Content warning: This section of the guide discusses systemic racism and poverty, patient neglect and abuse, and drug use.

“My hope is that their story—and the stories of the hospitals and clinics that are barely surviving in poor neighborhoods—will be taken seriously by the leaders calling for change in America’s health care system. Any reform plan that aspires to be both effective and just must pay careful attention to the day-to-day experiences of poor families. Anything less is not worth the effort.”

Abraham makes her mission statement for the book in the Introduction, directly addressing “leaders” (presumably lawmakers) as those whom she wants her message to reach. For 21st-century readers, this declaration places Mama Might Be Better Off Dead within the context of a long campaign of healthcare reform that is ongoing.

“From her perspective, the eight-lane highway is an escape route for the employees of the various hospitals and social service institutions, for people who do not carry poverty home with them in a plastic bag.”

Abraham frequently takes on the perspectives of the Banes family, paraphrasing their ideas, as she does with Jackie here. The comparison of the highway to an escape route is a politically pointed one that hints at the profound distrust and Misunderstandings Between Medical Workers and Marginalized Patients that will be revealed throughout the rest of the book.

“Robert tries to curry Jackie’s favor with small gestures such as pretending not to smoke and buying her a box of candy when she gets mad. What Jackie wants most, though, is for him to stay away from cocaine, and that he has a harder time doing. He sometimes goes weeks, even a month or two, without using cocaine but then binges and spends every cent he can find on drugs. That leaves Jackie straining to meet her household budget, and it cannot be good for Robert’s health. Robert refuses to discuss drugs with anyone but Jackie and then only if she pushes the issue.”

The internal dynamics of the Banes family, including the building tension in Robert and Jackie’s marriage, are small-scale conflicts that Abraham ties directly to the difficulties they face navigating the healthcare system. Robert’s drug use is an issue that clearly weighs heavily on the family, both emotionally and financially. However, here are the first inklings of boundaries between Abraham and her subjects. This distance between the narrator and the story highlights the fact that Abraham’s insights are inherently limited in some key ways as an outsider.