I am a sociologist and macro social worker. I came of age
professionally around the time the US was dismantling its safety net through a
major overhaul of the welfare system in 1996. By the time I finished my MSW
degree, I was a single parent with a ton of student loan debt and not receiving
a penny in child support. After a few years of working in the field, doing
child policy, research, and advocacy work at the Children’s Defense Fund in
Washington, DC, then a small non-profit in Flint, Michigan (and still not
receiving a penny in child support), my career began to shift to the health
care space. I am just now beginning to understand why that was not a
coincidence.
About 25 years later, I find myself wondering why health
care and public health aren’t leveraging the knowledge available in the fields
of sociology and macro social work, specifically structural social work, to
address what public health calls the “social determinants of health.” I struggled
to understand why or how entire disciplines, or fields of work, would or could
be crammed into a single phrase. I finally found a big part of the answer to
that question in a 2015 article I stumbled across on LinkedIn called Why language
matters: insights and challenges in applying a social determination of health approach
in a North-South collaborative research program.
As it turns out, approaches to understanding and addressing public
health issues are significantly different between countries in the global North
and global South. Approaches in the North tend to be very quantitative and top
down in nature, while approaches in the South rely more heavily on mixed
methods and the knowledge and experience of the people directly affected by inequality
on a global scale. Using sociological terms, the North places emphasis on ‘objective’
truth, assuming independence from any kind of ideology.
In reality, the North
values the white male (colonizer) viewpoint over female and non-white perspectives.
This is reflected in scientific approaches that value quantitative over qualitative
or mixed methods approaches and valuing fields that use these approaches (health
care, public health, traditional economics) over other fields (sociology,
social work, anthropology).
Approaches in the South are more consistent with the
far less-valued fields of sociology, social work, and anthropology in the North.
Southern approaches to health care and public health use a more holistic
approach, combining quantitative and qualitative methods, including taking into
account the lived experiences of those affected by the global and societal dynamics
that directly impact quality of life, particularly for low- and moderate-income
people.
It is past time for health care and public health to invite other disciplines to the table. Health care and public health in the US benefit greatly from white male (and arguably colonizer) viewpoints. As illustrated in the recent JAMA debacle (structural racism does not exist), the white male perspective is baked into existing systems and perspectives.
The white male (colonizer) viewpoint
is simply incapable of understanding the lived experiences of oppressed people.
In fact, it, and the fields of health care and public health, benefit from
their relatively privileged standpoints. If the fields do not take into account
knowledge from other disciplines, they will very likely continue to participate
in the structural perpetuation of racism.
Back to my original point. I had a huge debt-to-income ratio, so I relied on my quantitative data skills to make a living, which led me to working in health care for the past 17 years. Now I see that literally, social service funding has been diverted into health care in the US. No wonder my need for financial survival led me here. The US spends more on health care and disproportionately more on health care than social services than other countries (The American Health Care Parardox: Why Spending More is Getting Us Less), which is wildly inefficient from an economic standpoint. The US diverts funds from the people who need it (and pay a disproportionate amount of taxes relative to more privileged people) into health care.
I see public health folks trying to get a piece of the pie (I will talk about the problems with the ‘wrong pocket problem’ in a separate post), but people not realizing the funds should be invested in the actual people who need help via social services (cash assistance), the earned income tax credit, and similar means. After all, wouldn’t some kind of assurance of basic income provide the funds needed to support grocery stores, pharmacies, and other services in low-income communities?
Addressing social
needs using taxpayer money through a largely profitable health care system, or
even a struggling public health system, will not address the underlying
structural systems that thrive because of oppression and the relative privilege
gained (for some) as a direct result of existing systems. There is a real risk
of perpetuating structural inequality if other sources of knowledge and
experience continue to be sidelined as money is invested in addressing these issues through the limited perspective of "social determinants of health."
