The idea that paying people to stay home during a pandemic isn’t “cost-effective” is possible under a status quo where health is seen as an individual characteristic & responsibility, & thus, HC costs must be borne by individuals, regardless of the structural drivers of illness
If anything, a pandemic shows us the limits of methodological individualism in biomedicine & public health.
But that doesn’t mean that limit is heeded as the least protected & most marginalized individuals are expected to bear the weight of state failure.
"The #SDoH framework similarly allows certain “acceptable” structural problems to become visible and treatable, while downplaying problems that might more substantively challenge the structures that the framework operates within."
1) Racism is a fundamental cause 2) The SDoHs are structured by racism & other forms of oppression within society 3) The framework addresses downstream effects of racism, not racism itself. It does not grasp the root.
We’re not going to medicalize our way out of the social inequities that are killing Black, indigenous... folks.
Just as we’re not going to medicalize our way out of the social inequities that are killing LGBTQI2... folks. Gender & sexual orientation have long been medicalized (frequently as a ‘deviation’ from a heterosexist & cis-sexist norm) & it has not brought us well-being or justice.
I’ll spell it out:
Medicalization is a sure fire way of making people & communities who bear the brunt of social inequities into *the social problems*.
And frequently, medicalization demands individual-level solutions based in the same stigma that produces health inequities.
Saying that un(der)insured people who forego care are ‘infecting’ others is to frame them as embodied social problems, when the problem is that healthcare is inaccessible & inequitable, rationed by employment status & income amid structural unemployment.
The language we use is so important- especially in an emergent situation where danger is unevenly distributed (older & immunocompromised people). It communicates who does or does not matter
E.g. most of the messaging WRT mask use excludes people who are immunocompromised.
See also: calls for quarantine & isolation (not equivalent in public health parlance) that ignore the reality that most workers in the US- esp. low-paid workers- do not get paid sick leave. If folks are already un(der)insured & foregoing care, they can’t afford to miss work.
“A new NIH-funded study of more than 175,000 U.S. women diagnosed with breast cancer from 2010-2016 has found that nearly half of the troubling [racial] disparity in breast cancer detection can be traced to lack of adequate health insurance.” directorsblog.nih.gov/2020/01/21/ins…
- Employer-sponsored insurance as the primary means of coverage among working-age people
- Amid structural unemployment, which disproportionately affects Black & indigenous folks
- & these same communities have poorer spatial access to care (PCPs & specialist)
This conversation about addressing social needs or SDoH in healthcare provision highlights the need to revisit the fundamentals:
- social inequity patterns health outcomes
- healthcare intervenes @ the level of the individual *after* the cumulative disadvantages take a toll
- you can address patient-level "social needs" in the short term and not see an effect in long-term health status changes because the fundamental causes have not changed, & the cumulative disadvantage compounds as they age
- social needs are NOT SDoH
And this folds into itself:
- in conjunction with the ways that social inequity pattern poor health outcomes, social inequity patterns inequities in access to the care necessary to remedy the outcomes of social inequity
Periodic reminder that “we are all immigrants” is false.
The US is a settler colony built on the forcible exploitation of trafficked & enslaved Africans, genocidal displacement & dispossession of indigenous people, & the concurrent transfer of stolen ‘wealth’ to white settlers.
Further, the history of immigration & asylum regimes in this settler colony highlights the quotidian violence that upholds the border. Quotas, excluding sick & disabled people, redefining indigenous people as ‘foreign’ when the border crossed them.
Further, a study of immigration law & asylum processes in this settler colony is a study of racism itself.
I don’t think I have ever explicitly talked about my approach to talking about race/ism (phrasing coined by Shay Akil McLean).
Some thoughts below 👇🏾
I take a more materialist approach that does not linger on discourses of racist ‘inferiority’ or ‘superiority’. Instead, I focus on the material consequences of the political & socio-spatial ordering of society under racism & related systems of oppression
I am not preoccupied with defending people who are negatively racialized as Other (Black, indigenous, AfroLatinx... along the skin color & class gradients) against white supremacist narratives of ‘inferiority’ or ‘insufficiency.’ Too often, that’s a trap.
No, racism is not a Social Determinant of Health (SDoH).
Racism is a root cause of the social arrangements that allocate life to some (white, wealthy, non-disabled), and premature death to others (racialized Others, impoverished, underpaid, sick & disabled).
.@MatthewLeeMPH (who I suggest following!) rightly suggests reading Link & Phelan's work on fundamental causes 👇🏾
I can’t get with arguments to the tune of ‘social justice is the core of medicine’ or ‘social justice is core to public health’ because both fields are so heavily rooted in eugenics. There is no eugenics (positive or negative) without medical & public health practitioners.
I mean, think of the convergence in the ‘harvesting’ of Henrietta Lacks’ cells without consent. The broader context of paternalistic health care provision- whereby impoverished & Black patients implicitly traded all privacy/right to consent for care in ‘charity’ hospitals.
Consider that in the context of the Flexner Report a few decades before- the closure of medical schools that trained Black doctors/nurses, the continued segregation of/closure of Black community-serving hospitals- which reinforced the sorting of Black PTs into charity hospitals.
I finally put my finger on why the ‘Moving to Opportunity’ study- conceptually & epistemologically- raises 🚩🚩🚩 for me:
- imputes mechanistic nature to social relations
- treats poverty as an exposure or state (not an outcome of policy w/ intergenerational effects)
- places onus on impoverished people to move to ‘opportunity’, despite a wealth of social scientific work on placing opportunities where people are
- side-steps the problem of social networks & capital- how moving often disrupts those
- treats places as simply filled in spaces
But, all of these objections arise from my orientation as a social scientist & a geographer. I begin w/ the assumptions:
- poverty & income inequity are policy choices
- mechanisms: social sorting in social space via residential segregation & rationing by price in rental market
My least favorite form of critique is calling systems "broken" when they are working as designed.
"omg financializing crisis isn't actually incentivizing responses to crises! it's as if the arbitrary mortality thresholds were defined by people unaffected by said crises!"
Things that are not "broken":
- a financial system that favors the "haves" by dispossessing/producing "have nots"
- the carceral state & its extension, surveillance capitalism
- highly marketized health care systems that ration care, disadvantaging improverished, racialized PTs