- About HHR
Mariana Chilton, Jenny Rabinowich, Christina Council, and Jennifer Breaux
Health and Human Rights 11/1
Published June 2009
When the lives and the rights of children are at stake,
there must be no silent witnesses.1
Currently 30.2 percent of female-headed households with children in the United States experience food insecurity, defined as the lack of access to enough food for an active and healthy life. In 2007, approximately 12.4 million children were at risk for hunger. When female-headed households and households with children have the highest prevalence of food insecurity and hunger in the US, the participation of low-income mothers in the development and administration of policies and programs related to nutrition and poverty are fundamental to the process of ending hunger and improving child wellbeing.
In this article, we describe the Witnesses to Hunger program, a participatory advocacy project that uses the “photovoice” technique to engage mothers to take photos and record their stories about poverty and hunger with the intent to inform social welfare policy in the US. Witnesses to Hunger is grounded in the human rights framework that is supported by international conventions on the rights of women, the rights of the child, and economic, social, and cultural rights. The Witnesses to Hunger program works to increase civic participation of low-income women and to maintain a strategic public awareness campaign.
After introducing the Witnesses to Hunger program, this article describes the past decade of unchanging food insecurity disparities, demonstrates the lack of participatory dialogue in health and welfare programs, and provides examples of how Witnesses to Hunger counters the conventional dialogue about welfare. Throughout, this paper demonstrates how the participatory approach of the Witnesses to Hunger program improves our understanding of basic human needs and the social determinants of health, and informs legislators on how to improve health and welfare policy.
Women’s vulnerability to hunger and food insecurity has long been recognized in the human rights documents of the United Nations.2 Because women and children are especially vulnerable to food insecurity and to socioeconomic processes that cause it, ensuring women’s rights and the rights of children are important correlates of the right to food.3 While “right to food” dialogue often focuses on women and children in developing countries who are caught in a life-cycle of malnutrition (where the mother’s malnutrition subsequently affects her child’s development, employment potential, and own reproductive health), women in the United States also suffer from generational poverty and the negative effects of food insecurity. This paper describes one program, called Witnesses to Hunger, in which low-income women in urban Philadelphia have begun to try to break this cycle — not only for themselves, but also for other women like them.
Witnesses to Hunger seeks to advance social, economic, and cultural rights by increasing civic participation through a strategic public awareness campaign that is informed directly by low-income mothers of young children in Philadelphia. The work of these women is at the nexus of the rights of women, the rights of the child, and economic, social, and cultural rights. Their contributions to the dialogue are grounded in personal experiences of being poor in the United States and negotiating the patchwork of the current welfare system.
Through their participation, women in the Witnesses to Hunger program are actively challenging the orthodoxies of the welfare system. They speak on behalf of their rights, the rights of their children, and the right of all people to health and to food. The Witnesses to Hunger program engages each mother to speak on her own behalf in order to draw attention to the negative affects of household food insecurity and poverty on the health and wellbeing of young children. Through the program, the mothers’ voices are reaching local, state, and federal policy makers through testimonies and briefings, letters, and written reports. They also have begun to inform the general public through the Witnesses to Hunger website (http://www.witnessestohunger.org), local speaking engagements, press events, and media coverage of their work.
In this paper, we describe the methods of our work and the rationale behind the Witnesses to Hunger program as a response to the unchanging racial, ethnic, and gender disparities in household food insecurity. We introduce the human rights framework upon which the program was built. We then provide examples of how the Witnesses to Hunger program seeks to counter prejudice and discrimination and to portray the experience of hunger as an unacceptable, health-defying series of trade-offs.
Witnesses to hunger: Background and methods
Currently, 30.2 % of female-headed households with children in the United States experience food insecurity, defined as the lack of access to enough food for an active and healthy life. In 2007, some 12.4 million children lived in food insecure households.4 Because female-headed households and households with children have the highest prevalence of food insecurity and hunger in the US, female heads of household should be able to actively participate in the national dialogue about hunger and poverty. “The people’s participation” is central to the advancement and implementation of the right to food.5 It is also a major tenet of the entire human rights framework.6 Although the United States may be considered a participatory democracy, there is minimal participation of the poor in the development of the policies and programs that affect them most. This is especially true for urban low-income families.7
The Witnesses to Hunger program seeks to ensure that the people who understand poverty and nutritional deprivation from personal experience are able to participate in the national, state, and local policy dialogue through hunger and health policy debates, hearings, briefings, and planning sessions. To promote such dialogue, Witnesses to Hunger utilizes the methodology of “photovoice.” Photovoice is a participatory action research strategy that includes providing cameras to those participants who are usually the “subjects” of policies and programs (or the subjects of research studies) to ensure that they can provide their own frames of reference around issues most meaningful to them in order to educate the public and to inform policy makers about those aspects of policies and programs that need to change in the view of the participant.8 The intention of photovoice methodology is to provide a way for those who are the recipients in public programs — people who are usually treated as passive or voiceless — to express their individual voices through photographs and accompanying narratives.
