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am honored and grateful for the care that Javier Arbona, Paul Jackson, Becky Mansfield, and Katherine McKittrick have taken in their thoughtful responses to Health Rights Are Civil Rights. And my tremendous thanks also to Shiloh Krupar for organizing this review and an author meets critic session at the Association of American Geographers meeting in Tampa in 2014. Theirs is the kind of care and intellectual generosity that sustains academic life, especially in difficult political times. In my essay, I’d like to respond to some of the issues that the reviewers make regarding the double-edgedness of health and the ongoing relevance of histories of 1960s and 1970s health activism to the current moment.
The School of Public Health in which I teach proudly upholds social justice in its mission. Public health is a field in which population health is operationalized in concrete and abstract ways – epidemiological and biostatistical analyses become the “evidence base” for programmatic and policy interventions. And this science of health is held in tension with values of participation, community engagement, and cultural humility. The politics of knowledge – whose definitions, categories, and explanations of health count – are part of public health as a field and professional practice. And no less so for what we might mean by social justice.
One of the ways to make this ethic concrete (and necessarily contested) is through our curriculum. My colleague Lorraine Halinka Malcoe, who is trained as a social epidemiologist, and I developed a class that all of our Master’s students focusing on policy and epidemiology take. I think of the class as social theory for public health professionals. Our objective for the course is to provide students with the skills to analyze the structural relations that produce health and health inequities and to make health interventions that promote health equity. As such, it’s a gratifying challenge to build history (of public health thought and practice), theory (on the social construction of race, gender, sexuality, and health), and geography (on the politics of scale, racial capitalism, and the city) into one MPH course.
The double-edged quality of health that Becky Mansfield and Javier Arbona speak to, are part of discourses, institutions, and practices of health that we in this course and health workers necessarily navigate. The history of health is not simply one of benevolence and scientific advances, but it is also one where violence, racialization, exploitation, and exclusion have been fundamental to constituting knowledge of human biology and “health” for some. It can be easy to approach shameful histories of medical testing or public health’s involvement in the racialized policing of national boundaries as egregious practices of the past that we are now enlightened enough to avoid. This narrative of progress is bolstered by discourses of continuous assessment, quality improvement, and perhaps even reflexivity.
Given the largely positive connotations of health (though far more contested role for government interventions, from the left and right), it can be far more difficult to recognize (and contest) the contemporary power relations shaping health, how the term and associated institutions and resources are operationalized, and the contradictory ways in which groups benefit from and are subject to its disciplinary and regulatory power. Articles on the principle of “health in all policies,” which has become a hallmark of contemporary public health practice, for example, often read as if health was not already part of many policies. But, health continues to be part of US Immigration and Naturalization Act provisions for determining whether non-citizens may be granted entry to the United States. Or, as I show in HRCR building on the work of Laura Pulido and historian David Freund, health is embedded in private property values and land use policy. Asking how and to what end health shall be part of policy (be it in housing, transportation, agricultural, trade, or criminal justice) also requires (to my mind at least) a historically and theoretically informed understanding of the power relations of health. (Calls for health equity in all policies and health equity impact assessments seem closer to the mark for establishing a clearer objective.)
I like to think of the insurgent doctors, medical students, and other professionally trained health practitioners that I write about in Health Rights Are Civil Rights as abolitionists. The reference harkens from health workers about whom I write who were contesting both war and structural violence. The only medical diagnosis for surviving nuclear war, they contended, is not perpetuating that war. Likewise, working to end the root causes of many of the afflictions that bring people to the doctor would also diminish the need for many curative services. From these professionals and many other people we learn that health can become an insurgent category for people struggling to identify the source of ailments – say, industrial or nuclear toxics – or a resonant avenue for political analysis and mobilization. That is, health is part of, though certainly is not captured by categories of biomedicine or biopower. Conceptualizations of health remain as politically expansive as concepts like collective and intergenerational trauma used to theorize, document, heal from, and organize around histories of racial terror and how such violence becomes embodied, accumulates over time, and circulates interpersonally. Or we can think of Iraq Veterans Against War’s campaign for healing, which for IVAW includes supporting soldiers’ resistance to redeploying and reparations for countries against which the US has waged wars.
