Looking Deeper into Social Determinants

Usually I write about healthcare, health IT and digital health. But my first career was as a social worker and my heart remains with social justice issues.

This post is a review of a book by a friend in Cleveland, sociologist, Tim Black. The book is “It’s a Setup: Fathering from the Social and Economic Margins.” The book presents a unique merger of policy and interviews with fathers to enlighten the reader on the impact of those policies on those on the margins.

Fathers growing up in poverty have been labeled for decades as “deadbeat dads”. Similar to the stereotype of welfare mothers, this false narrative of people on the margins blames the victims rather than the system. Tim and his coauthor Sky Keyes make the point that a cascade of public policies have made it impossible for fathers who live on the margins and are caught in an impossible cycle of demands to provide for their children but face barrier after barrier to fulfilling those demands.

For example, fathers who live on the edge are expected to pay child support even while in prison (without a source of income, what sense does that make?) or if the notice goes to an address they no longer live there. So why don’t they just get a job and pay the support? First, the job opportunities for those who did not complete high school and have a criminal record are few and far between. They include under-the-table work, running the streets for drugs or other illegal activities (risking imprisonment), or temp agencies which pay minimally and for short periods. Failing to pay child support leads to jail time, separation from their children and rarely any mercy in the courts.

Although many of the fathers who are interviewed for the book sincerely want to be with their children, provide for them and have dreams for their future based on social ideals, the “setup” makes it impossible to achieve these dreams. One father viewed fatherhood as a form of redemption, regretting many of the things he had done in the past but also paralyzed with shame and lacking confidence in reuniting with his child.?

There are many examples the authors offer on the barriers to fatherhood. “In this political-economic context, the state has attempted to force poor men and women to comply with declining labor force conditions, by replacing welfare with precarious, low-wage work and through incarceration.”?

During the Great Recession, many of these men searched for weeks and months to find work and attempted to pay child support to no avail. The authors devote a whole chapter on “Welfare Reform and Market Conformity”, referring to the policies which attempted to incentivize those on welfare to find work of any kind. One of those types of work was through temp agencies. “The increasing number of temporary jobs and jobs that don’t pay sustainable wages, the withdrawal of government support for those precariously employed or no longer looking for work in a dismal labor force, and the concentration of poverty, social isolation and idleness policed in urban ghettos and prisons create dismal conditions that manifest in interpersonal relationships.” They also note that the Great Recession of 2008-9 made challenges to “austerity politics” nearly impossible.

The book discusses the unrelenting punishment for being “deadbeat”, imprisonment, at length in a chapter titled, “Fathering Through the Looking Glass.” While some mothers of the men in the book brought the children to visit the fathers in prison, others decided to end the relationship and avoided visits. The time in prison gave many men time to reflect on their lives and fatherhood, hoping to change once released. The authors do not use the term, but in my opinion, the child support laws essentially amount to a debtor’s prison

?which most countries eliminated decades or more ago. Also, much of child support policy is aimed at the poor and as reflected in the 1619 Project, has its roots in slavery and racism, viewing people of color as lazy and needing to be controlled and forced to work.

There are also implications for health and healthcare. The crack and HIV epidemics added to the devastation of the marginalized, making child support even less achievable.?

So what are potential solutions from a policy, economic and cultural viewpoint?

• As for policy, the authors call for changes such as child support debt being forgiven. Also, some states have changed how child support orders are determined, allowing fathers a basic level of income before the support level is determined. Most child support payments go to the states rather than to the mothers; this needs to change as well.
• Regarding economic issues, issues like housing and food insecurity need to be addressed as is now being actively discussed as Social Determinants of Health.
• But cultural attitudes must change also - we must destroy the concept of deadbeat dads and instead support these non-traditional and marginalized families as needing society’s respect and support. Progressive policies from the Biden administration are beginning to address the problems created by austerity politics, where the worker shortage and wage increases as a result of the pandemic will offer hope to those marginalized especially during the Great Recession.

As you can tell, I strongly recommend this book as a way to get beyond superficial discussions of Social Determinants of Health. A deeper understanding of those socially and economically marginalized can offer hope.