International Development and Health: Rethinking Global Pessimism About the Future

By Sean A. Valles, Director and Associate Professor, Center for Bioethics and Social Justice, College of Human Medicine, Michigan State University

Pessimism about the future is rising around much of the world. Meanwhile, the social institutions of democracy are experiencing slipping public support. The global COVID-19 pandemic has also drawn attention to the importance and fragility of trust.

Unfortunately, none of this should be considered new. The pandemic arrived more than a decade into a trend of declining trust in social institutions. More recently, news reports of fraud and corruption, such as misuses of pandemic relief funds, can push us to see the world as filled with people undeserving of our trust or care. Such an observation can start to look like a moral justification for our own selfishness: “the system is corrupt so I’m just going to get mine and look out for myself.”

We do not need to resign ourselves to selfishness and isolation.

Group of surgeons wearing blue medical scrubs and face masks.
Image description: Cropped shot of a group of surgeons wearing blue scrubs and face masks performing a medical procedure in an operating room. Image source: PeopleImages/iStock.

Economist Elinor Ostrom won the Nobel Prize for showing how examples from around the globe undercut the pessimistic but widespread view among scholars that the “tragedy of the commons” is practically inevitable—the idea that fishers are doomed to selfishly overfish the waters they share with other fishers, etc. That theory of inevitable selfishness and tragedy is rooted in assumptions of human nature that intuitively resonate with a lot of people, which made Ostrom’s debunking work all the harder. Not coincidentally, Garrett Hardin, the creator of a supremely pessimistic view of humanity, was a vocal racist and nativist who saw his pessimism about cooperation as grounds for treating the less privileged peoples of the world as potential invaders threating to take resources from the metaphorical “lifeboat” occupied by the privileged. Extreme pessimism about the possibility of cooperation and solidarity is toxic.

Extreme pessimism about human nature oversimplifies human behavior. Even overtly bad and apparently selfish behavior by others can be evidence of the possibility of future cooperation. For instance, recent research on academic dishonesty by students has found that cheating and plagiarism are driven in part by a desperate desire to be allowed to continue learning as part of a school’s community.

I see the COVID-19 pandemic as a series of failed but fixable attempts at ethical collaboration, and not evidence that cooperation is hopeless during crisis. Yes, the pandemic was rife with selfish acts from those previously mentioned cases of financial misconduct, extending to the problem of wealthy countries quickly buying up much of the global vaccine supply. Disturbingly, many people have felt ethically self-assured in their selfishness, such as a professor who approached me after one of my pandemic ethics lectures, complaining to me that COVID-19 vaccines were surely unethical because they allowed “the weak” to survive nature’s culling.

Despite the innumerable examples of bad behavior, there were also innumerable attempts at cooperation that either succeeded or showed enough of a spark of success that future success seems possible. Consider the case of Dorothy Oliver and Drucilla Russ-Jackson, who defied conventional wisdom about the stubbornness of vaccine skeptics by using kindness and respectful human connections to convince nearly their entire rural Alabama town to get COVID-19 vaccinations. At the global level, the World Health Organization, World Bank, and Gavi the Vaccine Alliance (among many others) all made strides toward helping ease the unethical burdens of the pandemic harming the vulnerable of the world. Each organization was in large part prevented from doing better, however, due to running into needless hurdles such as national governments resisting attempts to get more transparency in their national public health data.

International development is an endeavor based on a fundamental optimism: the conviction that helping faraway strangers is a worthwhile task. As became increasingly clear over the 20th century, ethically helping faraway strangers is no easy task. We can easily hurt those whom we seek to help. But as with the instructive failed efforts during the pandemic, the point is that it remains possible for cooperative efforts to do better next time.

In the spirit of the desire to always do better next time in international development, the Center for Values in International Development has partnered with the Michigan State University Center for Bioethics and Social Justice. Our centers share a fundamental optimism that despite the injustices of the world, and the world’s mixed track record of attempts to make them better, the goal of creating a more equitable world is well worth working for.

One obstacle faced by our two Centers’ endeavors is that global health work and global development work remain partly stuck in their own silos, such as in the ways national and international agencies divide up their roles. Yes, effective and meaningful international development work does need to include the development of societies’ health infrastructure, but not to the exclusion of focusing on wider, intersectional issues of healthcare justice. Sectoral segmentation works against wider inclusion, the acknowledgment of intersectionalities, and consideration of structural issues in how we view human wellbeing. It remains all too common to think of health development work as another slice of the overall pie of development needs, alongside transportation development, housing development, better sewage treatment, financial management capacity strengthening, etc.

In my work, I emphasize the importance of distinguishing between the healthcare system vs. the health system. The healthcare system is just one part of the much larger set of social institutions that steer the health of populations, such as the agricultural systems that determine which foods are available in markets and at what prices. So, while healthcare (hospitals, medicines, and such) should get only a slice of the budgetary pie in international development budgets, it is important to remember that housing policies are health policies too; the same goes for transportation policies and numerous other policies. Housing security is crucial for a healthy life. Transportation is essential for meeting other life needs (shopping, accessing healthcare, etc.), while poor transportation policies can lead to air pollution and other unwanted side effects.

