Article
Public Health, Embodied History, and Social Justice: Looking Forward
International Journal of Health Services 0(0) 1–14 ! The Author(s) 2015 Reprints and permissions: sagepub.com/journalsPermissions.nav DOI: 10.1177/0020731415595549 joh.sagepub.com
Nancy Krieger
Abstract This essay was delivered as a commencement address at the University of California– Berkeley School of Public Health on May 17, 2015. Reflecting on events spanning from 1990 to 1999 to 2015, when I gave my first, second, and third commencement talks at the school, I discuss four notable features of our present era and offer five insights for ensuring that health equity be the guiding star to orient us all. The four notable features are: (1) growing recognition of the planetary emergency of global climate change; (2) almost daily headlines about armed conflicts and atrocities; (3) growing public awareness of and debate about epic levels of income and wealth inequalities; and (4) growing activism about police killings and, more broadly, “Black Lives Matter.” The five insights are: (1) public health is a public good, not a commodity; (2) the “tragedy of the commons” is a canard; the lack of a common good is what ails us; (3) good science is not enough, and bad science is harmful; (4) good evidence—however vital—is not enough to change the world; and (5) history is vital, because we live our history, embodied. Our goal: a just and sustainable world in which we and every being on this planet may truly thrive. Keywords social justice, public health, health equity, embodiment, epidemiology
Department of Social and Behavioral Sciences, Harvard T. H. Chan School of Public Health, Boston, Massachusetts, USA Corresponding Author: Nancy Krieger, Department of Social and Behavioral Sciences, Harvard T. H. Chan School of Public Health, 677 Huntington Avenue, Kresge 717, Boston, Massachusetts 02115, USA. Email: [email protected]
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Good morning. I am deeply honored to be part of your commencement today. This is my third time giving your school’s commencement talk. The first time was in May 1990,1 25 years ago, one year after I received my doctorate from this very institution. It was a time of great change in the world. Six months earlier, the Berlin Wall had come down, signaling the denouement of the Cold War.2 Many, including myself, harbored perhaps illusory hopes that the proverbial swords could be turned into ploughshares, with resources freed up from militarism devoted instead to the well-being of people and our planet. As we are all too painfully aware, that’s not exactly what happened. Although world military expenditures did decline for a few years, a part of the longed-for “peace dividend,”2 by the mid-1990s, they began rising again and, in constant dollars, are now back up where they were in the late 1980s,3 with the United States still the leading arms exporter.3 Armed conflict is with us still, and the most recent estimate for arms expenditures is $1,747 billion for 2013 alone,4 for which the World Health Organization’s (WHO) current biennial $4 billion budget is barely a rounding error.5–7 Imagine if those vast sums were instead devoted to shoring up, everywhere, the people’s health, and sustainable and equitable economies, guided by the inseparable quintet of human rights: that is, political, civil, cultural, social, and economic rights, hand in hand with respect and dignity. It is possible: Costa Rica, after a divisive and deadly civil war in the 1940s, abolished the military and dedicated itself to well-being—and today ranks near the top among nations for health status, life expectancy, health services, and environmental sustainability.8–10 The second time I gave your school’s commencement address was nine years later, in 1999.11 As the new millennium dawned, public health discourse celebrated various improvements in on-average rates of morbidity and mortality in various countries, while noting that health inequities nevertheless persisted within and between nations.12,13 Also still salient were the themes I had emphasized in my 1990 talk, regarding the interwoven needs for political and economic democracy, leadership, and accountability.11 In 1999, after all, inequalities in income and wealth were ratcheting up at a dizzying pace. This was no accident, but instead attested to the success of the dominant policies of the dominant countries of the age, which since 1980 had become ever more committed to privatization, reduced taxes, and reduced government regulation, as justified by ever-growing veneration of a self-declared “free market” that nevertheless relied mightily, as it always has, on state might and rules, and their enforcement and imposition, across and within countries.13,14 Emblematic of this shift, the top 1% share of total pre-tax income in the United States rose from its historic low of 9% in 1978 to more than 20% in 1999, the highest it had been since 1929, the eve of the stock market crash that triggered the Great Depression—and the 1 percent’s share now is close to 23%.15 Poverty in 1999 remained stubbornly high, especially among children, of whom nearly one in five lived below the stingy U.S. poverty line, an on-average rate
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concealing the obscene reality of the impoverishment of one in three U.S. black, Latino, American Indian, and Alaska Native children.16,17 Issues of gun violence and police violence, moreover, were seared in the public consciousness by the 1999 Columbine High School massacre18,19 and by the 41-bullet police killing in New York City of yet another unarmed African-American man, Amadou Diallo, age 22, for which all four officers were acquitted.20,21 Indeed, when I spoke at commencement in 1999, the ambitious goal of “Health for All in the Year 2000,” coined at the WHO in 1977 and promulgated at the United Nations Alma Ata conference in 1978,10,22,23 was clearly not reachable. This conference, possibly a mystery to many of you, and barely referred to in the peer-reviewed scientific literature,24 in fact was attended by the governments of most nations on earth plus myriad WHO and nongovernmental organizations.10,25 It had the audacity to declare: 1. Health is “a fundamental human right and that the attainment of the highest possible level of health is a most important world-wide social goal whose realization requires the action of many other social and economic sectors in addition to the health sector.” 2. “The existing gross inequality in the health status of the people, particularly between developed and developing countries as well as within countries, is politically, socially, and economically unacceptable and is, therefore, of common concern to all countries.” 3. “The people have the right and duty to participate individually and collectively in the planning and implementation of their health care.” 4. “An acceptable level of health for all the people of the world by the year 2000 can be attained through a fuller and better use of the world’s resources, a considerable part of which is now spent on armaments and military conflicts.” Imagine that: a widely attended international conference, in 1978, under the aegis of the WHO, which declared health to be a human right, which declared health inequities within and between nations unacceptable, and which called for investing in people, in primary care, and in social and economic development, rather than in militarism and war. Alma Ata did not seek to make a utopia. It did not promise immortality. We are of course mortal, we and our loved ones all will die, and we will know grief. But the central question of health equity is: who will live and who will die, at what age, with what degree of preventable suffering?26 And too: is the well-being of some purchased or obtained at the expense of the well-being of others?10,13,26 Alma Ata’s vision was informed by the concrete successes of the 1960s and 1970s, as nations and people struggled to free themselves of both colonialism and the mindsets that viewed social inequality as the natural state of the world.
