Towards a social determination of health framework for understanding climate disruption and health-disease processes

1 "This is the peer reviewed version of the following article: “Towards a social determination of health framework for understanding climate disruption and health-disease processes,” Medical Anthropology Quarterly (2024), which has been published in final form at DOI: 10.1111/maq.12866. This article may be used for non-commercial purposes in accordance with Wiley Terms and Conditions for Use of Self-Archived Versions. This article may not be enhanced, enriched or otherwise transformed into a derivative work, without express permission from Wiley or by statutory rights under applicable legislation. Copyright notices must not be removed, obscured or modified. The article must be linked to Wiley’s version of record on Wiley Online Library and any embedding, framing or otherwise making available the article or pages thereof by third parties from platforms, services and websites other than Wiley Online Library must be prohibited." 2 TITLE Towards a social determination of health framework for understanding climate disruption and health-disease processes AUTHORS José Enrique Hasemann Lara (Iscte-IUL, CRIA-Iscte, Lisbon Portugal) *corresponding autor ([email protected]) Alejandra Díaz de León (Department of Sociology and Criminology, University of Essex, Colchester, UK) Deniz Daser (Department of Sociology, University of St. Gallen HSG, St. Gallen Switzerland) John Doering-White (Department of Anthropology and College of Social Work, University of South Carolina, Columbia, USA) Amelia Frank-Vitale (School of Public and International Affairs and Department of Anthropology, Princeton University, New Jersey, USA) ABSTRACT We compare the social determinants of health (SDOH) and the social determination of health (SDET) from the school of Latin American Social Medicine/Collective Health. Whereas SDET acknowledges how capitalist rule continues to shape global structures and public health concerns, SDOH proffers neoliberal solutions that obscure much of the violence and dispossession that influence contemporary migration and health-disease experiences. Working in simultaneous ethnographic teams, the researchers here interviewed Honduran migrants in their respective sites of Honduras, Mexico, and the United States. These interlocutors connected their experiences of disaster and health-disease to lack of economic resources and political corruption. Accordingly, we provide an elucidation of the liberal and dehumanizing foundations of SDOH by relying on theorizations from Africana philosophy and argue that the social determination of health model better captures the intersecting historical inequalities that structure relationships between climate, health-disease, and violence. KEYWORDS multi-sited ethnography, health-disease, climate change, migration, justice 3 Introduction Astrid’s living room is cramped and dark. A half-broken fan whirrs in the corner; the tiny sofa is worn, the cushions collapsing under her body as she talks. She counts herself lucky to be in this space; her house, her real house, sits on the other side of the Sula Valley, still full of mold and mud and memories and what is left of the belongings that she had accumulated over the years. Astrid fled her home when back-to-back hurricanes hit Honduras in the fall of 2020; her neighborhood was one of the many that turned into lakes as the water rose. Co-author Amelia Frank-Vitale interviewed Astrid in May of 2022 to understand how she managed in the aftermath of these hurricanes. She talked about being displaced, about the lack of warning or preparation from the government, about staying in schools turned into makeshift shelters, and about eventually being offered a place to stay by a relative living in the United States, who had this small house in Choloma, Honduras that she could use. But Astrid’s reticence to return to the house she owns - and owning a home is no small feat in San Pedro Sula - isn’t just because of the damage the storms wrought. Astrid now lives alone, but when the waters were rising in 2020 and she was making the decision to abandon the home that she had worked her whole life to buy, Astrid had a whole family. She and her partner, Melinda, had been together for years. They each had a child from previous relationships, both teenagers now. In the wake of hurricanes Eta and Iota, as they bounced around from shelter to shelter, Melinda started to suffer from asthma. Melinda’s lungs were already susceptible. Years before, the two women had decided to leave Honduras and migrate to the United States. Being a lesbian in Honduras entails dealing with multiple layers of violence and discrimination (Ghoshal 2020; 4 Menjívar and Walsh 2017). Most, though not all, of Astrid’s family was supportive of their relationship, but Melinda’s family refused to accept that they were anything other than friends. They made it to the US-Mexico border, where they were separated and Astrid was quickly deported from the United States. Melinda was held in detention for months, trying to pursue an asylum claim, when she contracted tuberculosis. She, too, was then deported, but before the course of treatment was completed. When Melinda was returned to Honduras, the medicines she needed were simply too expensive. At the end of December 2020, Melinda started to