The Havana confab brought together public health and social scientists from sixteen different Latin American countries, and focused on three interrelated themes: the social determinants of health; food security and nutrition, and the prevention and control of disease.
During the November 15-18 meeting, the most compelling discussion centered on the difference between the social determinants of health and the social determination of health and the implications of this debate for policy and intervention strategies. The WHO Commission on Social Determinants of Health expanded the “social determinants” of health framework to include the “social determination of health” perspective, but they continued to use the term “social determinants” in this expanded conceptual model. At the Havana meeting, however, the term social determination of health was used to contrast this larger scheme of conceptualization with the traditional framework. The core issue in this discussion was to identify the framework best suited to guide research that enhances understanding of the determinants and mechanisms which shape health outcomes and guide policy-making that illuminates entry points for health intervention. Neighborhood effects on health outcomes was a sidebar to the larger discussion, but deliberations on this question added to understanding the difference between the two concepts.
The discourse caused me to reflect on the subtle, but hugely important, distinctions among social determinants, social determination, and neighborhood effects on health and the implications of this discourse for policy-making and the shaping of health intervention strategies. In this blog, I will outline my views on the topic.
The social determinants and social determination of health frameworks view health and disease as social products, which are unevenly distributed throughout society. Health, then, is a social phenomenon that intersects with health equity and social justice. It is influenced by multifarious social, economic and physical conditions, including economic stability, education, social and community context, health and health care, and neighborhood and built environment, and, as such, it requires an intersectoral approach to research, policy-making, and intervention.
Although similar, important distinctions exist between these two frameworks. The social determinants of healthframework is concerned with the influence of social, economic and physical conditions on health outcomes, including quality of life and premature death; and it calls for a policy-action agenda that focuses on the mitigation of these intermediary social determinants of health. The social determination ofhealth framework expands this foci to include the structural determinants of health. So, while the social determinants model is concerned with symptoms, the social determination model emphasizes symptoms and theirroot causes. This framework views social factors, such as poverty, food insecurity, limited education, behavioral, and neighborhood and built environment issues as the outcomes (symptoms) of structural failures (root causes). The socioeconomic and political context (structure), then, decides one’s socioeconomic positionality in society (social class), which, in turn, determines the social factors that influences their health outcomes. Thus, to realize health equity in practice, a policy-action agenda is required that attacks both the structural and socialdeterminants of health.
This is where neighborhood effects comes into play. Both determination frameworks minimize the importance of adverse neighborhood conditions on health outcomes in underdeveloped communities. While both frameworks acknowledge the importance of underdevelopedneighborhoods as a site where social determinants influence health outcomes, they nevertheless minimize the neighborhood setting by juxtaposing it with economic stability, education, social and community context, and health and health care. All five sites are considered equally important as entry points for intervention.
The underdeveloped neighborhood, however, is not just a site; it is the primary site, where the interaction of social factors with the built environment produces a powerful negative synergism that spawn undesirable health outcomes. This expanded neighborhood effects model also includes a structural dimension, where root causes are found. The neighborhood, then, should be the crucial entry point for policy-making and health intervention. Concurrently, to bring about sustainable change, action must also be taken on the structural determinants of these neighborhood-based social determinants of health.
In the 1990s, Democrats helped shift the national conversation away from systemic racism. If the country’s first black president could not disrupt the racial status quo, what can we expect Hillary Clinton to accomplish?
You always know an election is near in the US when Democrats and Republicans start to discuss the plight of black Americans.
Most of the time, little is said about the high levels of poverty in black communities. Ditto with unemployment. Before the eruption of the Black Lives Matter movement, almost nothing was ever said about police violence. Until recently these issues were simply facts of life, so omnipresent that racial inequality passes for the norm for both Republicans and Democrats.
Two years ago, Republican leader Paul Ryan described the higher rates of black unemployment as attributable to a “tailspin of culture”. On the other side of the political spectrum, both Barack Obama and Chicago’s mayor, Rahm Emanuel, have respectively blamed an absence of “role models” and “parenting” for violence in black neighborhoods. In effect, both parties have long been saying that what is needed is personal transformation – not the reform of ways that wealth and resources are distributed in our country.
Blaming black communities for their own problems is not new; it’s been a staple of US politics for the last 50 years. But as Democrats anxiously try to rally their bases, the concern is that there is limited enthusiasm from black millennial voters – that is, African American voters roughly between the ages of 18 and 35.
There’s no question that black voters will support Hillary Clinton over Donald Trump in large numbers, but the real question is whether they will actually come out and vote for her. Democrats believe they need a turnout of black voters on par with the numbers reached during the 2008 and 2012 election. Then, more than half of young black voters participated, outpacing their white and Latino peers in the process. More than 92% of them voted for Obama; black millennial support for Clinton peaked at 60% this August.
