The Political Context of Health and Social Policy

International Journal of Health

Public Health, Services

2015, Vol. 45(4) 587–600
! The Author(s) 2015
Embodied History, Reprints and permissions:
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and Social Justice: DOI: 10.1177/0020731415595549
joh.sagepub.com
Looking Forward

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: nkrieger@hsph.harvard.edu
588 International Journal of Health Services 45(4)

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 cele-
brated 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 empha-
sized 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 gov-
ernment 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 coun-
tries.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
Krieger 589

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 nongovern-
mental 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 collect-
ively 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.
590 International Journal of Health Services 45(4)

These shifts in power and in frameworks engendered, not surprisingly, a fierce

backlash, fostered by the dominant powers and implemented by global eco-
nomic 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 redu-
cing 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 pos-
sibilities 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
Krieger 591

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 sys-
tems 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, transpor-
tation 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
592 International Journal of Health Services 45(4)

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 pol-
iticians they underwrite as we strive for better regulation of hazardous expos-
ures, for minimum wages that are living wages so that people working full-
time 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 gov-
ernmental 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 abor-
tions; 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
Krieger 593

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 his-
tory 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 renoun-
cing war and building peace, and whose origins have been traced back to a pre-
Civil 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
594 International Journal of Health Services 45(4)

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, author-
ship, and/or publication of this article.
Krieger 595

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,
600 International Journal of Health Services 45(4)

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 dis-
ease 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.