Photovoice has been shown to be an effective way for people who have lower literacy skills and little access to resources to communicate their life experiences, expertise, and knowledge to the world.9 In turn, policy makers are exposed to the community and to issues that may otherwise be hidden from view. The methodology adopts the tradition of Paulo Freire’s “critical consciousness.”10 On a broader scale, the methodology seeks to enhance internal reflection, self-awareness, and the exchange of individuals’ perceptions in order to initiate personal and community change.11 The innovative approach of the photovoice methodology extends beyond the literacy skills of participants and simultaneously provides a venue to effectively communicate women’s experiences to decision makers.12 Photovoice has proven to be an effective tool for low-income women in maternal and child health research and policy. It has also been used effectively to inform policy makers and to create tangible legislative change.13 This type of photography — done by a group of non-professionals who are victims of human rights violations or are witnesses to them — has been used in other venues as well, including international interactive websites, peer-reviewed publications, exhibits, books, and documentary film. To date, however, a photovoice project such as Witnesses to Hunger — large-scale, rights-based, and grounded in public health policy — has not been attempted in the United States.
The Witnesses to Hunger photovoice methodology focuses its efforts on informing and improving health and US welfare policy. Through direct and indirect contact with legislators and policy makers, Witnesses to Hunger participants utilize their photographs and stories to inspire policy change. Such contacts take place through a traveling exhibit that actively engages policy makers in dialogue; through direct participation in informal testimonies, briefings, written reports, and press conferences; through video and photo postings; and by means of letters and emails sent directly to individual legislators. The goals are not simply to improve viewers’ and listeners’ understanding and compassion; but rather, to demand accountability from city, state, and government actors on issues related to the health and wellbeing of young children in poverty.
In 2008, the Witnesses to Hunger program provided digital cameras to 42 women in Philadelphia, all of them mothers of young children, and recorded their stories about the resulting photographs. The women documented their experiences with hunger and poverty and their ideas for change. Through their digitally recorded individual interviews (described below), the photographers constructed written narratives from their lived experiences in ways that incorporate these images. The images and associated narratives are displayed on an interactive website that is searchable by mother/child, issue, policy, and keyword (www.witnessestohunger.org). The site also has integrated links to pages on associated social networking sites such as YouTube, Facebook, and Twitter.
Women were recruited for the program through a flier sent out to caregivers of young children under the age of three who had requested outreach through the ongoing research of Children’s HealthWatch (www.childrenshealthwatch.org), another project that the authors were directing at a local hospital in Philadelphia. Participants who responded to the flier by calling our offices received a home visit in order to complete an informed consent process (approved by the Drexel University Institutional Review Board), and underwent a brief interview regarding child and maternal health and their participation in welfare programs. Each woman who joined the program participated in at least two individual interviews and one of four focus groups with other women in the project. Each participant received her own Canon PowerShot digital camera (to keep) and either US$25 or US$50 in cash, depending on the length of the interviews. The women received brief one-on-one training on how to use the digital camera and were asked to take photos of what they wanted the public and policy makers to see and to witness about their lives.
After two to three weeks, the authors visited each participant again for a semi-structured and video-recorded interview that used the women’s digital photographs as a guide. Using the photovoice technique, these interviews included questions about 1) why the participants took the photos, 2) what they want the public to see, and 3) what they want others to do or to change. The Witnesses to Hunger project team developed these audio and visual documentaries into a traveling exhibit featuring still photography, audio recordings, written narratives, and video clips. The multi-media Witnesses to Hunger website was created to complement the exhibit.
The professionally installed exhibit, with still photos and several videos, was launched in Philadelphia in December 2008. Senator Bob Casey Jr., (D-PA) invited the exhibit to Washington, DC, where it was displayed in the United States Senate Russell Building Rotunda in May 2009. Senator Casey hosted a reception with several other US senators, including Senators Arlen Specter (D-PA) and Tom Harkin (D-IA). Congressman Jim McGovern (D-MA), co-chair of the House Hunger Caucus, invited the exhibit to display in his home district in Massachusetts, to raise awareness about hunger in America and to hear the women speak on their ideas for improving the programs that most affect them.