The language that began emerging in the 2000s is that we need “health in all policies.” That phrase has two meanings. First, it’s a call to action, asking that we make sure a society’s policies are conducive to health. For instance, development programs that encourage farmers to grow cash crops also need to take into account health impacts, such as the availability of crucial food crops and the related impacts on community nutrition. Second, “health in all policies” is a description of the way the world works. Development programs seeking to change agriculture and other vital parts of social life simply are also health policies, whether we recognize it or not. International development work affects the health of societies in innumerable ways, and often ways that get too little attention. The Center for Values in International Development brings much-needed explicit attention and analysis to the ethical dimensions of international development work and humanitarian response; we need ethics in all policies. The Center for Bioethics and Social Justice enthusiastically joins in that effort, since there is health in all policies, and our Center specializes in getting attention and analysis to the ways that such health impacts positively or negatively contribute to making health systems more “compassionate, respectful, and responsive to people’s needs, so that equity, inclusion and social justice are available to all.”

This piece was also published by the Center for Values in International Development

Recent publications from Center faculty

Leonard Fleck photo

Center Professor Leonard Fleck, PhD, has had two articles published so far this year. Online ahead of print is “Precision medicine and the fragmentation of solidarity (and justice)” in the European journal Medicine, Health Care and Philosophy. In the article Fleck “offer[s] multiple examples of how current and future dissemination of […] targeted cancer drugs threaten a commitment to solidarity.”

Fleck and co-author Leslie Francis, PhD, JD, were published in the most recent issue of Cambridge Quarterly of Healthcare Ethics. Their article debates the question: “Should Whole Genome Sequencing be Publicly Funded for Everyone as a Matter of Healthcare Justice?”

Sean Valles photo

In the February issue of Studies in History and Philosophy of Science, Center Director and Associate Professor Sean Valles, PhD, has a reply by the author in response to reviews of his 2018 book Philosophy of Population Health: Philosophy for a New Public Health Era. The book forum section of the issue includes three reviews of Valles’ book from Eric Mykhalovskiy, Quill R. Kukla, and Ross Upshur.

Upcoming webinar on the relationship between the criminal legal system, structural racism, and health

Monday, September 13, 2021; 1:00-2:30 PM ET
Zoom registration: bit.ly/bsj-hfhs-sept13

Trauma, Community Health and the Criminal Legal System

Why should we care about the effects of incarceration and policing on communities and their health? This virtual panel discussion and audience Q&A on the relationship between the criminal legal system, structural racism, and health will also explore terminology—including “mass incarceration”—and explore different ways of thinking about trauma.

This webinar is co-presented by the Michigan State University Center for Bioethics and Social Justice and the Henry Ford Health System Health Disparities Research Collaborative. Panelists include Jennifer Cobbina, PhD, and Christina DeJong, PhD, from the Michigan State University School of Criminal Justice, Carmen McIntyre Leon, MD, from Wayne State University School of Medicine, and Center for Bioethics and Social Justice Director Sean A. Valles, PhD. Henry Ford Health System Health Disparities Research Collaborative Director Christine Joseph, PhD, will moderate the session.

This webinar is free to attend and open to all individuals. A recording will be available following the event.

About the panelists

Jennifer Cobbina, PhD

Jennifer Cobbina is an Associate Professor in the School of Criminal Justice at Michigan State University. She received her PhD in criminal justice at the University of Missouri-St. Louis in 2009. Her primary research focuses on community responses to police violence and the strategies that communities employ to challenge police expansion and end state sanctioned violence. Her research also examines the intersection of race, gender, and how neighborhood contexts shapes crime and criminal justice practices. Finally, her work focuses on corrections, prisoner reentry and the understanding of recidivism and desistance from crime. She is the author of Hands Up, Don’t Shoot: Why the Protests in Ferguson and Baltimore Matter and How They Changed America.

Christina DeJong, PhD

Christina DeJong is an Associate Professor in the School of Criminal Justice at Michigan State University. Her research interests focus on gender, sexuality, crime, and justice. Dr. DeJong’s current work is focused on Queer Criminology, specifically the homicide of transgender people in the United States and how sexuality shapes juvenile offending. She is also currently studying bullying and misconduct in academe. Dr. DeJong received her PhD in Criminal Justice and Criminology from University of Maryland. She is an associated faculty member with the MSU Center for Gender in Global Context.

Carmen McIntyre Leon, MD

Carmen McIntyre Leon completed undergraduate studies at the University of Michigan, attended Wayne State University for medical school, and the Medical College of Pennsylvania (now Drexel) for psychiatry residency and NIMH research fellowship. She worked as medical director for partial programs, inpatient units, research units, and SUD/Methadone programs before returning to Michigan, eventually co-founding Community Network Services, an adult community mental health provider in Oakland County. After a brief stint in New Zealand she returned to Detroit to help lead the newly created Detroit Wayne Mental Health Authority as the Chief Medical Director. She is now the Associate Chair for Community Affairs and Director of Public Psychiatry Fellowship with the Wayne State University School of Medicine Department of Psychiatry and Behavioral Neuroscience; and Chief Medical Officer for the Michigan Department of Corrections.

