Health is the manifestation of all that the human body experiences. The water we drink, the homes we live in, the streets we walk on – all of this shapes our health. That is to say, how resources are distributed within our society and who has the power to determine that distribution are critical determinants of health. Ensuring the health of entire populations and preventing illness and injury requires engaging with those power structures. In other words, public health is, by definition, political.
However, powerful forces and actors have sought to neutralize the political nature of public health by shifting how we understand and approach health issues. Such a depoliticized approach to public health is severely limited in its ability to promote the public’s health. In this critical time in which both public health institutions and marginalized communities are under attack, we must reclaim public health’s political roots if we are to promote and protect the public’s health. Doing this requires a deep understanding of how we got here and a vision of where we can go. As we seek this understanding, there’s much we can learn from the work of public health historians, cancer scientists, and prison-industrial complex abolitionists alike.
According to public health historians, the modern field of public health has its roots in the mid-nineteenth century, when a broad coalition of professionals and activists––physicians, labor organizers, housing advocates, and even abolitionists––came together with the explicit goal of improving the health of people living in poverty. They sought to address the environmental and economic conditions that were causing disease, particularly among people in racially, culturally, and economically marginalized communities. While these social reformers certainly had their flaws, their efforts led to many key policy successes, including mandates for indoor plumbing, improved workplace regulations, and better food and nutrition standards. This work sought to rein in the power of slumlords and corporate overlords in order to limit their ability to produce conditions that were harmful to the public’s health.
However, in the century and a half since then, public health has become increasingly apolitical. The twentieth century saw the rise of bacteriology and molecular biology, the consolidation of the medical-industrial complex, and the McCarthy Era’s stoking of anti-communist fears to suppress any work that could be deemed anti-capitalist. In response to these social, political, and economic pressures, the field moved away from its earlier focus on addressing working and living conditions towards a more biomedical framework for health. This new framework focused on identifying the pathogenic and genetic causes of disease, and on promoting individual responsibility for health through behavior change campaigns such as smoking cessation and weight loss. This paradigm fit well within biomedicine’s emphasis on individual-level treatment over population-level prevention. As such, this shift enabled the field of public health to align itself with the increasingly powerful medical-industrial complex while avoiding the more disruptive work of challenging powerful people and institutions for their role in producing disease. This left the field of public health greatly hampered in its ability to address the structural determinants of health, or the ways in which power inequities disproportionately harm the health of racially, economically, and culturally marginalized communities.
Even with the greatest advancements in medical technology, there are serious limitations to what a depoliticized, individual-focused, behavior change centered, and treatment-oriented approach to health can achieve. One recent work that highlights this particularly well is Nafis Hasan’s “Metastasis: The Rise of the Cancer-Industrial Complex and the Horizons of Care.” In it, Hasan––a cancer scientist by training––details how our ways of understanding and addressing cancer have shifted towards an individualistic approach as a result of social, political, and economic forces, as well as what the consequences of that shift have been for cancer patients and society alike.
According to Hasan, the dominant theory of carcinogenesis in the mid-twentieth century was that cancer was caused by occupational and environmental exposures to carcinogens. As a result, there was a focus on preventing cancer through banning known carcinogens and improving regulation of new chemicals. However, the 1970s and 80s saw the rise of a new theory of carcinogenesis known as Somatic Mutation Theory. Unlike the environmentalist theory, Somatic Mutation Theory focused on the role of genetic mutations causing cancer to arise in individual somatic cells, which then proliferate and lead to the production of tumors. The incoming neoliberal Reagan regime––which favored cutting regulations on corporations and emphasizing individual responsibility for health––preferred this explanation for cancer. As such, the federal government began shifting funding away from cancer prevention and towards biopharmaceutical research focused on developing treatments. This influx of funding and political support led to a massive increase in genetic studies focused on finding a “cure” for cancer, an approach that dominates to this day.