feel ill again. Over the course of a few days, her breathing declined. After a few more days, she was in such bad shape that her family took her to the public hospital, Catarino Rivas. This was an act of desperation. Often called “Matarino” Rivas (a play on the Spanish word matar, to kill), Catarino Rivas has a reputation for being ill-equipped, understaffed, and unlikely to help anyone who is dying. There are not enough gurneys in the hospital. Because new patients will not be admitted until a gurney becomes available, sick people will often go to the morgue to move bodies off gurneys themselves, in a macabre bid to get admitted and receive care. When Melinda was taken to Catarino Rivas in the middle of the COVID-19 pandemic, it was a last resort. Astrid couldn’t visit her due to COVID resrictions, and for some reason patients were not allowed to have their cell phones with them. A friendly nurse facilitated intermittent communication between them, but Melinda, like so many, never made it out of the hospital. Melinda died from COVID. But what killed her? As ethnographers working in Honduras, Mexico, and the United States, we start this article with Astrid and Melinda’s story to bring attention to how climate change and health- 5 disease intertwine (Baer and Singer 2009; Singer 2021). We see climate change and healthdisease as two areas of emerging study that require critical examination of how existing legal and conceptual frameworks might obscure complex relationships between rapidand slow-onset climatic disruptions, interpersonal and structural forms of violence, and acuteversus slow-onset health-disease processes. In Honduras, climate change and health-disease demanded attention, as hurricanes Eta and Iota battered the country within two weeks of each other during the COVID19 pandemic in late 2020. These back-to-back hurricanes are notable not only because of their devastating impacts as discrete “rapid-onset” climatic disruptions, but also because they represent a form of “slow-onset” climatic disruption. Both storm intensity and frequency are likely to increase in the coming years (Reyer 2017), and the intertwining of rapidand slowonset climate events complicates legal regimes throughout Central America, Mexico, and the United States that grant humanitarian aid and legal recognition in the wake of discrete disaster events or incidents of political persecution and interpersonal violence. These interests are in dialogue with the recent rise of the “climate refugee” as a touchstone figure across a variety of governmental, institutional, and organizational contexts. In 2020, advocates celebrated the Human Rights Court ruling in the case of Ioane Teitiota, which sought to apply the principle of non-refoulement to individuals fleeing rising sea levels in Kiribati, Teitiota’s home island. Non-refoulement is the international legal principle that disallows a nation-state from deporting asylum seekers who face “persecution or danger to life or freedom” in their home countries (Behrman and Kent 2020: 14). The Teitiota ruling points to a potential expansion of international protection frameworks to include people fleeing slow-onset climatic disruptions. 6 Despite the hopefulness in the ruling, we remain concerned about the potential for the figure of the “climate refugee” to replace the (colonial) humanitarian subject without transforming underlying biopolitical logics that have characterized regimes of humanitarian assistance and foreign aid (Stevenson 2014). Both humanitarian assistance and foreign aid entail addressing the consequences of structural violence while leaving unquestioned capitalist structures that cause precarity and displacement (Baer and Singer 2009). We saw this play out in response to rapid-onset disasters like Hurricane Mitch in 1998, when a relatively small number of Hondurans were granted Temporary Protected Status (TPS), a framework rooted in the assumption of eventual return, in the US, and where post-hurricane recovery efforts focused on neoliberal capitalist (re)development that enriched some while exacerbating precarity for most, similar to what was documented during post-Hurricane Katrina reconstruction efforts in the Gulf South region of the US (Adams 2013). Hurricane Mitch’s devastating effects in 1998 were front of mind for Indra, a Honduran woman who in 2007 joined the undocumented labor force rebuilding New Orleans in the wake of Hurricane Katrina. Talking with co-author Deniz Daser, she recounted the horrors of seeing whole houses and families washed away and having to carry water up and down 150 steps every day for years after Mitch. But it wasn’t just Mitch that shaped her migration. A serious infection led to several operations in Honduras, one of which went wrong due to lack of resources. Meanwhile, she watched houses in her neighborhood get rebuilt with funds from relatives working in the US. She decided that her economic future and physical health depended on leaving. Recounting her journey northward, she explained, “You finally make it to the border. And THEN the suffering begins.” 