Sean A. Valles, PhD

Sean A. Valles is director and associate professor in the Center for Bioethics and Social Justice in the Michigan State University College of Human Medicine. Dr. Valles is a philosopher of health specializing in the ethical and evidentiary complexities of how social contexts combine to create patterns of inequitable health disparities. His work includes studying the challenges of responsibly using race and ethnicity concepts in monitoring health disparities, scrutinizing the rhetoric of the COVID-19 pandemic as an ‘unprecedented’ problem that could not be prepared for, and examining how biomedicine meshes with public health and population health. Dr. Valles received his PhD in History and Philosophy of Science from Indiana University Bloomington.

Christine Joseph is a Senior Epidemiologist in the Department of Public Health Sciences at Henry Ford Health System. Her research interests include racial/ethnic health disparities, adolescent health, asthma and allergic disease, adherence, and school-based health management. She has experience in the design and implementation of community-based and pragmatic clinical trials. Dr. Joseph has worked on a variety of studies focusing on vulnerable populations and social determinants of health, and has publications in the areas of asthma, food allergy, sleep, LGBTQ health, and health literacy.

Don’t Scapegoat Immigrants for the COVID-19 Pandemic Surge

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This post is a part of our Bioethics in the News series

By Larissa Fluegel, MD, MHS, and Sean A. Valles, PhD

The U.S. COVID-19 pandemic summer surge has inspired a public search for answers as to why wide vaccine availability has not been sufficient to prevent a new wave of infections. Certain answers are plausible, such as blaming the surge on some combination of the more infectious delta variant spread, vaccination rates remaining too low on average and excessively low for some populations, a relaxation of formal disease control restrictions, as well as more nuanced informal social habits such as diminished mask-wearing, more indoor parties, etc. Yet others cast blame onto a much less plausible target: immigrants.

Florida Governor Ron DeSantis blames President Joe Biden for being too lax on the southern U.S. border immigration enforcement, suggesting that Biden has been “helping [to] facilitate” the pandemic. Governor Greg Abbott of Texas took things further, ordering that state law enforcement could “begin pulling over vehicles whose drivers are transporting migrants who pose a risk of carrying COVID-19.” Both of these responses to the pandemic spread are unethical, incoherent, and ineffectual. Accusations against Latin American immigrants are unethical and misguided.

For many reasons, blaming those immigrants crossing the southern U.S. border for negative health outcomes is problematic. Such targeted blame is dehumanizing to immigrants—it promotes negative stereotypes that perpetuate discrimination, mistreatment and health disparities, and by extension, it is detrimental to non-immigrants’ health. Moreover, it is a form of blame shifting that prevents authorities and the public from effectively taking responsibility for community-wide problems.

Image description: a black and white photo of an individual holding a sign that reads “Hamilton was an immigrant. Einstein was a refugee.” They are wearing a long jacket and a tricorne hat. Image source: Victoria Pickering/Flickr.

Blaming immigrants is dehumanizing

There is a long history of dehumanizing immigrants to the U.S., although such dehumanization is generally done selectively. Immigrants such as Charlize Theron and Albert Einstein are treasured, while others are despised for having the “wrong” skin color, accent, occupations, and so on. Dehumanizing and targeting immigrants has been part and parcel of U.S. history, from 19th century church-burning riots that terrorized Irish immigrants, and the overtly racist Chinese Exclusion Act, to current cases of medical abuse and neglect in migrant detention centers. Philosopher David Livingstone Smith traces these sorts of systemic cruelties to a process of dehumanization in which we find ways of convincing ourselves to think of certain groups of people as somehow less than human. To convince ourselves we seek justifications such as depicting immigrants as vermin infecting or invading a country. According to Livingstone Smith, such depictions then give us permission to act aggressively against those groups and to “exclude the target of aggression from the moral community.”

In sum, we find ways to give ourselves permission to dismiss the ethics of how we treat certain groups of people. With such misplaced permission, we decide that certain groups, in this case select immigrants, don’t count as fellow humans worth caring about, and so abuse doesn’t really count as abuse. It’s this sort of misguided logic that also explains Governors Abbott and DeSantis’ school mask requirement bans. Paradoxically, their purported attempt to reign-in government restrictions on individuals simultaneously reveals disregard for the ways in which harsh immigration enforcement strategies negatively impact the lives of immigrants.