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These shifts in power and in frameworks engendered, not surprisingly, a fierce backlash, fostered by the dominant powers and implemented by global economic institutions. Variously termed neoliberalism, by those who don’t like it,10,13,27–29 or economic liberalism, by those who do,30 its tenets are, as I noted earlier: “free trade, open markets, privatisation, deregulation, and reducing the size of the public sector”—as concisely stated in a series of reflections on the passing of Margaret Thatcher in 2013, who, along with President Reagan, was a key proponent of this agenda, and for which she famously declared, repeatedly, “There is no alternative.”30 But alternatives always exist. In the fall of 1999, a World Trade Organization meeting was routed by fierce demonstrations in Seattle; these demonstrations united movements for economic, racial, and environmental justice in a joint campaign to combat free trade agreements that eviscerated national sovereignty and undermined environmental and labor standards, thereby undercutting possibilities for fair wages, healthy workplaces, and healthy environments.27,31–33 In 2001, the first World Social Forum was held in Porto Alegre, Brazil, a global grassroots gathering to counter the elite Davos World Economic Forum; its slogan?—“Another World is Possible.”34 Building on this energy, in 2005, WHO convened a new Commission on the Social Determinants of Health,35 in part in reaction to its 2002 Commission on Macroeconomics and Health report, which had concluded that poverty was chiefly a consequence, not a cause, of poor health.10,36,37 The final report of the new commission, however, reversed the direction of the causal arrows and boldly declared: “Social injustice is killing people on a grand scale”.38,39 Also in 2008, the Lancet “rediscovered” the Declaration of Alma Ata.40,41 Two years later, in 2010, the U.S. Department of Health and Human Services replaced the timid 1999 National Institutes of Health definition of health disparities as simply “differences” in health across various “population groups,”42,43 to clarify instead that “health disparities” involve “characteristics historically linked to discrimination or exclusion”—including race/ethnicity, socioeconomic position, gender, sexual orientation, gender identity, age, and mental and physical disabilities.44 And here we are in 2015. I am with you for a third time, midway into the second decade of the 21st century C.E. I speak with you at what again feels like a momentous time. Let me mention four notable features: 1. First, the planetary emergency of global climate change looms ever larger, as does organizing to address it, while governmental and private-sector actions remain far short of where they need to be.27 2. Second, headlines continue to report daily on yet another atrocity involving armed conflict or attacks in yet another region in our unstable world, and in their wake follow yet more public heath crises, of which the Ebola epidemic is but one of many that could be named.10,45–48
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3. Third, we see ever more public acknowledgement of—and public debate about—epic levels of income and wealth inequality.29,49–52 Earlier this year, Oxfam reported that “Just 80 individuals now have the same net wealth as 3.5 billion people—half the entire global population”.53 Epic levels of cash from the financial elite are likewise flooding and corrupting the political systems of high-, middle-, and low-income nations, and together are harming capacity for healthy democratic governance, healthy ways of living, and viable health care systems.54–57 4. Fourth, here in the United States, in response to the newly publicized but long-endemic police killings of unarmed people of color, especially black men58–61—including such recent victims as Mike Brown in Ferguson, Eric Garner in New York City, Walter Scott in North Charleston, South Carolina, and Freddie Gray in Baltimore62–64—there has been a new wave of movement for racial justice.65 “Black Lives Matter” because all lives matter—and the inclusive website of the U.S. collective of black women who conceived this slogan proudly and explicitly affirms that all black lives matter—black women, girls, men, boys, gay, lesbian, bi, queer, transgender, immigrant, differently abled, incarcerated—all of these lives are precious precisely because all lives matter.65 How do we make a world in which all lives matter? You are part of making this happen. In this turbulent world, we need you. You, who are graduating today, you, the next generation of public health professionals, you, with your energy, your expertise, your hopes, your fears, your questions, your confidence, your skills—and your dedication and commitment to the people’s health. We need you. And I do mean all of you: we need you who are doing basic lab science; you who are working to improve people’s living and working conditions, transportation and food systems, and the ways we eat, play, rest, and learn; you who are devising new statistical methods and computing and communication systems; you who are analyzing the societal determination of health and developing ways to have health equity be part of all policies and to terminate those that are harmful; and you who are developing better ways to improve people’s access to appropriate and high-quality care. We need all of you, working together, and working with others, here and across the world, and especially the very people whose health is most harmed by deprivation and discrimination. As someone, then, who was literally in your place, 26 years ago, let me share with you five insights to help ensure that health equity be a guiding star to orient us all: . Insight #1: Public health is a public good, not a commodity. The goal of public health is to be useful, with a priority on prevention and health equity.10,23,26,66 This is a different goal than that of being profitable, that is, making the