7 While Indra had “made it,” life in the US brought other forms of suffering: wage theft, work injuries, constant concern about law enforcement, the stressors of distant family, and the expenses of being undocumented. “We pay a price,” she explained, “We are far from our family. We cannot get medical insurance. We can’t have licenses. We can’t have any benefits.” Additionally, due to complications arising from her operations in Honduras, she learned in New Orleans that she could no longer have children, a devastating blow to someone who frequently discussed her wish to be a mother. Still, Indra retained a desire to do more than simply suffer less. She also wanted to have a good life, one without constant wear and tear on her body and with some comfort and stability, in harmony with her surroundings. To some degree, she has achieved that. Yet as she enters middle age, her ongoing undocumented status raises questions about any possibility for retirement, her ability to visit aging parents in Honduras, and the chronic health effects not only of inadequate health care in Honduras but also the backbreaking and chemically-laden work of cleaning up after Katrina, itself a rapid-onset climatic disaster. As we found through our fieldwork, Hondurans like Indra conceptualized well-being as dependent upon an intertwined understanding of climate, health-disease, and freedom from violence and exploitation. We take these emergent mobility regimes as a starting point for asking how people in Honduras and across its diaspora think about the relationship between climate change, migration, and health-disease. Within this conversation we understand well-being as the conditions that make it possible to access the material, social, and political resources necessary to lead health-full lives (Abadía-Barrero and Martínez-Parra 2017; Breilh 2021; Singer and Baer 1995). This includes accounting for systematic practices of exclusion based on dehumanization (Gordon 2004). We join a longstanding conversation that constructs health-disease as more than 8 either biological or individual by addressing the historically constituted social and political economic contexts in which lives are lived (Breilh 1994; Singer and Baer 1995). We adopt a critical political economic perspective, understanding that health-disease processes are significantly shaped by differential and historically-mediated distributions of power, and that approaches to understanding health-disease inequalities tend to deconstruct social reality for heuristic ease (e.g., climate change, health-disease, violence) but then fail to reassemble these pragmatic separations into a single whole (Singer 1990). 1 In what follows, we argue that the political project that informs the social determinants of health (SDOH) both represents a Eurocentric approach to health-disease processes and best explains/characterizes the health 2 interventions, or lack thereof, experienced by our interlocutors within a given context of power relations. In turn, we propose that the social determination of health (SDET) provides a different understanding of health-disease processes that can better serve our interlocutors because it fundamentally requires searching for alternative social arrangements. Establishing the distinction between SDOH and SDET can help us to further question global health as a project (see Benton 2014) by questioning the tenets of one of its most effectively diffused models (SDOH). We build on recent critiques of SDOH by Yates-Doerr (2020) and Chenhall and Senior (2017) but also move past them by adopting a decolonial perspective (Breilh 1994, 2021). Although we consider work by Yates-Doerr (2020) and YatesDoer et al. (2023) valuable, we also want to mark a separation. We side with Adia Benton (2014) in questioning whether global health can ever align with a decolonial political project. In that respect, we follow from recent argumentation by Ugo Felicia Edu (2023), where Edu provocatively identified the residual colonial and Eurocentric values that texture evaluative 9 practices in Brazilian public health; we join Edu’s (2023) argumentation to what some (AffunAdegbulu and Adegbulu 2020; Basile and Feo Istúriz 2022) have, in a few words, articulated as the coloniality (see Grosfoguel 2011) of global health—how global health may at times operate to sustain a complex web of interacting structures and institutions that legitimate exploitation/oppression by naturalizing social difference (i.e., dehumanization). On the Origins of Social Determinants (SDOH) and Social Determination (SDET) Epidemiologist Michael Marmot (2004) helped develop SDOH during the 1990s, following his involvement with the Whitehall II study, a longitudinal study of British civil servants from 1985 to 1988 meant to evaluate their life outcomes. The study yielded a social gradient in health: life outcomes were determined by individuals’ relative standing within a social hierarchy. These outcomes were not mediated by income alone, however, but by a set of unevenly distributed social factors that led to individuals adopting health-damaging practices that could be altered through relative adjustments to conditions of life. Marmot and Richard Wilkinson (Solar and Irwin 2010) then expanded on these ideas, arguing that an individual’s ability to act in relation to healthdamaging practices was impacted by both proximal (e.g., immediate living conditions) and distal factors (e.g., public policy) distributed along a continuum. Although SDOH moved discussions on health within international organizations towards acknowledging that the distribution of health problems across the world was patterned and systemic (Arias-Valencia 2017; CSDOH 2008), its proponents claim that “where systematic differences in health are judged to be avoidable by reasonable action, they are…unfair” (CSDOH 2008: ii) and that “the question should no longer be capitalism or not, but what kind of capitalistic 16 progressively through targeted efforts orchestrated by private enterprises. 