Blaming immigrants promotes unrealistic, unhealthy negative stereotypes

Blaming immigrants promotes negative stereotypes that perpetuate discrimination, social mistreatment, and unjust health disparities. Since early in the pandemic, anti-Asian racism and xenophobia mixed in with COVID-19 politics has led to a worldwide phenomenon of hate crimes against anyone appearing to be of Asian descent, and vicious expressions of misguided blame directed at anyone from the same vague region as where the pandemic originated. Historically, and erroneously, people in the U.S. have associated immigrants with human disease and contagion. Immigration authorities have long scrutinized immigrant health when deciding who can enter or remain in the U.S. Additionally, there is a false perception that immigrant illnesses are predominantly acquired before entry to the U.S.; it is instead most often the case that immigrants tend to struggle with worsening health as they spend more time adopting U.S. cultural norms, including unhealthy eating habits.

Stereotypes about “unsanitary” immigrants represent cruel and unjustified blame shifting. For example, consider meat processing plants which have been hot spots for COVID-19 outbreaks. Staffed predominantly by an immigrant workforce, those workers face abusive and unsanitary working conditions (an open secret in the industry for over a century) that foster disease outbreak. Laying blame for this suffering on immigrant workers, or immigration generally, is a horrendous ethical mistake. Statements by public figures like Governors Abbott and DeSantis contribute to morally skewed views about immigrant health.

Unhealthy negative stereotypes hurt people and cost all Americans a lot of money

Another pragmatic consideration is how those immigrants who do fall ill interface with the U.S. health care system. Negative stereotypes about immigrants among health care providers lead to substandard and/or improper care. In fact, the anticipation of being mistreated coupled with fear among those with an undocumented immigration status serve to dissuade immigrants from seeking needed care. Such fears might even discourage some from getting the COVID-19 vaccine. In this way, blaming immigrants contributes to worsening the pandemic. (A related irony is that nearly 1 in 3 doctors are themselves immigrants.)

There is a public health concern to this sequence. Delaying or avoiding care harms immigrants as well as those around them. To avert transmission, contagious diseases need to be treated in a timely manner. Not doing so leads to an underestimation of actual disease distribution and burden. A correct estimation is necessary to determine the right amount of resources and timely measures necessary to contain them. It is a waste of public resources to have those in need use emergency rooms for care that, if identified and delivered in a timely manner, could have been averted before the situation worsened. Part of the motivation for the Affordable Care Act was to  increase access to regular necessary care, yet undocumented immigrants were excluded from benefitting from the Act, despite the fact that providing coverage would have improved public health and probably saved the public money as well. For example, consider strep throat, a condition that is easily treatable with inexpensive antibiotics. Left untreated, strep throat can get complicated and potentially cause serious long-term heart problems. Untreated strep throat might drive a person to seek care in an emergency department. Yet another example is an untreated dental cavity that might lead to a dental abscess or a deep skin infection of the mouth and neck, again possibly resulting in an emergency room visit. Once there, correct diagnosis would require fluid cultures and expensive MRI or CT imaging. The cost of delayed care is borne by all of us. Some combination of insurance companies, hospitals, or government pay those excess fees, passing along costs to everyone else.

Speaking out

It is unfortunately fashionable across the U.S. and Europe to blame immigrants for social problems. Economic and social problems are quickly blamed on immigrants. Conversely, the available evidence points to immigrants being economically and socially beneficial to their respective new country.

We, the authors, come to this issue as people who have committed their professional lives to making healthcare and health policy more humane—seeking to help our future physicians and our colleagues treat patients as complex human beings deserving of care, rather than revenue streams to be maximized. Similarly, we see immigration discussions falling prey to the same mistake so common in healthcare, wherein powerful decision-makers, such as politicians, lose sight of their shared humanity with the people whose lives depend on them. We need to demand better from our political leaders and importantly, we need to speak out when politicians dehumanize immigrants.

Larissa Fluegel photo
Sean A. Valles photo

Larissa Fluegel, MD, MHS, is an Assistant Professor with the Center for Bioethics and Social Justice and the College of Human Medicine at Michigan State University where she teaches social context of clinical decisions.

Sean A. Valles, PhD, is Associate Professor and Director of the Michigan State University Center for Bioethics and Social Justice. He is author of the 2018 book Philosophy of Population Health: Philosophy for a New Public Health Era (Routledge Press).

Join the discussion! Your comments and responses to this commentary are welcomed. The authors will respond to all comments made by Thursday, September 2, 2021. With your participation, we hope to create discussions rich with insights from diverse perspectives.

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Continue reading “Don’t Scapegoat Immigrants for the COVID-19 Pandemic Surge”

Dr. Valles gives “culture of health” seminar for The London School of Economics and Political Science

“Housing security’s place in a ‘Culture of Health’: Lessons from the pandemic housing crises in the U.S. and England”

Sean Valles photo

Center Director and Associate Professor Sean A. Valles, PhD, gave a seminar last month for The London School of Economics and Political Science Department of Philosophy, Logic and Scientific Method. Valles presented “Housing security’s place in a ‘Culture of Health’: Lessons from the pandemic housing crises in the U.S. and England” as part of the department’s “Conjectures and Refutations” series.

Dr. Valles has provided a summary of his talk below. A recording is available to watch on YouTube via the LSE Philosophy channel.