If “War is Not Healthy for Children and Other Living Things” as Another Mother for Peace contended, and if “America’s Greatest Health Problem is Fascist Pig Brutality,” as the Black Panther Party observed, what would a health impact assessment for (ever increasing) spending on war and policing reveal? One reason why I insist upon thinking about health in relation to violence is an obvious one, that health tends to be understood as the opposite of violence, a conceptualization that can erase how health knowledge and practices are part of war-making. We can think of the ongoing controversies over the adequacy of veterans health care, or about a medical doctor whom I discuss in HRCR who refused to train medics for the Vietnam War, Nadine Ehler’s (2012) exploration of the chemical warfare of cancer treatment, Shiloh Krupar’s work in Hot Spotter’s Report (2013) about how epidemiological methods are being deployed to deny sick defense workers their compensation claims, or the revelations reported by NPR of the testing of mustard gas on Black, Japanese-American, and Puerto Rican soldiers during World War II. Or we can also think about New York Congressman Peter King’s defense of NYPD Police Officer Daniel Pantaleo in killing of Eric Garner. After the grand jury refused to indict Pantaleo for choking Garner to death, King asserted:
“If he [Eric Garner] had not had asthma, and a heart condition, and was so obese, he would not have died from this.”
The Congressman turns Garner’s own bodily vulnerability into the cause of his death, erasing this incident of violence and related violence of systematic policing. (We can imagine King fitting well in John McCone’s commission into the study of urban uprisings.)
I’d like to end by saying something more about my definition of health – individual and collective bodily self-determination – which Paul Jackson correctly identifies as a feminist project. This definition is one crafted clearly within the context of struggles over racist and classist population control and reproductive justice. Its politics are also very much informed by histories of mutual aid and institution-building on the part of Black people in this country. When the Black Panthers talked about survival pending revolution, they were talking about a collective care project. When community activists in Watts wanted to determine the health-promoting services at the government-funded clinic in their neighborhood, they were enacting this definition of health.
Health as individual and collective bodily self-determination also speaks to questions of freedom that Katherine McKittrick highlights. I do not think it is incidental that Herbert Marcuse wrote about freedom being biological at about the same time as peace scholar Johan Galtung defined structural violence in terms of premature death. Galtung, whether he knew it or not, was building on concepts developed by Friedrich Engels, Rudolf Virchow, and W. E. B. Du Bois who identified the economic, social, and political structures that create health inequities, or to put it another way, how processes of exploitation, oppression, and dispossession that concentrate wealth and resources in the hands of the few also become embodied. And so we can also see Ruthie Gilmore’s definition of racism in this lineage:
“state-sanctioned and or extra-legal production and exploitation of group-differentiated vulnerabilities to premature death” (2006, 28).
In this light, we can see how Congressman King not only erases the violence against Eric Garner through sanctioning it, but how he also exploits Garner’s health vulnerability in order to uphold the legitimacy of policing.
In diagnosing the social and economic causes of excess death, Du Bois observed that, “the amount paid for sickness is highest among the poorer classes and lowest among the better-to-do. It seems that the sickness bill increases inversely with wages” (1906, 90). We might use Du Bois’ observation, along with those of the health activists in Health Rights Are Civil Rights, as fundamental rejections of the notion of universal health care as a drain, and instead name the ongoing claims of state rights in health care as manifestations of the racist and anti-poor exploitation that they are. Health justice, then, is a budget issue. It is a feminist, anti-violence, anti-racist, and anti-capitalist issue. And because the politics of health are so multi-scalar and because the pathologization of space is such a pernicious dimension of perpetuating structural violence, health justice is a project that invites geographic inquiry.