4 This approach “enables global health to present itself as concerned with the problem of global health inequality without committing itself” to altering structural conditions (Reid-Henry 2016: 723). In doing so, SDOH tends to overlook capitalism as a mechanism and ideology for accumulation via dispossession that emerged with and from European colonial expansion in the Americas (Grosfoguel 2011). 5 European (and later US) colonial expansion in the Americas over four centuries left residual and persistent effects that continue to shape relationships between former colonial powers and former colonies (Grosfoguel 2011). Following Anibal Quijano, Ramón Grosfoguel (2011: 11-15) calls this the “colonial power matrix,” or the complex web of interacting structures and institutions which establish and sustain hierarchies that naturalize exploitation/oppression and legitimate “colonial forms of domination after the end of colonial administrations” (Grosfoguel 2011: 14). The racist, sexist, misogynist, classist, religious and patriarchal norms that facilitated the consolidation of colonialism and capitalism still structure everyday conditions of life without needing to directly reaffirm that control over life. 6 Ultimately, our understanding of capitalism in regards to health-disease processes draws from Gargi Bhattacharyya's (2018) rethinking of “racial capitalism” which argues that 1) dehumanization is an inevitable result of capitalist development processes; and that 2) dehumanization is patent in the denied capacity of some groups to manage or access forms of care that enable desirable lifeways. To that effect, any conversation on health-disease that takes capitalist relations as a fixed starting point may also assume the fixity and inevitability of unequal health outcomes. In the context of conducting simultaneous fieldwork across three sites (Honduras, Mexico, and the United States), our interlocutors’ responses consistently pointed to the ways that 17 climate change and health-disease are inextricably bound up in overlapping processes of violent dispossession that surpass liberal political understandings of atomized individuals and politically isolated geographical locales. We foreground our interlocutors’ words and experiences to argue that there exist a multiplicity of relationships between climate change, health-disease, and migration, borne from sharing an underlying root cause. On Liberal Political Theory and Justice María, a 33-year-old Honduran woman from Concepción, Copán, was traveling with her two young children when she was interviewed by Díaz de León and Doering-White at a migrant shelter in Central Mexico. She left Honduras because, “Eta took away my house and close to us, in front of our house, they killed my cousin. A young man who was on drugs killed him. He was my sister’s [brother-in-law]. And it is still very upsetting, we saw when he was killed, even the children were scared.” In her retelling, she made the verbal jump from Eta, a sudden-onset climate disaster, to the overt interpersonal violence she and her family experienced. Eta also destroyed the coffee crops, she added, so that she couldn’t work cutting coffee anymore, thus taking away her livelihood. The government did not help them rebuild after the hurricane. María’s story highlights the difficulty in approaching geographically expansive and regionally interconnected problems through the limiting and homogenizing lens of liberal political thought (Gordon 2007, 2021). According to Gordon, liberal philosophical approaches begin from the assumption that achieving justice is a matter of constructing better ways of regulating life to maintain the stability of an order assumed to be almost perfect (Gordon 2021), rather than creating the conditions necessary to “shift the conditions of rule” (Gordon 2007: 7). Liberal political views 18 on justice start by constructing a universal subject, which is typically an idealized reflection of privileged groups in society who already have their interests and lives significantly protected under the dominant scheme (Gordon 2007). Second, liberal political views on justice fail to consider that access to meaningful participation in racist societies is conditioned by whether one’s humanity is acknowledged by a dominant Other (Gordon 2007). Third, liberal political views on justice privilege individual rights over collective restructuring of access to social goods (Gordon 2021: 44-45). All these factors limit liberal political conceptions of justice to conceiving of social change in terms of, for example, “what kind of capitalistic society do we want to have?” (Marmot 2014: 248), which could also be reformulated as: “what forms of injury are permissible, and to whom, to maintain the system?” This approach reduces governmental response to controlling harms, responding to injury, and dealing with victims (Gordon 2021: 16-17, 63-64) to safeguard the integrity of the system itself (Gordon 2021: 42; see also Anderson 1999). It is precisely at this point of governmental and institutional