People experiencing homelessness had been suffering extreme health and economic hardships before the COVID-19 pandemic, and even more so during it. The notion that housing is a human right is gradually picking up momentum in both the U.S. and England. And that ethical recognition is combining with a growing set of scientific evidence of the effectiveness of “housing first” policies, which provide stable long-term housing to people experiencing homelessness, rather than shuffling people in and out of temporary shelters. Every person ethically deserves safe housing, and failing to provide this has also resulted in a system that cruelly (and at great expense) pushes suffering people into emergency rooms and prisons.

England earned praise for its “Everyone In” program, which was aimed to provide safe housing for every person experiencing homelessness beginning early in the pandemic. By contrast, cities across the U.S. continued defying CDC recommendations by bulldozing temporary encampments set up by people experiencing homelessness, including in Lansing. Meanwhile both the U.S. and England banned evictions of renters who fell behind on their rent during the pandemic, but both also failed to make realistic long-term plans for how to secure housing and income for people who have no way of paying past-due rent once the eviction bans expire.  On both sides of the Atlantic, the pandemic inspired governments to stumble toward recognizing how essential housing is for good health in general and also dealing with this fact. The challenge now is to keep up the momentum, and push for universal housing, since trying to survive without secure housing was already difficult before the pandemic, and will remain so after it ends.

Listen: Social Justice-Oriented Bioethics

No Easy Answers in Bioethics Episode 25

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This month the Center was proud to officially announce its new name: Center for Bioethics and Social Justice. This name change reflects an updated mission with a focus on social justice-oriented bioethics. This episode features a conversation between Director Sean Valles, PhD, and Assistant Director Karen Kelly-Blake, PhD. Together they discuss moving forward in the bioethics space, what engaging in service to the people means to them, and the important work to be done to a create a healthier and more socially just world. They also explore questions related to the practical application of bioethics, and the challenge of preparing medical students for clinical practice in an inequitable world.

Ways to Listen

This episode was produced and edited by Liz McDaniel in the Center for Bioethics and Social Justice. Music: “While We Walk (2004)” by Antony Raijekov via Free Music Archive, licensed under a Attribution-NonCommercial-ShareAlike License. Full episode transcript available.

About: No Easy Answers in Bioethics is a podcast series from the Center for Bioethics and Social Justice in the Michigan State University College of Human Medicine. Center faculty and their collaborators discuss their ongoing work and research across many areas of bioethics. Episodes are hosted by H-Net: Humanities and Social Sciences Online.

Center for Bioethics and Social Justice: new name, mission, and leadership

Green Spartan helmet with text: Center for Bioethics and Social Justice, College of Human Medicine, Michigan State University

The MSU Center for Ethics and Humanities in the Life Sciences is proud to announce its new name: Center for Bioethics and Social Justice. This name change as of April 1 reflects an updated mission with a focus on social justice-oriented bioethics. The Center has a vision of a health system that is compassionate, respectful, and responsive to people’s needs, so that equity, inclusion, and social justice are available to all.

Photo of Sean Valles
Director Sean A. Valles, PhD

“Without an orientation, bioethics has no built-in real-world goals; it is merely a field of study. Doing social justice-oriented bioethics means we have a goal—advancing social justice in the real world with meaningful applications—as the north star for our journey as an institution,” said Center Director Sean A. Valles, PhD.

The updated name and mission follow the appointment of Valles as director earlier this year, along with the promotion of Karen Kelly-Blake, PhD, to assistant director.

“One key piece of the new name and mission is a rethinking and a recommitting of our identity,” said Valles. “The Center aims to be a hub for collaborations and conversations around the relationship between social justice and health. To do that, we will actively seek to engage with our college and university colleagues, local communities, and organizations in order to learn their concerns about the ways our society makes it hard to live a healthy life, and to begin trying to help.”

Photo of Karen Kelly-Blake
Assistant Director Karen Kelly-Blake, PhD

The Center’s mission is to educate health professionals with skills, knowledge, and attitudes necessary to contribute to a world in which health practices are equitable, inclusive, and bolstered by conditions of social justice; to research the nature of bioethics and enhance its applications to the pursuit of equitable, inclusive, and just healthy societies; and to engage researchers, clinicians, policymakers, and communities around shared interests in the attainment of a healthier and more just world.

“Building bridges among MSU experts and outward to communities is of value to everyone involved,” added Valles.

The Center began in 1977 with the formation of the Medical Humanities Program. In 1988, the program became the Center for Ethics and Humanities in the Life Sciences. Faculty in the Center are committed to teaching medical students in the College of Human Medicine and developing social context of clinical decisions content for the Shared Discovery Curriculum. Center faculty are also committed to research, scholarship, and public outreach and education—all working toward the goal of creating a more just world.

Visit the Center’s website to learn more about its faculty and outreach activities, such as public seminars, podcast episodes, and monthly blog posts that explore timely bioethics topics.