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highest return possible for private investors.49–52 Yet, we now live in an age where what is praiseworthy, at least in the mainstream, is “entrepreneurial,” even for public health67–70—and in which private philanthropists drive public agendas with little or no public accountability.67 But never forget that gains in public health are often made by cutting into the ill-gotten profits of those who take shortcuts with the public’s safety and well-being. If that weren’t the case, we wouldn’t endlessly have the fights we do with corporations and the politicians they underwrite as we strive for better regulation of hazardous exposures, for minimum wages that are living wages so that people working fulltime are not below the poverty line, and for regulations that curb corruption; the list goes on and on.10,13,26–29,36,37 Never lose sight of the “public” in public health, or the public good. . Insight #2: The “tragedy of the commons” is a canard; the lack of a common good is what ails us. I would suspect that few of you here today have actually read the highly influential 1968 article published in Science whose title gave us the enduring phrase: “The tragedy of the commons”.71 Read it. Why? Because, even though it is now roundly critiqued by leading economists and ecologists,72–76 it remains touted as a sound analysis of why common property causes ecological devastation, and why private property free of governmental regulation is essential to well-being. In fact, it is a dyspeptic screed by a self-described “genetically trained biologist,”71(p1247) Garrett Hardin, who never studied people—or economics. I quote (and I promise I am not making up these quotes!): 1. “If we love the truth we must openly deny the validity of the Universal Declaration of Human Rights”71(p1246) because it affirms that “any choice and decision with regard to the size of the family must rest with the family itself, and cannot be made by anyone else.”71(p1246) 2. “The most important aspect of necessity that we must now recognize is the necessity of abandoning the commons in breeding.”71(p1248) In other words: preventing overpopulation requires stripping people of their reproductive rights. Yet the accumulating evidence makes dramatically clear that it is the upholding and extension of reproductive and sexual rights, in conjunction with other human rights, that has led to more education for girls—and boys; better access to safe, effective contraceptives and legal abortions; reduced infant mortality rates; and, oh yes, voluntarily lower fertility rates.66,77 The larger point: beware arguments that pit public health against human rights and the common good, because when people argue for reducing rights to improve well-being, you can be sure something is askew. Hence: . Insight #3: Good science is not enough, and bad science is harmful. The point is not science versus politics. For us in public health, we need the best science
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possible to advance the public’s health and to make the case for why we need health equity. Saying this, however, does not mean we can frame science as if it were outside of politics. It is not.26,78 We all know—or should know—and confront the sorry histories and current realities of scientific racism, sexism, and eugenics.26,79,80 Nor is good science reducible to politics. There is always a tension between having our ideas—and actually testing them, publicly, in a way that others could test them, too, and with recognition that ideas and methods deemed sound at one time can be shown fallacious at another.26,78 Cherish this tension. And embrace yet another: . Insight #4: Good evidence, however vital, is not enough to change the world. Mobilization matters: that is, people exerting power—whether the elite, via their concentrated wealth, or the many, via their numbers. Hence the 99%. Public change for the good of the people’s health has always been powered by the strength of social movements.10,81 So think always of to whom your work is directed, in terms of who is vital for pushing for change, and make sure your work is always of top-notch quality, because the public’s health demands no less. And do not be afraid to call for action for the people’s health. Finally: . Insight #5: History is vital, because we live our history, embodied. We cannot understand our biology or our societies apart from history. We live as our phenotypes, which are our embodied history—and indeed this embodied history is, for all beings, all organisms, the very marrow of this living earth.26,82–84 To act well, to be wise, we must know and understand our context and how it has come about, and this means we must take the time to learn our history, critically, and that of the people with whom we work and who are the focus of our work. Knowledge is essential precisely because it is a potent antidote to one poisonous feature of privilege, which gives license to—and reveals itself through—what one can afford to ignore.85 We all can learn—and only by collectively grappling with this history, for bad and for good, can we make health inequities history, a subject for historians to study, not for people to endure. And so, in closing, I would like to invite all of you now to stand up—and to hear your collective voice! In a departure from usual ceremony—and perhaps to create a new tradition!—I am sharing with you the last five minutes of the time allotted for my address. What we are going to do is sing, together, new words to a traditional song. The tune is that of the classic “Down by the Riverside,” which calls for renouncing war and building peace, and whose origins have been traced back to a preCivil War U.S. slave song.86 The new words have been composed by a colleague of mine, Makani Themba, the founding executive director of the Praxis Project, a leading U.S. grassroots movement institution whose mission is to build “healthy communities by transforming the power relationships and structures
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Figure 1 “Where all can truly thrive”—uniting in song at the University of California–Berkeley School of Public Health Commencement, May 17, 2015.