response that our intervention argues for a more critical approach to justice than that found in the SDOH. The above requires recognizing, for example, how Maria has been impacted by the underlying imperial dynamics surrounding coffee cultivation in the region (Tucker 2008). From the early nineteenth century on, US-led interventions into countries like Honduras ensured the development of US capitalism, militarism, and the extraction of coffee, bananas, and other commodities (Sluyter et al. 2015). Twentieth century firms headquartered in New Orleans, the site of Daser’s fieldwork, such as United and Standard Fruit, became deeply involved in the political economy of Honduras and Central America more broadly (Acker 1988; Karnes 1978; Soluri 2005). More recently, neoliberal reforms implemented in the wake of Hurricane Mitch in 1998 and the 19 2009 coup d'etat against then-president Manuel Zelaya have instituted pro-business policies and encouraged extractivist industries in tourism that have contributed to increased dispossession (Daser and Fouts 2021: 118). Across the northern coast of Honduras, including in the Sula and Aguan Valleys, agricultural communities have been losing land to palm oil plantations, which require little labor, consume immense amounts of water, and require extensive chemical inputs that quickly destroy the land quality after a few years while exposing workers and people living in nearby communities to harmful fertilizers and pesticides (Holland 2014; Palomo Contreras 2022). María herself clearly draws connections between multiple stressors that affected her and her loved ones’ health-disease. Rather than a single, socially determining factor, an array of structural and personal events inform her decision – and her ability – to migrate. She is able to leave while her sister cannot, but both sisters are now left separated, without the familial and social connection and support that proximity might offer. “Escape” as the only potential path towards a violence and disaster-free life is an inherently individualizing solution which responds to an acknowledged harm over addressing structurally rooted conditions that impact a larger social collective. We lack data that speaks to specific interventions that impacted María’s trajectory. That being said, it is instructive to examine interventions proposed by prior studies that take an SDOH lens to improving health in Central America. One study (Aragón et al 2011), for example, proposes targeting “those most in need” and “efficient regulation of hazardous exposures and other dangers” (236) through the implementation of international covenants, such as ILO 187, as a means of addressing broader health inequities experienced by agricultural workers. However, the authors also recognize that “the implementation and reach of protective regulations are deficient in the 20 face of neoliberal deregulatory tendencies” (Aragón et al. 2011: 23). These proposed interventions speak to how SDOH risks reifying logics of individual deservingness (“help those with a duly justified/recognized need”) while separating out determinants (“hazardous exposures”). Doing so fails to fully recognize how causes of violence and illness are mutually constitutive and structured by the underlying colonial historical processes mentioned above. Such interventions place responsibility on individual needs and discrete instances of exposure, while obscuring how ongoing imperialist dispossession of certain regions and certain people for capitalist accumulation underlies the intervention’s original target. María’s story calls for a historically aware analysis that takes power differentials into account in ways that liberal political thought does not. Liberal political philosophy and other “liberalisms” ignore the history of colonialism and persistent coloniality and their continued structuring effects (Sanín-Restrepo and Méndez-Hincapié 2015), in this case by displacing the historical structural legacy that makes forced migration a reality that both sisters must contend with, regardless of its economic availability to only one of them. Competing Views on Justice in Health: Dispossession, Capabilities, and Labor Roque, a Honduran man Díaz de León and Doering-White interviewed during his transit through Mexico, understands the ambiguity of supporting market practices at the expense of long-term local well-being and how, when treated as natural and necessary, market production conceals root causes that affect people differently. In the region where Roque lived, El Paraíso, there used to be a small mountain with trees that held the moist mountain air, “You could feel the sereno, the dew in the mornings,” Roque explained. Eventually, someone started illegally logging what members of Roque’s community considered to be public lands to build more coffee plantations. “I thought 21 the forest was public,” he stated, “but I guess either they bribed or threatened someone.” Roque was initially happy about the changes taking place. Logging brought jobs to the community, and later Roque earned money picking coffee on the new plantation. A couple of years later, however, the weather started turning. With fewer moisture-retaining trees, the air became drier and hotter. Coffee rust decimated the plantation, and Roque, like most of his fellow workers, was laid off. Ultimately, Roque found himself unemployed and