Related: Announcing Center Director Sean A. Valles and Assistant Director Karen Kelly-Blake

Announcing Center Director Sean A. Valles and Assistant Director Karen Kelly-Blake

The Center for Ethics and Humanities in the Life Sciences is pleased to announce the appointment of Dr. Sean A. Valles as Center Director. Additionally, associate professor Dr. Karen Kelly-Blake has been promoted to Assistant Director.

Sean A. Valles photo
Director Sean A. Valles, PhD

Dr. Sean A. Valles is a philosopher of health specializing in the ethical and evidentiary complexities of how social contexts combine to create patterns of inequitable health disparities. He was most recently an associate professor in Lyman Briggs College and the Department of Philosophy at Michigan State University. He served as Director of Graduate Programs in the Department of Philosophy, and Director of the interdisciplinary Science and Society at State program. His research spans a range of topics in the philosophy of population health, from the use of evidence in medical genetics to the roles played by race concepts in epidemiology.

Dr. Valles is author of the 2018 book Philosophy of Population Health: Philosophy for a New Public Health Era. He is also co-editor of the Oxford University Press book series “Bioethics for Social Justice.” Dr. Valles received his PhD in History and Philosophy of Science from Indiana University Bloomington.

Karen Kelly-Blake photo
Assistant Director Karen Kelly-Blake, PhD

Dr. Karen Kelly-Blake is an associate professor in the Center for Ethics and the Department of Medicine. She has been with the Center since 2009. Her research interests include health services research, shared decision-making, decision aid development and implementation, clinical communication skills and training, mHealth, racism and morbidity and mortality, bioethics, medical workforce policy, and men’s health.

Dr. Kelly-Blake is a co-investigator on the NIH-funded project “Improving Diabetic Patients’ Adherence to Treatment and Prevention of Cardiovascular Disease.” She is also co-chair of the College of Human Medicine Admissions Committee. Dr. Kelly-Blake received her PhD in Medical Anthropology from Michigan State University.

Please visit our website to read a joint statement from Dr. Valles and Dr. Kelly-Blake on moving toward a new health justice and equity mission for the Center.

The White House outbreak: How to criticize irresponsible leaders without getting stuck in the illness blame game

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This post is a part of our Bioethics in the News series

By Sean A. Valles, PhD

In a twist of fate, there was an outbreak of COVID-19 at a White House celebration of the nomination of Amy Coney Barrett for the Supreme Court of the United States. This elicited a wide range of reactions to seeing a gathering of opponents of strict COVID-19 control measures being hurt by the very pandemic they have downplayed. While others have worried about the moral philosophy of taking pleasure in others’ suffering, or the hypocrisy of evading rules one publicly espouses, I have a different worry. A poll shortly after the White House outbreak found that a majority of respondents believed that Trump had acted “irresponsibly” in how he had handled his personal risk of infection from people he interacted with. While I do not worry about the president being blamed for his illness, I do worry about the wider cultural practices of 1) victim-blaming by attributing a person’s illness to their personal moral failure, and 2) insisting that health is a matter of individual choice. While the distinction might not seem important at first, I will argue there is an important difference between victim-blaming the ill and holding leaders accountable for setting bad examples with their conduct and other leadership failures. The first kind of blame is toxic in a society, and the second kind of blame is an important part of a well-functioning democracy.

President Donald Trump in the Oval Office nominating Amy Coney Barrett to the Supreme Court
Image description: President Donald J. Trump and First Lady Melania Trump pose for a photo with Judge Amy Coney Barrett, the President’s nominee for Associate Justice of the Supreme Court of the United States, her husband Jesse and their children on Saturday, Sept. 26, 2020, in the Oval Office of the White House. Image source: Official White House Photo by Andrea Hanks.

Blaming people for their ill health is a strategy with an awful track record. It doesn’t do any good for the people subjected to “you’re too fat” messages. It doesn’t do any good for survivors of sexual assault or domestic violence. When directed inward, we self-blame for failing to do enough de-stressing self-care, rather than directing our blame to more appropriate targets like the needlessly bad working conditions or economic insecurities that make us stressed in the first place. Repeated messages that “sickness is the result of individual moral failure” also reinforce stigma. Stigma is a nasty phenomenon, with a “corrosive impact on the health of populations” and is particularly bad in cases of infectious diseases like COVID-19 because it actively encourages people to hide their infection, which is obviously bad for them and for others who interact with them.

A second problem with blaming people for their ill health is that ethics of blaming individual behavior reflects a misunderstanding of how health behavior works in the first place. Seemingly individualistic choices like diet, condom use, smoking, alcohol consumption, etc. are not made independently. We choose such things in roughly the same way we “choose” our religions or the languages we speak at home. Yes, each of us can choose to practice an entirely different religion (or lack thereof), and each of us can learn and use a different language in the home. Some of us do. In all of these cases, though, the vast majority of us don’t venture too far from a combination of what we learned while growing up and the cues we get from the people we interact with. We eat the foods familiar, convenient, and affordable to us. We adopt the values and beliefs (including trust in aspects of the scientific endeavor) of our communities, etc. Individual choices exist, but they exist within larger social contexts that have powerful but subtle effects on our choices.