that affect our lives.”87 Makani penned these new words for a special celebration we had last year at the American Public Health Association to mark the 20th anniversary of the Spirit of 1848 Caucus, which I cofounded and chair, and which is focused on the inextricable links between social justice and public health.88,89 And so, everyone, please open your program to the section for the song (Figure 1). All graduates, all faculty, all staff, and your loved ones and family, please rise! - and may we together bring our skills, our expertise, our intellect, and our passion to the urgent work of creating a just and sustainable world in which we and every being on this planet may truly thrive—so that we may all live, love, work, and die with our dignity intact and our humanity cherished. Let us sing! Declaration of Conflicting Interests The author declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
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Funding The author received no financial support for the research, authorship, and/or publication of this article.
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52. Roy A. Capitalism: A Ghost Story. Chicago: Haymarket Books; 2014. 53. Milne S. The Davos oligarchs are right to fear the world they’ve made. The Guardian. January 22, 2015. http://www.theguardian.com/commentisfree/2015/jan/22/davos -oligarchs-fear-inequality-global-elite-resist. Accessed May 19, 2015. 54. Transparency International. Global corruption reports. http://www.transparency. org/research/gcr/gcr_2001_inaugural_edition/0/. Accessed May 19, 2015. 55. Tran M. Global corruption survey reveals one in four people paid a bribe last year. The Guardian. July 8, 2013. http://www.theguardian.com/global-development/2013/ jul/09/global-corruption-survey-bribery. Accessed May 19, 2015. 56. Lessig L. Republic Lost: How Money Corrupts Congress – and a Plan to Stop It. New York, NY: Twelve, Hachette Books; 2011. 57. Rodwin MA. Institutional corruption and the pharmaceutical policy. J Law Med Ethics Fall. 2013;41(3):544–552. 58. Johnson MS. Street Justice: A History of Police Violence in New York City. Boston: Beacon Press; 2003. 59. Skolnick JH. Policing. In: Smesler NJ, Wright J, Bates PB eds. International Encyclopedia of the Social & Behavioral Sciences. New York, NY: Elsevier; 2001:11535–11541. 60. Monkkonen EH. From cop history to social history: the significance of the police in American history. J Soc Hist. 1982;15(4):575–591. 61. Walker S. The urban police in American history: a review of the literature. J Polit Sci Admin. 1976;4(3):252–260. 62. Swaine J. South Carolina shooting witness: victim ‘just wanted to get away from the Taser.’ The Guardian. April 9, 2015. http://www.theguardian.com/us-news/2015/apr/ 08/feidin-santana-bystander-walter-scott-shooting-interview. Accessed May 19, 2015. 63. Yuhas A. Families of police killing victims on Walter Scott video: ‘I can see it all over again’. The Guardian. April 9, 2015. http://www.theguardian.com/us-news/2015/apr/ 08/families-police-shooting-victims-discuss-videos-eric-garner-michael-brown. Accessed May 19, 2015. 64. Fernandez M, Tarantola D, Annas G, Gruskin S. Freddie Gray’s injury and the police “rough ride.” New York Times. April 30, 2015. http://www.nytimes.com/ 2015/05/01/us/freddie-grays-injury-and-the-police-rough-ride.html. Accessed May 19, 2015. 65. Black Lives Matter. http://blacklivesmatter.com/. Accessed May 19, 2015. 66. Grodin M, et al. (eds). Health and Human Rights in a Changing World. 3rd ed. New York, NY: Routledge; 2013. 67. Birn AE. Philanthrocapitalism, past and present: the Rockefeller Foundation, the Gates foundation, and the setting(s) of the international/global health agenda. Hypothesis. 2014;12(1):e8. doi:10.5779/hypothesis.v12i1.229. 68. Jacobson PD, Wasserman J, Wu HW, Lauer JR. Assessing entrepreneurship in governmental public health. Am. J. Public Health. 2015;105(Suppl 2): S318–S322. 69. Herna´ndez D, Carrio´n D, Perotte A, Fullilove R. Public health entrepreneurs: training the next generation of public health innovators. Public Health Reports. 2014;129(6):477–481. 70. Jung T, Harrow J. New development: philanthropy in networked governance – treading with care. Public Money Manage. 2015;35(1):47–52.