living in a hotter place with less water for his crops while, as he explained it, “the guys who built the finca are doing all right.” In Roque’s case, the SDOH perspective would suggest addressing the determinants that “mediate the effect of socioeconomic position on health” (Solar and Irwin 2010: 51), such as improving working conditions or providing access to clean water. An example of this logic is an article that outlines a series of projects implemented by Presbyterian aid workers in partnership with Heifer International and an indigenous community in rural Honduras (Reifsneider et al. 2021). The authors describe interventions that correspond to particular determinants of health, including housing, clean water, and education. The assumption is that improving housing, clean water access, and education in turn improves health. This approach deals with immediate issues and individual victims without considering the conflicts that caused the situation: in this case, corruption that leads to dispossession, logging, and increased heat in the region. Roque was a campesino, a peasant. He owned a tiny plot of land that, even at the best of times, did not provide enough produce to support his family. He was forced to sell his body, his labor, in order to earn money. He had rough hands; he would limp after standing for too long. His back hurt constantly and his skin bore signs of significant sun-exposure. Despite all this, he woke up every morning, sometimes seven days a week, to work in what had been a public forest that 22 had now become a coffee plantation. He had to struggle on land that had been stolen from the community. He was fired as soon as his body was no longer needed. And then he had nothing left, no forest, no job, no one to buy his labor. He was not critical about the deforestation to build a plantation. He was happy about the jobs it brought. However, being fired contributed to his realization of the huge power differential between himself and the plantation owner: “They just don’t care. We are worse [than before]. They fire everyone and wait it out. They don’t lose money. They always have food and water. They are safe.” After he was fired, Roque tried to change his situation. Like many of our interviewees, he tried to make it work. He looked for another job, ignoring his aches and pains, making plans. Still, eventually, he had to admit that ganas de trabajar, desire to work, and a body that could still sell labor, were no longer enough in El Paraíso. He left. His story shows that the capabilities of the more powerful annul any capabilities that Roque has. Those who caused the damage, in this case the coffee plantation owner and the corrupt officials, provide a service to the market and thus are protected. For those who are unprotected, the only alternative is to leave and see if somewhere else they are still useful as a working body. For individuals like Roque, the multiple effects of climate change, neoliberal land policy, and political corruption create a brew of factors contributing to the ill health he has experienced, and which cannot be addressed through a market-justice approach. In Roque’s history, we can see how the inseparable capitalist and individualist moves of the coffee plantation owner produced limited wellbeing for some, for a time. However, the privatized finca affected the life conditions of the community, generating dispossession, leaving them poorer and more vulnerable. Respecting the trees would have provided years of cool days, water, and predictable weather for the 23 community. However, the short-sighted actions of the businessman and some residents – not to mention the role of larger global capitalist relations desiring lumber consumption – resulted in damage to the ecosystem, the economy, and the health of both individuals and the community as a whole. We see this story repeat over and over again. Sometimes, like in Roque´s case, there is a slow process of dispossession and abuse. For others, like Janette, the shock is much swifter. Díaz de Leónand Doering-White interviewed Janette in a storage room full of donated clothes at the shelter in Mexico. When Díaz de León asked her about her reasons for leaving and how they related to climate change, Janette understood immediately what she meant. She stated how initially she had some problems with some people who were threatening to kill her. Before the issue was resolved, the hurricanes arrived, “I lost my house; I lost my dad; I lost a son. My dad was my only support and I lost him.” After that, someone she loved was killed and “I just kept on suffering and I was forced to come [to Mexico] because I have no other options to feed my children.” Since leaving her house, she has tried to get to the United States, but she has been unlucky. And she feels she cannot go back home empty-handed. She concludes, “those are the reasons that led me to leave. I left without being ready because I lost my father, I lost a son in the hurricanes, I lost my house, I have nothing…” Echoing other interviewees, Janette makes connections between the multiple stressors that triggered her need to leave. For her, part of the problem is that the hurricane destroyed the houses, then people had nowhere to live, and then crime increased. They were hungry because the planted corn was lost. And they had to see the dead bodies, buried by the hurricane. “You can never forget that,” she told her interviewers, as she started crying. Health, climate, dispossession, 24 migration; Janette’s account reminds us that these conditions are impossible to isolate into atomized factors. Concluding Discussion: nature-climate change, health-disease, and migration In this article, we articulated some of the differences we identified between the social determination of health (SDET) and the social determinants of health (SDOH). We focused on this critique because “contexts of power exist before and beyond…intentions.” 