After spending the winter and spring months describing black voters as a “firewall” against the surging Bernie Sanders campaign, Clinton surrogates now try to explain the reluctance to embrace Clinton as stemming from a lack of information about her campaign. In other words, if the campaign simply tweaks its messaging or if young black voters would only consult her website, they would see that Clinton has a robust platform to address their concerns.
While it is certainly true that Clinton has gone out of her way to use the language of the Black Lives Matter movement and to highlight the unquestioned racism of Donald Trump, she faces three problems that no campaign promise can adequately address.
The first problem for the Democrats is the dreadful continuation of police killing black men.
The police killings came so quickly in September that most people had forgotten that on 15 September, police in Columbus, Ohio, shot and killed 13-year-old Tyre King. Described as 4ft 11in and 95lb, King was shot three times in the back, according to an autopsy. And in the last several weeks, there have been continued protests in El Cajon in southern California and in Charlotte, North Carolina, in response to two killings. There was also the video-recorded killing of unarmed Terence Crutcher in Tulsa, Oklahoma.
Even where police killings of black men and boys do not receive national attention, they reverberate within the neighborhoods and wider communities for days, weeks and months afterward. Indeed, the crisis of police violence was identified by black millennials as their number one concern above all other issues. In a poll taken last August, 91% of black and 71% of Latino millennials described “police killing of Black people as a serious problem”. Seventy-seven per cent of black millennials said that they or someone they knew had been “harassed” by the police.
The Democratic party has appeared completely incapable of putting a stop to it.
It has now been 19 months since Obama’s commission on policing in the 21st century released its report and offered 58 recommendations for reform. The police have killed more than 1,000 people in that time. Furthermore, for all the publicity that some cases have received, it is more likely than not that the police officers will not even be charged, let alone punished.
In the absence of actual reform, Democrats led by Obama seem to stress the need for understanding on both sides – as if police violence were the product of misunderstanding as opposed to oppression at the hands of an armed appendage of the state.
Hillary Clinton’s platform is more substantive than that, as she calls for spending a billion dollars to better train police, legislation against racial profiling and dismantling the school-to-prison pipeline. While one can debate Clinton’s ability to actually follow through on these promises (and whether they would actually produce the kind of accountability the Black Lives Matter movement is demanding), the bigger problem for Clinton is one of credibility.
Supporters of Clinton have denounced the perception of her as untrustworthy, calling it ignorance or sexism. It is undeniable that some of the vitriol directed at Clinton has misogynistic undertones, especially when it comes from Trump and his supporters. But to reduce all criticism of Clinton to gender discrimination is both disingenuous and dishonest.
America’s ‘first black president’? The problematic Bill Clinton legacy
When a young black woman confronted Hillary Clinton at a fundraiser over Clinton’s description of young offenders in the 1990s as “super predators” that needed to be brought “to heel”, it was an educational moment for a new generation of voters who may have been unaware of the Clintons’ complicated history with African Americans.
The discourse of “super predators” was not an unfortunate misstatement; it was a racist, political calculation intended to publicly demonstrate a lack of sympathy for black people and support for a regime of punishment and retribution.
The folklore of the black middle class, combined with the electoral needs of the Democratic party, has worked to recast the 1990s as a happy time of low unemployment when Toni Morrison called Bill Clinton the ‘first black president’. What has been left out of the happy tale is the way Clinton used poor and working-class black people as political grist to rebuild an electoral coalition of old Reagan Democrats and moderate white Republicans.
In 1993, Bill Clinton went to the church where Martin Luther King Jr delivered his last speech before his assassination. Clinton said:
[King] would say, “You did a good job creating a black middle class of people who really are doing well … You did a good job. You did a good job in opening opportunity.” But he would [also] say, “I fought for freedom … but not for the freedom of people to kill each other with reckless abandonment, not for the freedom of children to have children and the fathers of the children to walk away from them and abandon them, as if they don’t amount to anything. I fought to stop white people from being so filled with hate that they would wreak violence on black people. I did not fight for the right of black people to murder other black people with reckless abandonment.”
Clinton had perfected the southern cadence – in this case, literally speaking as if he were Martin Luther King Jr – that intimated an insider’s perspective on black life, while clearly communicating to white voters a rejection of the “systemic racism” which Hillary Clinton speaks so much about today.
(Of course, these were the words of Bill and not Hillary – but the painful efforts to parse out where her politics begin and his end are specious. Aside from the fact that Hillary’s comments about “super predators” aped the sentiment at the core of Bill’s law and order agenda, we can’t ignore how she has cast her years in the White House as part of her vast political experience that makes her more prepared than anyone else to be president.)