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71. Hardin G. The tragedy of the commons. Science. 1968;162(3859):1243–1248. 72. Ostrom E. Governing the Commons: The Evolution of Institutions for Collective Action. Cambridge: Cambridge University Press; 1990. 73. Ostrom E. A general framework for analyzing sustainability of social-ecological systems. Science. 2009;325(5939):419–420. 74. Ostrom E. A long polycentric journey. Annu Rev Polit Sci. 2010;13:1–23. 75. Rudel TK, Roberts TJ, Carmin J. Political economy of the environment. Annu Rev Sociol. 2011;37:221–238. 76. De Angelis M. Climate change, mother earth and the commons: reflections on El Cumbre. Development. 2011;54(2):183–189. 77. Bustreo F, Hunt P, Gruskin S, et al. Women’s and Children’s Health: Evidence of Impact of Human Rights. Geneva: World Health Organization; 2013. http://www.clam.org.br/uploads/arquivo/pesquisa_WHO.pdf. Accessed May 19, 2015. 78. Ziman J. Real Science: What it is and What it Means. Cambridge: Cambridge University Press; 2000. 79. Kevels D. In the Name of Eugenics: Genetics and the Uses of Human Heredity. New York, NY: Knopf; 1985. 80. Bashford A, Levine P. The Oxford Handbook of the History of Eugenics. New York, NY: Oxford University Press; 2010. 81. Brown TM, Fee E. Social movements in health. Annu Rev Public Health. 2014;35:385–398. 82. Krieger N. Embodiment: a conceptual glossary for epidemiology. J Epidemiol Community Health. 2005;59(5):350–355. 83. Krieger N. History, biology, and health inequities: emergent embodied phenotypes & the illustrative case of the breast cancer estrogen receptor. Am J Public Health. 2013;103(1):22–27. 84. Krieger N. Embodied histories & health inequities: racism, class, mortality, body size, & breast cancer – an ecosocial analysis. Invited presentation, RWJF Health & Society Scholars Seminar, Harvard Center for Population and Development Studies; January 31, 2013; Cambridge, MA. 85. Krieger N. Researching critical questions on social justice and public health: an ecosocial perspective. In: Levy BS, Sidel VW eds. Social Injustice and Health, 2nd ed., Oxford: Oxford University Press; 2013:465–484. 86. Sandburg C. The American Songbag. New York, NY: Harcourt Brace; 1927:480–481. 87. The Praxis Project. http://www.thepraxisproject.org/about. Accessed May 19, 2015. 88. Spirit of 1848. http://spiritof1848.org/. Accessed May 19, 2015. 89. Krieger N, Birn AE. A vision of social justice as the foundation of public health: commemorating 150 years of the spirit of 1848. Am J Public Health. 1988;88(11):1603–1606.
Author Biography Nancy Krieger is a professor of social epidemiology in the Department of Social and Behavioral Sciences at the Harvard T. H. Chan School of Public Health and director of the school’s Interdisciplinary Concentration on Women, Gender, and Health. She is an internationally recognized social epidemiologist (PhD,
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epidemiology, University of California–Berkeley, 1989), with a background in biochemistry, philosophy of science, and history of public health and more than 30 years of activism in social justice, science, and health. In 2004, she became an ISI highly cited scientist, a group comprising “less than one-half of one percent of all publishing researchers.” Her work addresses conceptual frameworks to understand, analyze, and improve health, including the ecosocial theory of disease distribution she proposed in 1994 and its focus on embodiment and equity; etiologic research on societal determinants of population health and health inequities; and methodologic research on improving monitoring of health inequities. She is the author of Epidemiology and the People’s Health: Theory and Context (2011). In 1994 she cofounded, and still chairs, the Spirit of 1848 Caucus of the American Public Health Association, which is concerned with links between social justice and public health.
Public Health, Embodied History, and Social Justice: Looking Forward
International Journal of Health Services 0(0) 1–14 ! The Author(s) 2015 Reprints and permissions: sagepub.com/journalsPermissions.nav DOI: 10.1177/0020731415595549 joh.sagepub.com
Nancy Krieger
Abstract This essay was delivered as a commencement address at the University of California– Berkeley School of Public Health on May 17, 2015. Reflecting on events spanning from 1990 to 1999 to 2015, when I gave my first, second, and third commencement talks at the school, I discuss four notable features of our present era and offer five insights for ensuring that health equity be the guiding star to orient us all. The four notable features are: (1) growing recognition of the planetary emergency of global climate change; (2) almost daily headlines about armed conflicts and atrocities; (3) growing public awareness of and debate about epic levels of income and wealth inequalities; and (4) growing activism about police killings and, more broadly, “Black Lives Matter.” The five insights are: (1) public health is a public good, not a commodity; (2) the “tragedy of the commons” is a canard; the lack of a common good is what ails us; (3) good science is not enough, and bad science is harmful; (4) good evidence—however vital—is not enough to change the world; and (5) history is vital, because we live our history, embodied. Our goal: a just and sustainable world in which we and every being on this planet may truly thrive. Keywords social justice, public health, health equity, embodiment, epidemiology
Department of Social and Behavioral Sciences, Harvard T. H. Chan School of Public Health, Boston, Massachusetts, USA Corresponding Author: Nancy Krieger, Department of Social and Behavioral Sciences, Harvard T. H. Chan School of Public Health, 677 Huntington Avenue, Kresge 717, Boston, Massachusetts 02115, USA. Email: [email protected]
