legal scholar john a. powell once commented, only half in jest, “It’s actually better to be exploited than marginalized, in some respects, because if you’re exploited presumably you’re still needed.”87 Viewed in this light, the frantic accusations of genocide by poor blacks in the early years of the War on Drugs seem less paranoid. The intuition of those residing in ghetto communities that they had suddenly become disposable was rooted in real changes in the economy—changes that have been devastating to poor black commu- nities as factories have closed, low-skill jobs have disappeared, and Alexander, M. (2010). The new jim crow : Mass incarceration in the age of colorblindness. New Press, The. Created from towson on 2025-01-28 20:58:43. T HE N E W J IM C ROW 273 all those who had the means to flee the ghetto did. The sense among those left behind that society no longer has use for them, and that the government now aims simply to get rid of them, reflects a reality that many of us who claim to care prefer to avoid simply by changing channels. Copyright © 2010. New Press, The. All rights reserved. Alexander, M. (2010). The new jim crow : Mass incarceration in the age of colorblindness. New Press, The
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