This skilled blame game continued throughout Bill Clinton’s presidency, during which the Democratic party as a whole helped to structure the wider context within which the discussions about crime and welfare reform were taking place.
For example, in the aftermath of the Los Angeles Rebellion in 1992, the then candidate Bill Clinton traveled to South Central Los Angeles and diagnosed the roots of the crisis. He said:
“People … are looting because they are not part of the system at all any more. They do not share our values, and their children are growing up in a culture alien from ours, without family, without neighborhood, without church, without support.”
As a result, Clinton and the Democratic party of the 1990s played a pivotal role in helping to shift the discussion away from “systemic racism”, as it had been in the 1960s and 1970s, back to a focus on the culture and family structure of African Americans as the root of black inequality. Bill Clinton and his political partner, Hillary, were not passive observers of an ideological attack that posited crime and punishment over government assistance and public welfare; they, in the 1990s context, were its architects.
‘Free stuff’ and the anti-capitalist politics Hillary won’t touch
The second problem the Clinton campaign faces is the developing anti-capitalist politics of young voters, especially black millennials.
Though Clinton supporters chastised Bernie Sanders’ campaign for its poor showing among African Americans, what went without much comment is how well the Sanders campaign did among young black voters. In fact, 44% of black voters aged 18 to 30 voted for Sanders, compared with the 32% of votes that went to Clinton. Sanders, by comparison, received only 33% of the white youth vote.
Undoubtedly, Sanders’ campaign began with little attention paid to racial inequality, but that slowly shifted over its course. Nevertheless, young black voters were most attuned to Sanders’ redistributive political agenda. Polling found that “poverty and inequality” together were listed as the third most important issue for black millennials.
This fits with the growing anti-capitalist sentiment among young people today. According to a Harvard University poll of young adults from ages 18 to 29, 51% said they did not support capitalism; conversely, 33% said they supported socialism. This is a political awakening that has been developing over the last several years. In the year that the Occupy movement announced its arrival in 2011, a Pew poll found 47% of young people did not support capitalism.
Today, that sentiment is deeper than just an anti-capitalist feeling: it is also expressed positively and in support for redistributive social programs. Forty-eight per cent of millennials support health insurance as a “right for all people”. And 47% agree that basic necessities, such as food and shelter, are “a right that the government should provide to those unable to afford them”. Clinton mocked Sanders supporters during the primary fight for wanting “free stuff”.
A recent leak of remarks Clinton made during a February fundraiser demonstrates her grasp of at least some of the reluctance of millennials to embrace her candidacy:
And on the other side, there’s just a deep desire to believe that we can have free college, free healthcare, that what we’ve done hasn’t gone far enough, and that we just need to, you know, go as far as, you know, Scandinavia, whatever that means, and half the people don’t know what that means, but it’s something that they deeply feel. Some are new to politics completely. They’re children of the great recession. And they are living in their parents’ basement … They feel they got their education and the jobs that are available to them are not at all what they envisioned for themselves. And they don’t see much of a future … If you’re feeling like you’re consigned to, you know, being a barista, or you know, some other job that doesn’t pay a lot, and doesn’t have some other ladder of opportunity attached to it, then the idea that maybe, just maybe, you could be part of a political revolution is pretty appealing.
For whatever insights Clinton may demonstrate here, there is also a kind of smug undercurrent that links newness to politics with the “naive” desire for “free healthcare” and “free college”.
Months later, after a bruising primary with Bernie Sanders, Clinton now supports some aspects of “free college”. This sudden switch, in addition to contributing to the perception that Clinton will say anything to curry political favor, speaks to the larger disconnect between her campaign and young voters. Young people wonder how it is that a wealthy nation like the US with its 400 billionaires can also be home to 45 million people living in poverty. The young people, like those of the Occupy movement and Black Lives Matter, care less about what is politically realistic and more about what is just.
This concern expressed by millennials is not just altruistic, but it is deeply personal.
For some black millennials, their lives teeter on the edge of catastrophe. There is breathless reporting of gun violence in Chicago, but outside of the city there is remarkably little said about the conditions within which the violence gestates. Forty-seven per cent of 20- to 24-year-old young black men are unemployed. Among black 16- to 19-year-olds, 14% are neither working nor in school.
Candidate Obama was no President Obama
Finally, the main factor in black millennials’ shortage of enthusiasm for Clinton may be the thin portfolio of reform offered by Barack Obama.