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Good morning. I am deeply honored to be part of your commencement today. This is my third time giving your school’s commencement talk. The first time was in May 1990,1 25 years ago, one year after I received my doctorate from this very institution. It was a time of great change in the world. Six months earlier, the Berlin Wall had come down, signaling the denouement of the Cold War.2 Many, including myself, harbored perhaps illusory hopes that the proverbial swords could be turned into ploughshares, with resources freed up from militarism devoted instead to the well-being of people and our planet. As we are all too painfully aware, that’s not exactly what happened. Although world military expenditures did decline for a few years, a part of the longed-for “peace dividend,”2 by the mid-1990s, they began rising again and, in constant dollars, are now back up where they were in the late 1980s,3 with the United States still the leading arms exporter.3 Armed conflict is with us still, and the most recent estimate for arms expenditures is $1,747 billion for 2013 alone,4 for which the World Health Organization’s (WHO) current biennial $4 billion budget is barely a rounding error.5–7 Imagine if those vast sums were instead devoted to shoring up, everywhere, the people’s health, and sustainable and equitable economies, guided by the inseparable quintet of human rights: that is, political, civil, cultural, social, and economic rights, hand in hand with respect and dignity. It is possible: Costa Rica, after a divisive and deadly civil war in the 1940s, abolished the military and dedicated itself to well-being—and today ranks near the top among nations for health status, life expectancy, health services, and environmental sustainability.8–10 The second time I gave your school’s commencement address was nine years later, in 1999.11 As the new millennium dawned, public health discourse celebrated various improvements in on-average rates of morbidity and mortality in various countries, while noting that health inequities nevertheless persisted within and between nations.12,13 Also still salient were the themes I had emphasized in my 1990 talk, regarding the interwoven needs for political and economic democracy, leadership, and accountability.11 In 1999, after all, inequalities in income and wealth were ratcheting up at a dizzying pace. This was no accident, but instead attested to the success of the dominant policies of the dominant countries of the age, which since 1980 had become ever more committed to privatization, reduced taxes, and reduced government regulation, as justified by ever-growing veneration of a self-declared “free market” that nevertheless relied mightily, as it always has, on state might and rules, and their enforcement and imposition, across and within countries.13,14 Emblematic of this shift, the top 1% share of total pre-tax income in the United States rose from its historic low of 9% in 1978 to more than 20% in 1999, the highest it had been since 1929, the eve of the stock market crash that triggered the Great Depression—and the 1 percent’s share now is close to 23%.15 Poverty in 1999 remained stubbornly high, especially among children, of whom nearly one in five lived below the stingy U.S. poverty line, an on-average rate
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concealing the obscene reality of the impoverishment of one in three U.S. black, Latino, American Indian, and Alaska Native children.16,17 Issues of gun violence and police violence, moreover, were seared in the public consciousness by the 1999 Columbine High School massacre18,19 and by the 41-bullet police killing in New York City of yet another unarmed African-American man, Amadou Diallo, age 22, for which all four officers were acquitted.20,21 Indeed, when I spoke at commencement in 1999, the ambitious goal of “Health for All in the Year 2000,” coined at the WHO in 1977 and promulgated at the United Nations Alma Ata conference in 1978,10,22,23 was clearly not reachable. This conference, possibly a mystery to many of you, and barely referred to in the peer-reviewed scientific literature,24 in fact was attended by the governments of most nations on earth plus myriad WHO and nongovernmental organizations.10,25 It had the audacity to declare: 1. Health is “a fundamental human right and that the attainment of the highest possible level of health is a most important world-wide social goal whose realization requires the action of many other social and economic sectors in addition to the health sector.” 2. “The existing gross inequality in the health status of the people, particularly between developed and developing countries as well as within countries, is politically, socially, and economically unacceptable and is, therefore, of common concern to all countries.” 3. “The people have the right and duty to participate individually and collectively in the planning and implementation of their health care.” 4. “An acceptable level of health for all the people of the world by the year 2000 can be attained through a fuller and better use of the world’s resources, a considerable part of which is now spent on armaments and military conflicts.” Imagine that: a widely attended international conference, in 1978, under the aegis of the WHO, which declared health to be a human right, which declared health inequities within and between nations unacceptable, and which called for investing in people, in primary care, and in social and economic development, rather than in militarism and war. Alma Ata did not seek to make a utopia. It did not promise immortality. We are of course mortal, we and our loved ones all will die, and we will know grief. But the central question of health equity is: who will live and who will die, at what age, with what degree of preventable suffering?26 And too: is the well-being of some purchased or obtained at the expense of the well-being of others?10,13,26 Alma Ata’s vision was informed by the concrete successes of the 1960s and 1970s, as nations and people struggled to free themselves of both colonialism and the mindsets that viewed social inequality as the natural state of the world.