However, there are crucial limitations to this model of addressing cancer. For one, Somatic Mutation Theory has shortcomings as an explanatory theory of carcinogenesis, namely that scientists have yet to identify the existence of the supposed rogue individual cancer cell and that there are many cancers that develop without the presence of genetic mutations. Instead of the Somatic Mutation Theory, Hasan advocates for the use of Tissue Organization Field Theory, which posits that cancer occurs at the level of the organ (not the individual cell), and that it is a result of a breakdown of communication between different parts of the tissue caused by factors like exposure to endocrine-disrupting chemicals and other carcinogens. However, while cancer researchers have been focused on the role of DNA in carcinogenesis, our environments have become increasingly polluted with known carcinogens, leading to an increase in the incidence of cancer, especially in economically and racially marginalized frontline communities such as Cancer Alley. Perhaps the most important limitation to this treatment-oriented approach, though, is that prevention––not treatment––is responsible for the majority of decreases in cancer-associated mortality rates over the past forty years, something that has even been acknowledged by one of the researchers whose work led to Somatic Mutation Theory. In other words, we would be better off to take a more prevention-focused, (nominally) public health approach to cancer, one that emphasizes limiting the public’s exposure to carcinogens rather than simply treating individuals once they have developed the disease.
Despite its limitations, there are two reasons that we continue to focus on cancer treatment according to Hasan. The first is that treating cancer patients is incredibly profitable. Over the past forty years, a cancer-industrial complex has risen up, with biopharmaceutical corporations, academic research institutions, and for-profit healthcare facilities all built around providing the most innovative, cutting edge treatments to patients.While cancer treatment is of course necessary to save the lives of people who have developed the disease, our current for-profit model of developing and administering treatment has led to exorbitantly high-priced drugs that provide only marginal improvements in mortality rates compared to older, more affordable treatment options. And while biopharmaceutical companies claim that the high cost is necessary to offset the risk of developing new drugs in search of the ever elusive magic bullet, much of this risk is actually subsidized by American taxpayers. In other words, one of the reasons that we continue to focus on cancer treatment over prevention is because there are powerful actors within our political system that have an expressed economic interest in maintaining the status quo. The second reason is that focusing on treatment instead of prevention––which would require severely limiting the ability of companies to pollute our environments––enables the government to avoid challenging the power of corporations in producing unhealthy, carcinogenic conditions (and thus allows the government to maintain good working relationships with corporate lobbyists).
Ultimately, what Hasan’s work shows us is that while we have come to think of cancer and other health issues as biological problems that can be addressed through our medical system, we should also, and perhaps more importantly, think of them as social and economic problems that must be solved through our political system.
In this way, Hasan’s critique of the cancer-industrial complex mirrors the critique that abolitionists make of the prison-industrial complex. Abolitionists argue that the ways in which we understand and address crime are a product of social, political, and economic forces. The dominant understanding of what causes crime is that some individuals are inherently (i.e. genetically) bad, and that these “predators” or “dangerous people”––dog whistles for Black and Latine men––are the ones who are responsible for committing crimes. Like the individual cancer cells of Somatic Mutation Theory, the thinking goes that these people must be surveilled, identified, and removed from society in order to punish them and protect the rest of the community. As a result, the last fifty years have seen the genesis and astronomical expansion of the prison-industrial complex.
Abolitionists take a different approach. They argue that the root cause of harm (both criminalized and otherwise) is not that there is something inherently wrong with the individual people who commit crimes. Rather, crime––like cancer––is ultimately a result of the environments that people live in, environments in which people have been systematically deprived of their basic needs like employment, education, and housing. The research backs this approach up: studies have shown that there is a strong relationship between community-level poverty and crime and that rates of homicide increase in places where resources are scarce and unequally distributed. Researchers posit that community- and individual-level poverty serve to break down social cohesion and lead to increased psychological strain and exposure to violent environments. In other words, crime (like cancer, according to the Tissue Organization Field Theory), is due to a breakdown of communication and collaboration within communities. Indeed, some of the forces that lead to increased rates of cancer are the very same forces that lead to crime––namely deregulation, the erosion of workers’ rights, and the consolidation of corporate power, what Ruth Wilson Gilmore calls “the organized abandonment of vulnerable communities.”