7 Practitioners of SDOH may have good intentions, but SDOH, much like global health (Adams 2010; Affun-Adegbulu and Adegbulu 2020; Bashford 2004; Benton 2014; Packard 2016; Povinelli 2006; Stevenson 2014), is part of a very long and complex history of power relations maintained by naturalizing dehumanization and concealing the mechanisms through which that dehumanization takes place (Wynter 2003). We propose SDET as an alternative to SDOH because SDET allows us to be in conversation with a set of thinkers that take dehumanization seriously. We do not pretend to have an answer or aspire to heroic gestures, rather we seek to contribute to a long, slow, and uncertain movement towards liberation (Salazar Parreñas 2023). To be specific, SDET differs from SDOH in that SDET incorporates how historically conditioned, reigning systems of political-economic organization fundamentally create the conditions that impact health-disease processes. Once we admit that capitalism depends on continual and systematic social differentiation (i.e., dehumanization), identifying capitalism as a root cause takes on pressing ethical dimensions as we begin to conceptualize the extent to which our dominant understandings of guiding principles are suffused with a dehumanizing ethos. For example, justice. Capitalist development privileges some by refusing access to a whole host of 25 rights, resources and forms of care to others, and to accomplish that patently unbalanced distribution of public goods forces us to re-define our relationships to each other and to the surrounding environment (Bhattacharyya 2018). SDET mobilizes an explicit imperative to recognize not only where care is needed or what forms of care are possible and how, but to continually expose the structures at work towards better forms of organizing life. SDET is both a model to study health-disease processes and an ethical commitment to a way of framing the complex and interwoven processes that condition our shared reality. As our fieldwork revealed, people know what health looks like for them. In contrast to the implications of the SDOH model, our interlocutors understand health in a holistic way, more akin to decolonial understandings of collectivity and justice. For people leaving Honduras, being healthy means the absence of physical pain like bone-deep aches and lack of fever. Health also includes collective wellbeing, such as everyone having enough to eat, having a calming surrounding, and living in a “healthy environment” without gangs. Roque’s body is scarred by the labor and sun of El Paraíso; so much so that Díaz de León and Doering-White could witness the wear. Indra’s body, scarred on the inside due to lack of resources in Honduras, is also, now, marked by the hard labor available to the undocumented in New Orleans. Jannette, Astrid, and Maria, and Maria’s sister as well, also bear the consequences of the intersections of health, climate, and migration, though perhaps their scars are primarily internal: separated from loved ones, grieving avoidable loss, and subjected to physical violence along with the social violences of displacement and dispossession. These interwoven stories reflect how social class, sexuality, time of migration, luck, legal status, and multiple other factors shape the possibilities for Hondurans journeying northward and 30 Heidbrink, Lauren. 2019. The Coercive Power of Debt: Migration and Deportation of Guatemalan Indigenous Youth. Journal of Latin American and Caribbean Anthropology. 24 (1): 263-281. Holland, Lynn. 2014. “The Lower Aguán in Honduras and the Deadly Battle Over Land Rights.” Carnegie Ethics Online, May 6, 2014. Hooker, Juliet. 2017. Theorizing Race in the Americas: Douglas, Sarmiento, Du Bois, and Vasconcelos. New York: Oxford University Press. Karnes, Thomas L. 1978. Tropical Enterprise: The Standard Fruit and Steamship Company in Latin America. Baton Rouge: Louisiana State University Press. La Gaceta. 2010. “Decreto 286-2009: Ley para el establecimiento de una visión de país y la adopción de un plan de nación para Honduras,” Diario Oficial República de Honduras, 32,329: 1-74. Marcus, George E. “Ethnography in/of the World System: The Emergence of Multi-Sited Ethnography.” Annual Review of Anthropology 24 (1995): 95–117. Marmot, Michael. 2004. The Status Syndrome: How Social Standing Affects Our Health and Longevity. New York: Henry Holt and Company. ———. 2014. The Health Gap: The Challenge of an Unequal World. New York: Bloomsbury. Menjívar, Cecilia, and Shannon Drysdale Walsh. “The Architecture of Feminicide: The State, Inequalities, and Everyday Gender Violence in Honduras.” Latin American Research Review 52, no. 2 (2017): 221–40. Miranda, Dana Franciso. 2020. “The Future of Alienation and the Possibilities of Fanonian Sociodiagnostics.” Entreletras 11(2): 53-71. 