Obama won in 2008 and 2012 in part because of the historic turnout of young black voters. This was the generation that had politically come of age during the endless wars of the Bush administration; it had witnessed the collective shrug of the federal government in response to the catastrophe of Hurricane Katrina. Black youths also watched as their families were the canaries in the mine shaft of the pending economic meltdown in 2008. The ensuing wave of home foreclosures began to take effect in black communities in 2006 and 2007.
This was the context of Obama’s run against Bush in 2008, when Obama jettisoned the cookie-cutter political campaign.
He righteously counseled: “Change doesn’t come from Washington … change comes to Washington.” While on the campaign trail, he made speeches that invoked the legacy of the abolitionist movement against slavery, the labor movement of the 1930s that made unions possible, the gay rights movement and, of course, the civil rights movement. Obama rhetorically tried to situate his campaign among those social movements: underdogs in the grassroots doing the impossible for the good of the nation.
But candidate Obama was no President Obama, who quickly distanced himself from the loftiness of his campaign. The rise of Black Lives Matter is, in no small part, a product of his inability or unwillingness to directly and forthrightly address the persistence of racial inequality. The paralysis of the president in the face of racism and injustice was a bitter pill to swallow.
Obama has reminded all who would listen that he was not the president of black America, but the president of the US. Even if this disappointment was never measured in opinion polls, today it can be measured in the waning interest of black millennials in the Clinton campaign. It can even be detected in the terse words of Obama, who recently said it would be a “personal insult” to him if black voters did not mobilize in big numbers to elect Hillary Clinton.
But perhaps it is most clearly borne out in the anger of black millennials, as exemplified in this letter from the St Louis artist and poet Tef Poe, written at the height of the Ferguson uprising:
When an assault rifle is aimed at your face over nothing more than a refusal to move, you don’t feel like the American experience is one that includes you. When the president your generation selected does not condemn these attacks, you suddenly begin to believe that this system is a fraudulent hoax – and the joke is on you. Racism is very much alive in America, but as a president with so much melanin in his skin, you seem to address it very bashfully … Now we are organizing against you and members of your party as though we didn’t vote for you to begin with. This saddens me, because we rooted for you. Me and my friends are young. We voted for you because initially you spoke our language. We believed you would be more of an activist than a typical suit-and-tie teleprompter politician. Are you not outraged by the treatment of your own people by law enforcement? Why is it so difficult for you to display a moment of honesty and reflection to the public about your own blackness?
If the nation’s first black president, who won a majority of the electorate and came into office with a super-majority in Congress, could not disrupt the racial status quo, then what can anyone expect Clinton to accomplish?
‘If things get worse’ isn’t a good political choice
Don’t let anyone tell you that America isn’t great. Donald Trump’s got America all wrong. We are a big-hearted, fair-minded country. I never lost my sense of pride at seeing our blue-and-white plane lit up on some far-off runway, with ‘the United States of America’ emblazoned on the side. That plane – those words – our country represents something special, not just to us, to the world. It represents freedom and hope and opportunity. I believe with all my heart that America is an exceptional country – that we’re still … the last, best hope of Earth.
The incongruent logic of deploring “systemic racism” while championing the US as “the last, best hope of Earth” lends itself to the constant questioning of Clinton’s sincerity.
Perhaps she thinks that both can be true, but others might conclude that the candidate has either not truly grasped the depth or scale of the crises in black communities today, or that she will say anything to get votes. Whatever her intentions, it will certainly take more than “ladders of opportunity” to address our country’s deep racism.
The myopic focus on Donald Trump’s rightwing and racist rhetoric cannot, in and of itself, undo the sense of disappointment and cynicism black millennials feel toward the Democratic party. As for the Clinton supporters who suggest that Trump represents a unique threat to free speech – do they believe that Trump will execute an executive order banning protests? Will he mobilize the military to stop demonstrations? Because this generation has already endured a violent crackdown on the Occupy encampments in the winter and spring of 2012 coordinated by Barack Obama’s FBI.
Black millennials who have taken up the cause of Black Lives Matter have already endured teargas, live ammunition, dogs, false arrest, military tanks, police beatings, fees, fines, prison time, jail, surveillance, infiltration and harassment. All with a black president at the helm. Under such circumstances, it is a remarkably hollow argument to insist that a vote for Clinton is a vote to be able to continue to organize.
The insistence that things will simply get worse under Trump as the motivation to vote for Clinton is to gloss over, if not ignore, the deep and profound ways that young people are already suffering. Yes, life can always get worse, but this narrow fixation ignores the more pressing question: how do things get better?
Clinton should pay heed: a growing number of young black people are not settling for the question of “who will cause the least harm”. They want to know: “How do we get free?”