Through shifting our focus to the underlying root causes of crime and harm, abolitionists help us to see why mass incarceration in the United States failed to have a large impact on crime rates: locking away individual people does not prevent crime from occurring in the first place. Rather, it shifts the blame for larger societal trends and injustices onto the individual, justifying their disappearance, while leaving the economic, political, and social conditions that are at the root of crime to remain. It focuses on the symptoms rather than addressing the underlying disease, attempting to put a bandaid on the situation while allowing the wound to fester. As Mariame Kaba and Kelly Hayes put it, “Prison is simply a bad and ineffective way to address violence and crime.” Yet like the cancer-industrial complex, the prison-industrial complex remains durable despite its ineffectiveness because of its profitability and because of the threat to power that addressing the root causes of crime would represent.
Abolitionists do not stop at critiquing the dominant approaches to understanding and addressing harms; they offer us another way forward. As Ruth Wilson Gilmore says, “Abolition is about presence, not absence. It’s about building life-affirming institutions.” Rather than pouring our resources into building and maintaining a vast network of prisons, surveillance systems, and hypermilitarized police forces that ultimately have little ability to prevent crime, abolitionists argue that we would be better off to invest those resources directly into our communities. Abolitionists call on us to imagine what our communities would look like if we put our time, energy, and money into building quality housing, walkable streets, well-resourced schools, and all the other things that strengthen the social fabric of our communities. Abolitionists call upon us to not only transform how we respond to harm once it has taken place to but to prevent harm from occurring in the first place through building a radically restructured society, one in which all people have their needs met. Pogo Park, while imperfect, is one example of how investing in green spaces can transform the wellbeing of a community and prevent harm from occurring.
Once we understand the abolitionists’ analysis and vision, we see that there are actually many parallels between the cancer-industrial complex, abolition, and public health. However, we cannot reach a reimagined society with an individualistic, biomedical, and depoliticized public health. We cannot protect and promote the public’s health through simply distributing vaccines, encouraging weight loss, and expanding access to healthcare. These are what abolitionists would call reformist reforms: small tweaks to the system that give the appearance of addressing the problem while maintaining the status quo. Yes, access to health care is a critical determinant of health, but it will not necessarily prevent people from becoming sick in the first place, especially as our waterways are polluted, workers are impoverished, and families are forcibly unhoused.
If public health wishes to return to its mission of protecting and promoting the health of the public, it must address the power structures that produce harm in the first place and reckon with the ways that the field perpetuates the medicalization of social and economic problems. As Danielle Carr wrote for the New York Times:
“Everyone agrees, for instance, that it would be good to reduce the high rate of diabetes plaguing the United States. But once we begin to de-medicalize it, diabetes starts to look like a biological problem arising from political problems: transportation infrastructure that keeps people sedentary in cars, food insecurity that makes a racialized underclass dependent on cheap and empty calories, the power of corporate lobbies to defang regulations, and so on. These are problems that people do not agree on how to solve, in part because some are materially benefiting from this state of affairs. This is to say, these are political problems, and solving them will mean taking on the groups of people who benefit from the status quo.”
As Carr makes clear, there are institutions, corporations, and individuals that directly benefit from producing carcinogenic environments, crime-stricken communities, and the medical- and prison-industrial complexes set up to “treat” them. These actors will do everything within their power to maintain these systems. That means that we need to have an explicitly political analysis of power and how that power shapes our efforts to both understand and address harm.
In this critical moment in which we see the Trump administration making massive cuts to public health institutions, even those within the most mainstream, politically averse corners of the field are coming to see how inherently political their work is. My hope for this moment is that we can do away with the fantasy that public health was ever anything other than political.
As we witness the horrifying rise of fascism, we as public health practitioners must continue to build coalitions across disciplines to directly address the abuses of power and political violence that are harming the public’s health. We must stand in solidarity with those who are leading the work to create a more abundant, just, and ultimately healthy world.
Like abolition, public health demands that we change everything. Some may push back, saying that it’s too much, that it’s outside the purview of public health. But as Mariame Kaba reminds us: “Changing everything might sound daunting, but it also means there are many places to start, infinite opportunities to collaborate, and endless imaginative interventions and experiments to create.”
Authored by Michaela Kupfer
Michaela Kupfer is a public health researcher and organizer living on unceded Lenape land in Brooklyn, New York. The author would like to thank Christine Mitchell and Nafis Hasan for their ideas and guidance, which were instrumental to the development of this article.
Art by Jen Bloomer of Radici Studios.