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These shifts in power and in frameworks engendered, not surprisingly, a fierce backlash, fostered by the dominant powers and implemented by global economic institutions. Variously termed neoliberalism, by those who don’t like it,10,13,27–29 or economic liberalism, by those who do,30 its tenets are, as I noted earlier: “free trade, open markets, privatisation, deregulation, and reducing the size of the public sector”—as concisely stated in a series of reflections on the passing of Margaret Thatcher in 2013, who, along with President Reagan, was a key proponent of this agenda, and for which she famously declared, repeatedly, “There is no alternative.”30 But alternatives always exist. In the fall of 1999, a World Trade Organization meeting was routed by fierce demonstrations in Seattle; these demonstrations united movements for economic, racial, and environmental justice in a joint campaign to combat free trade agreements that eviscerated national sovereignty and undermined environmental and labor standards, thereby undercutting possibilities for fair wages, healthy workplaces, and healthy environments.27,31–33 In 2001, the first World Social Forum was held in Porto Alegre, Brazil, a global grassroots gathering to counter the elite Davos World Economic Forum; its slogan?—“Another World is Possible.”34 Building on this energy, in 2005, WHO convened a new Commission on the Social Determinants of Health,35 in part in reaction to its 2002 Commission on Macroeconomics and Health report, which had concluded that poverty was chiefly a consequence, not a cause, of poor health.10,36,37 The final report of the new commission, however, reversed the direction of the causal arrows and boldly declared: “Social injustice is killing people on a grand scale”.38,39 Also in 2008, the Lancet “rediscovered” the Declaration of Alma Ata.40,41 Two years later, in 2010, the U.S. Department of Health and Human Services replaced the timid 1999 National Institutes of Health definition of health disparities as simply “differences” in health across various “population groups,”42,43 to clarify instead that “health disparities” involve “characteristics historically linked to discrimination or exclusion”—including race/ethnicity, socioeconomic position, gender, sexual orientation, gender identity, age, and mental and physical disabilities.44 And here we are in 2015. I am with you for a third time, midway into the second decade of the 21st century C.E. I speak with you at what again feels like a momentous time. Let me mention four notable features: 1. First, the planetary emergency of global climate change looms ever larger, as does organizing to address it, while governmental and private-sector actions remain far short of where they need to be.27 2. Second, headlines continue to report daily on yet another atrocity involving armed conflict or attacks in yet another region in our unstable world, and in their wake follow yet more public heath crises, of which the Ebola epidemic is but one of many that could be named.10,45–48
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3. Third, we see ever more public acknowledgement of—and public debate about—epic levels of income and wealth inequality.29,49–52 Earlier this year, Oxfam reported that “Just 80 individuals now have the same net wealth as 3.5 billion people—half the entire global population”.53 Epic levels of cash from the financial elite are likewise flooding and corrupting the political systems of high-, middle-, and low-income nations, and together are harming capacity for healthy democratic governance, healthy ways of living, and viable health care systems.54–57 4. Fourth, here in the United States, in response to the newly publicized but long-endemic police killings of unarmed people of color, especially black men58–61—including such recent victims as Mike Brown in Ferguson, Eric Garner in New York City, Walter Scott in North Charleston, South Carolina, and Freddie Gray in Baltimore62–64—there has been a new wave of movement for racial justice.65 “Black Lives Matter” because all lives matter—and the inclusive website of the U.S. collective of black women who conceived this slogan proudly and explicitly affirms that all black lives matter—black women, girls, men, boys, gay, lesbian, bi, queer, transgender, immigrant, differently abled, incarcerated—all of these lives are precious precisely because all lives matter.65 How do we make a world in which all lives matter? You are part of making this happen. In this turbulent world, we need you. You, who are graduating today, you, the next generation of public health professionals, you, with your energy, your expertise, your hopes, your fears, your questions, your confidence, your skills—and your dedication and commitment to the people’s health. We need you. And I do mean all of you: we need you who are doing basic lab science; you who are working to improve people’s living and working conditions, transportation and food systems, and the ways we eat, play, rest, and learn; you who are devising new statistical methods and computing and communication systems; you who are analyzing the societal determination of health and developing ways to have health equity be part of all policies and to terminate those that are harmful; and you who are developing better ways to improve people’s access to appropriate and high-quality care. We need all of you, working together, and working with others, here and across the world, and especially the very people whose health is most harmed by deprivation and discrimination. As someone, then, who was literally in your place, 26 years ago, let me share with you five insights to help ensure that health equity be a guiding star to orient us all: . Insight #1: Public health is a public good, not a commodity. The goal of public health is to be useful, with a priority on prevention and health equity.10,23,26,66 This is a different goal than that of being profitable, that is, making the
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highest return possible for private investors.49–52 Yet, we now live in an age where what is praiseworthy, at least in the mainstream, is “entrepreneurial,” even for public health67–70—and in which private philanthropists drive public agendas with little or no public accountability.67 But never forget that gains in public health are often made by cutting into the ill-gotten profits of those who take shortcuts with the public’s safety and well-being. If that weren’t the case, we wouldn’t endlessly have the fights we do with corporations and the politicians they underwrite as we strive for better regulation of hazardous exposures, for minimum wages that are living wages so that people working fulltime are not below the poverty line, and for regulations that curb corruption; the list goes on and on.10,13,26–29,36,37 Never lose sight of the “public” in public health, or the public good. . Insight #2: The “tragedy of the commons” is a canard; the lack of a common good is what ails us. I would suspect that few of you here today have actually read the highly influential 1968 article published in Science whose title gave us the enduring phrase: “The tragedy of the commons”.71 Read it. Why? Because, even though it is now roundly critiqued by leading economists and ecologists,72–76 it remains