Each of our everyday behaviors related to COVID-19 exist in a complex ecosystem of influences. Mask wearing and other social distancing measures have become intensely politicized and tied to masculinity. Masks and other health behavior measures also create new inconveniences and financial expenses. Social pressures also vary vastly from one setting to the next—in one store there are prodding questions and judgmental stares for wearing a mask, at an adjacent store there are similar pressures on those who don’t wear a mask. How we move our bodies and (un)cover our faces within these intense social pressures is not simply an individual choice.

Take the case of one of the attendees of the party at the White House, University of Notre Dame President, the Rev. John I. Jenkins. He did not wear a mask at the indoor/outdoor party, shook hands with attendees, and otherwise did not follow the standards he had imposed on members of his own university. He knew better and did not do better. Many of us have likely also gone against our better judgment to fit the incautious social distancing norms of a setting. Whether it is the university president or the university student, this is indeed hypocritical, and irresponsible in a sense. But, such blame is aside from the point, and more importantly it contributes to the sort of harmful cultural practices mentioned earlier—especially victim-blaming and stigmatizing the ill. Pointing out hypocrisy and the assigning of blame for individual health behavior distracts from the far more damaging thing Jenkins and the other leaders at the White House party did. As cultural leaders, they undercut efforts to build new norms, like public mask-wearing, the habit of greeting people without needlessly touching hands, etc.

We ought to blame Trump, Jenkins, and many other leaders who attended that party. We ought to blame them for failing in their relationships to the people they lead. That is a devastating form of irresponsibility. And it is very important to separate that kind of blame and irresponsibility accusation from the destructive form of blame discussed above: blaming people for having irresponsible relationships with their bodies/health.

The “personal responsibility” blame game has been the go-to talking point of conservative governors as they use their power to obstruct or dismantle public health measures. “You shouldn’t have to order somebody to do what is just in your own best interest and that of your family, friends and neighbors,” according to Alabama Governor Kay Ivey. Scolding people about “personal responsibility” during a public health crisis is a strategy based on how one wishes the world worked and not how it is actually working. Along similar lines, abstinence-only sex education doesn’t work (“teenagers: be sexually responsible by just not having sex before marriage!”), and neither does “just say no to drugs” education. Jenkins was at least right to point out that his behavior was a failure of leadership. As many of my colleagues in population health science say, we need to build a “culture of health.” That will require leaders suited to the task, and we ought to blame them when they fail in that leadership. Just skip the personal health blaming.

Sean Valles photo

Sean A. Valles, PhD, is an Associate Professor with an appointment in the Michigan State University Lyman Briggs College and the Department of Philosophy (where he is also Associate Chair). His research spans a range of topics in the philosophy of population health, from the use of evidence in medical genetics to the roles played by race concepts in epidemiology. He is author of the 2018 book Philosophy of Population Health: Philosophy for a New Public Health Era. He is also co-editor (with Quill R. Kukla) of the Oxford University Press book series “Bioethics for Social Justice.”

Join the discussion! Your comments and responses to this commentary are welcomed. The author will respond to all comments made by Thursday, November 5, 2020. With your participation, we hope to create discussions rich with insights from diverse perspectives.

You must provide your name and email address to leave a comment. Your email address will not be made public.

More Bioethics in the News from Dr. Valles: We Need Healthier Schools, and Student Activists Are Stepping Up; Recognizing Menstrual Supplies as Basic Health Necessities: The Bioethics of #FreePeriodsTrump’s Attempt to Reignite the Coal Industry Is Another Health Policy BlunderPolitics and the Other Lead Poisoning: The Public Health Ethics of Gun ViolenceClimate Change and Medical Risk

Continue reading “The White House outbreak: How to criticize irresponsible leaders without getting stuck in the illness blame game”

We Need Healthier Schools, and Student Activists Are Stepping Up

Bioethics in the News logoThis post is a part of our Bioethics in the News series

By Sean A. Valles, PhD

California just passed two laws that advance health in schools in ways that might not seem intuitive: pushing middle school and high school start times to after 8am, and banning school districts from “lunch shaming” that treats students differently based on whether they have unpaid school lunch debt. These laws are part of a collection of diverse efforts to make U.S. schools healthier places. The fact that some of these efforts have been led by students themselves is especially heartening.

Bioethics of school policies
The two new laws in California are worthy of attention in a bioethics blog because U.S. schools are, for many students and in many ways, unhealthy places. Not simply because they are crowded spaces infamous for spreading coughs and colds (and stress). For many students, they are also places of food insecurity, social stigma, or even fear of violence. Those problems also shed light on larger problems in society. Even as a child in Los Angeles, I grasped that the local high school having a metal detector at the door signified that something much bigger had gone horribly wrong in my community. Most student problems have their roots outside the school walls, but we can at least do our best to design schools to contend with the difficult realities of young people’s lives.