31 Morales-Borrero, Carolina, Elisa Borde, Juan Eslava-Castaneda, and Sonia Concha-Sánchez. 2013. ““¿Determinación Social o Determinantes Sociales? Diferencias Conceptuales e Implicaciones Praxiológicas.” Revista de Salud Pública 15 (6): 797–808. Navarro, Vicente. 2009. “What We Mean by the Social Determinants of Health.” International Journal of Health Services 39 (3): 423–41. Ojeda, Diana. “Los paisajes del despojo: propuestas para un análisis desde las reconfiguraciones socioespaciales.” Revista Colombiana de Antropología 52, no. 2 (December 2016): 19–43 https://orcid.org/0000-0003-2009-8060 Packard, Randall. 2016. A History of Global Health: Interventions into the Lives of Other Peoples. Baltimore: Johns Hopkins University Press. Palomo Contreras, Arelí. 2022. “La muerte del Panaco: Un área protegida que nunca fue - Contra Corriente.” Contra Corriente, October. https://contracorriente.red/2022/10/10/la-muerte-delpanaco-un-area-protegida-que-nunca-fue/ Peñaranda, Fernando. 2015. “The Individual, Social Justice and Public Health.” Ciência e Saúde Coletiva 20 (4): 987–96. Povinelli, Elizabeth. 2006. The Empire of Love: Toward a Theory of Intimacy, Genealogy, and Carnality. Durham, N.C.: Duke University Press. Reid-Henry, Simon. 2016. “Just Global Health?” Development and Change 47 (4): 712–33. Reifsnider, Elizabeth, Phebe W. Packer, Autumn Argent-DeLorme, and Christina Suarez. 2021. “Community development for improved housing, health equity, and education in rural Honduras.” Public Health Nursing 38(4): 680-686. 32 Reyer, Christopher, Sophie Adams, Torsten Albrecht, and Florent Baarsch et al. 2017. “Climate Change Impacts in Latin America and the Caribbean and Their Implications for Development.” Regional Environmental Change 17: 1601–21. Ribeiro, Gustavo Lins. 2023. “From Decolonizing Knowledge to Postimperialism: A Latin American Perspective.” American Ethnologist 50 (3): 375–86. Ruger, Jennifer Prah. 2016. “Global Health Inequalities and Justice.” In Understanding Health Inequalities and Justice: New Conversations across the Disciplines, edited by Mara Buchbinder, Michele Rivkin-Fish and Rebecca L. Walker, 64–87. Chapel Hill: University of North Carolina Press. Salazar Parreñas, Juno. “Ethnography after anthropology.” American Ethnologist 50 (3): 453461. Sanín-Restrepo, Ricardo, and Méndez-Hincapié. 2015. “Manifest Injustice from the (de)Colonial Matrix: The Reversal of the Panoptic.” Philosophy and Social Criticism 41 (1): 29–36. Sen, Amartya. 2000. Development as Freedom. New York: Alfred Knopff. ———. 2015. “The Idea of Justice: A Response.” Philosophy and Social Criticism 41 (1): 77– 88. Singer, Merrill. 1990. “Reinventing Medical Anthropology: Toward a Critical Realignment.” Social Science and Medicine 30 (2): 179–87. ———. 1998. “The Development of Critical Medical Anthropology: Implications for Biological Anthropology.” In Building a New Biocultural Synthesis: Political-Economic Perspectives on Human Biology, edited by A.H. Goodman and T.L. Leatherman, 93–124. Ann Arbor: University of Michigan Press. 33 ———. 2021. Perils of Eco-Crises Interaction: Human Health and the Changing Environment. Hoboken, NJ: Wiley. Singer, Merrill, and Hans Baer. 1995. Critical Medical Anthropology. 2nd Edition. United Kingdom: Routledge. Soluri, John. 2005. Banana Cultures: Agriculture, Consumption, and Environmental Change in Honduras and the United States. Austin: University of Texas Press. Sluyter, Andrew, Case Watkins, James P. Chaney, and Annie M. Gibson. 2015. Hispanic and Latino New Orleans: Immigration and Identity Since the Eighteenth Century. Baton Rouge: Louisiana State University Press. Kindle edition. Solar, O., and A. Irwin. 2010. “A Conceptual Framework for Action on the Social Determinants of Health. Social Determinants of Health Discussion Paper 2 (Policy and Practice).” Geneva: WHO. Stevenson, Lisa. 2014. Life Beside Itself: Imagining Care in the Canadian Arctic. Berkley and Los Angeles: University of California Press. Stoler, Ann. 2013. “Introduction.” In Imperial Debris: On Ruins and Ruination, edited by Ann Stoler, 1–35. Durham and London: Duke University Press. Waitzkin, Howard. 1981. “The Social Origins of Illness: A Neglected History.” International Journal of Health Services 11 (1): 77–103. Walker, Rebecca, Michele Rivkin-Fish, and Mara Buchbinder. 2016. “Introduction.” In Understanding Health Inequalities and Justice: New Conversations across the Disciplines, 34 edited by Mara Buchbinder, Michele Rivkin-Fish and Rebecca L. Walker, 1–30. North Carolina: University of North Carolina Press. Wimmer, Andreas, and Nina Glick Schiller. “Methodological Nationalism, the Social Sciences, and the Study of Migration: An Essay in Historical Epistemology.” The International Migration Review 37, no. No. 3 (Fall 2003): 576–610. Wynter, Sylvia. 2003. “Unsettling the Coloniality of Being/Truth/Freedom: Towards the Human, After Man, Its Overrepresentation--An Argument.” The New Centennial Review 3 (3): 257– 357. Yates-Doerr, Emily. 2020. “Reworking the Social Determinants of Health: Responding to Material-Semiotic Indeterminacy in Public Health Interventions.” Medical Anthropology Quarterly 34 (3): 378–97. Yates-Doerr, Emily, with Lauren Caruth, Gideon Lasco, and Rosario García-Meza. 2023. “Global Health Interventions: The Military, the Magic Bullet, the Deterministic Model—and Intervention Otherwise.” Annual Review of Anthropology 52: 187-204.