touted as a sound analysis of why common property causes ecological devastation, and why private property free of governmental regulation is essential to well-being. In fact, it is a dyspeptic screed by a self-described “genetically trained biologist,”71(p1247) Garrett Hardin, who never studied people—or economics. I quote (and I promise I am not making up these quotes!): 1. “If we love the truth we must openly deny the validity of the Universal Declaration of Human Rights”71(p1246) because it affirms that “any choice and decision with regard to the size of the family must rest with the family itself, and cannot be made by anyone else.”71(p1246) 2. “The most important aspect of necessity that we must now recognize is the necessity of abandoning the commons in breeding.”71(p1248) In other words: preventing overpopulation requires stripping people of their reproductive rights. Yet the accumulating evidence makes dramatically clear that it is the upholding and extension of reproductive and sexual rights, in conjunction with other human rights, that has led to more education for girls—and boys; better access to safe, effective contraceptives and legal abortions; reduced infant mortality rates; and, oh yes, voluntarily lower fertility rates.66,77 The larger point: beware arguments that pit public health against human rights and the common good, because when people argue for reducing rights to improve well-being, you can be sure something is askew. Hence: . Insight #3: Good science is not enough, and bad science is harmful. The point is not science versus politics. For us in public health, we need the best science
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possible to advance the public’s health and to make the case for why we need health equity. Saying this, however, does not mean we can frame science as if it were outside of politics. It is not.26,78 We all know—or should know—and confront the sorry histories and current realities of scientific racism, sexism, and eugenics.26,79,80 Nor is good science reducible to politics. There is always a tension between having our ideas—and actually testing them, publicly, in a way that others could test them, too, and with recognition that ideas and methods deemed sound at one time can be shown fallacious at another.26,78 Cherish this tension. And embrace yet another: . Insight #4: Good evidence, however vital, is not enough to change the world. Mobilization matters: that is, people exerting power—whether the elite, via their concentrated wealth, or the many, via their numbers. Hence the 99%. Public change for the good of the people’s health has always been powered by the strength of social movements.10,81 So think always of to whom your work is directed, in terms of who is vital for pushing for change, and make sure your work is always of top-notch quality, because the public’s health demands no less. And do not be afraid to call for action for the people’s health. Finally: . Insight #5: History is vital, because we live our history, embodied. We cannot understand our biology or our societies apart from history. We live as our phenotypes, which are our embodied history—and indeed this embodied history is, for all beings, all organisms, the very marrow of this living earth.26,82–84 To act well, to be wise, we must know and understand our context and how it has come about, and this means we must take the time to learn our history, critically, and that of the people with whom we work and who are the focus of our work. Knowledge is essential precisely because it is a potent antidote to one poisonous feature of privilege, which gives license to—and reveals itself through—what one can afford to ignore.85 We all can learn—and only by collectively grappling with this history, for bad and for good, can we make health inequities history, a subject for historians to study, not for people to endure. And so, in closing, I would like to invite all of you now to stand up—and to hear your collective voice! In a departure from usual ceremony—and perhaps to create a new tradition!—I am sharing with you the last five minutes of the time allotted for my address. What we are going to do is sing, together, new words to a traditional song. The tune is that of the classic “Down by the Riverside,” which calls for renouncing war and building peace, and whose origins have been traced back to a preCivil War U.S. slave song.86 The new words have been composed by a colleague of mine, Makani Themba, the founding executive director of the Praxis Project, a leading U.S. grassroots movement institution whose mission is to build “healthy communities by transforming the power relationships and structures
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Figure 1 “Where all can truly thrive”—uniting in song at the University of California–Berkeley School of Public Health Commencement, May 17, 2015.
that affect our lives.”87 Makani penned these new words for a special celebration we had last year at the American Public Health Association to mark the 20th anniversary of the Spirit of 1848 Caucus, which I cofounded and chair, and which is focused on the inextricable links between social justice and public health.88,89 And so, everyone, please open your program to the section for the song (Figure 1). All graduates, all faculty, all staff, and your loved ones and family, please rise! - and may we together bring our skills, our expertise, our intellect, and our passion to the urgent work of creating a just and sustainable world in which we and every being on this planet may truly thrive—so that we may all live, love, work, and die with our dignity intact and our humanity cherished. Let us sing! Declaration of Conflicting Interests The author declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
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Funding The author received no financial support for the research, authorship, and/or publication of this article.
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Author Biography Nancy Krieger is a professor of social epidemiology in the Department of Social and Behavioral Sciences at the Harvard T. H. Chan School of Public Health and director of the school’s Interdisciplinary Concentration on Women, Gender, and Health. She is an internationally recognized social epidemiologist (PhD,
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epidemiology, University of California–Berkeley, 1989), with a background in biochemistry, philosophy of science, and history of public health and more than 30 years of activism in social justice, science, and health. In 2004, she became an ISI highly cited scientist, a group comprising “less than one-half of one percent of all publishing researchers.” Her work addresses conceptual frameworks to understand, analyze, and improve health, including the ecosocial theory of disease distribution she proposed in 1994 and its focus on embodiment and equity; etiologic research on societal determinants of population health and health inequities; and methodologic research on improving monitoring of health inequities. She is the author of Epidemiology and the People’s Health: Theory and Context (2011). In 1994 she cofounded, and still chairs, the Spirit of 1848 Caucus of the American Public Health Association, which is concerned with links between social justice and public health.