There is now compelling evidence that later start times for schools are better for adolescent health than early morning ones. As pointed out in one review of the research, adolescents’ bedtimes seem to be more or less independent of when school starts in the morning, partly due to biological clock rhythms changing during puberty. Students forced to begin school early in the morning suffer all of the resulting harms of insufficient sleep (most readers are surely aware that insufficient sleep is bad for physical and mental well-being). This change is surprising in part because the American Academy of Pediatrics has, with limited success until now, been pushing for later school start times, insisting that school start times should facilitate the 8.5-9.5 hours of sleep appropriate for adolescent biology. It will be a difficult schedule transition for some California schools and families/guardians to adjust to, but the health rationale remains powerful.

Stigmatizing and manipulating students are problems, not solutions
It is also encouraging to see California legislate against lunch shaming. Unless prohibited, U.S. schools have the freedom to intentionally or incidentally shame students for being unable to afford their lunch meals. They have done so by giving indebted students inferior meals, marking the students with wristbands or stamps, etc. This is a serious health matter because imposing a stigmatized status upon a child, or even just amplifying an existing one, is a harmful act. Research is quite clear that stigma (“the co-occurrence of labeling, stereotyping, separation, status loss, and discrimination in a context in which power is exercised”) is a powerful and pervasive cause of health injustices. Stigma stresses bodies, socially controls people, and excludes them from social opportunities and resources available to others. Being a child without enough money to pay for lunch is quite hard enough, without one’s school officials metaphorically painting a target on one’s back.

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Image description: Young person at the March for Our Lives protest, holding a placard painted with the words “AM I NEXT?” in red. Image source: Roger Jones/Public Domain.

The desirability of the California law gets clearer when one looks at a policy that goes in the opposite direction. In a widely-criticized lurch backwards, a newly-created policy in a New Jersey school district gives discretion to principals to ban students with lunch debt from participating in extracurricular activities. Which students? Under which circumstances? What goals are achieved by such exclusions? Certainly banning students from soccer practice or chess club doesn’t make money magically appear in their parents’ pockets. The policy is a setback, but I am encouraged by the backlash that gives a new sense of clarity to how remarkably regressive this policy is in light of the opposite trend.

Student advocacy should be welcomed
Most encouraging to me is the fact that students are advocating for themselves and the health of their schools. I am glad that the American Academy of Pediatrics and some California state legislators are advocating for healthier schools, but I have argued at length elsewhere that it is preferable to empower people advocate for themselves. And so students are. For instance, they have been at the forefront of a series of lobbying efforts (successful in Oregon and Utah) to get mental sick days recognized as legitimate reasons for missing school.

It is no coincidence that this push to create space for “mental health days” comes in the middle of a period of worsening mental health of young people in the U.S. Deaths from suicides just replaced deaths from homicides as the second leading cause of death among 15-19-year-olds (deaths from traffic accidents are down, but still exceed both). And homicides are also a target of student activism; after the Parkland school shooting, young people became the unexpected leaders of a new wave of gun control activism.

The late 2010s have been a time of disorienting rapid change, but I suspect that future historians will highlight one global social phenomenon: young people demanding a better world. The most prominent example is the rise of young climate change activists around the world—Greta Thunberg being the most famous—demanding action with a new sense of clarity and resolve. As I write this, Teen Vogue’s website teases an article with a link saying “Why Homeless Advocates Aren’t Happy With the 2020 Presidential Candidates” and an op-ed on radical labor organizing among nail salon workers.

Better health through better spaces
Even though lunch shaming, poor mental health, exhaustion and all sorts of other health problems still tragically afflict young people in schools, I am optimistic because it really does feel that the winds have shifted—thanks in large part to student activists, unhealthy schools are finally getting reforms they have long needed. As I argue at length in the book Philosophy of Population Health, health depends not just on whether we have good medical care, but also on whether the places where we live our everyday lives have been thoughtfully designed to support good health.

Sean Valles photo

Sean A. Valles, PhD, is an Associate Professor with an appointment in Lyman Briggs College and the Department of Philosophy at Michigan State University. His research spans a range of topics in the philosophy of population health, from the use of evidence in medical genetics to the roles played by race concepts in epidemiology. He is author of the 2018 book, Philosophy of Population Health: Philosophy for a New Public Health Era. He is also Director of the MSU Science and Society @ State Program, supporting interdisciplinary faculty collaborations that join the humanities, arts, and sciences.

Join the discussion! Your comments and responses to this commentary are welcomed. The author will respond to all comments made by Thursday, November 28, 2019. With your participation, we hope to create discussions rich with insights from diverse perspectives.

You must provide your name and email address to leave a comment. Your email address will not be made public.

More Bioethics in the News from Dr. Valles: Recognizing Menstrual Supplies as Basic Health Necessities: The Bioethics of #FreePeriodsTrump’s Attempt to Reignite the Coal Industry Is Another Health Policy BlunderPolitics and the Other Lead Poisoning: The Public Health Ethics of Gun Violence; Climate Change and Medical Risk

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