While the exhibit was in Washington, DC, three participants were invited to record their testimonies for the Senate Democratic Steering and Outreach Committee about President Obama’s Economic American Recovery and Reinvestment Act and its direct impact on their families. Nine Witnesses to Hunger participants also met privately with the House Hunger Caucus co-chair, Congressman McGovern. The witnesses also provided a staff briefing at the US House of Representatives in June 2009, hosted by Congressman Chaka Fattah (D-PA), the representative from the Philadelphia district in which many of the witnesses reside. This briefing addressed issues of early childhood nutrition that were relevant to the Child Nutrition Reauthorization of 2009, legislation that covers programs that fund school breakfast and lunch programs, the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC), and other related programs. The briefing also addressed issues related to heath care reform (such as adequate health care and prescription coverage for women and improved access to mental health treatment programs) and issues related to the current housing crisis in Philadelphia due to lack of adequate low-income housing, long wait lists for housing subsidies, and the closed waiting list for Section 8/Housing Choice.14
Other policy-related activities are planned. Additional focus groups will provide feedback and information to governmental agencies, such as the Pennsylvania Department of Welfare, to address concerns regarding the “welfare to work” training and education programs, and regarding the administration of the Low-Income Health and Energy Assistance Program. Further testimonies are also planned: several policy briefs using the women’s photographs and stories will be developed as legislative, administrative, and regulatory policies related to poverty, hunger, and welfare continue to change. Through these advocacy efforts, the program promotes meaningful dialogue among low-income families, mothers of young children, the public, and policy makers regarding poverty, hunger, and the healthy development of young children.
Photography is a unique and very public way to engage others in common dialogue, as it requires no functional literacy and transcends written language. In terms of the Witnesses to Hunger project, photography makes each woman’s experience more tangible, as one literally sees her living conditions and the faces of her children. Through the images, the viewer can sense the bodies, the intimacy of small moments, and the atmosphere of the women’s homes and neighborhoods. Accompanying statistics related to the prevalence of hunger and the injustices of poverty strengthen and support the photovoices and provide a rational argument against poverty. The causes of poverty and hunger are deeply rooted in discrimination, including classism and racism, issues that the common photograph can address by evoking the emotional and value-driven perceptions of others through the power of the image as it presents the subjects’ own humanity and demands a humanistic response.
The human rights framework of witnesses to hunger
Although the title of the project remains “Witnesses to Hunger,” the women were asked to frame their perception of hunger broadly, using images to express their most important concerns from their own perspectives. This process ensured that they had greater control over “framing” their lack of access to adequate food for an active healthy life. From the participants’ perspectives, the concepts of nutrition and hunger are inseparable from their experience of poverty and their access to welfare assistance programs. Their photovoices identified access to services as key concerns, that is, access to health care, to affordable and safe housing, and to assistance to pay for utilities. Such basic needs are tightly interrelated with human rights issues. Three particular areas of intersecting human rights are at the center of the Witnesses to Hunger message: the rights of women, as codified in the Convention on the Elimination of All Forms of Discrimination against Women (CEDAW); the rights of the child, as enshrined in the Convention on the Rights of the Child; and economic, social, and cultural rights, as delineated in the International Covenant on Economic, Social and Cultural Rights (ICESCR).15
Hunger and the human rights conventions
The Convention on the Elimination of All Forms of Discrimination Against Women delineates the ways in which women have the right to be treated equally before the law, equally in access to health care, and equally in access to education and work.16 It is also meant to promote the education of all people about women’s equality and dignity. The text of CEDAW gives special attention to the rights to health and to adequate nutrition during pregnancy and to ensuring that children have adequate care. The rights of women, as articulated in CEDAW, are interrelated with their children’s rights, including the child’s right to health and an adequate standard of living for optimal development. This focus complements Article 27 of the Convention on the Rights of the Child, which states that children have the right to “a standard of living adequate for the child’s physical, mental, spiritual, moral and social development.”17
In its statement on the right to a minimum standard of living, Article 25 of the Universal Declaration of Human Rights, which was made legally binding through the ICESCR, delineates a set of rights that are mutually dependent and inter-related: the rights to health, food, shelter, and social services. At the root of Article 25 is the intention to ensure that those who are poor can maintain a standard of living that will preserve basic human dignity. Dignity is thus enshrined in the very definition of the right to food. In 2002, Jean Ziegler, the then UN Special Rapporteur on the right to food, defined this as the “right to have regular, permanent and unobstructed access to quantitatively and qualitatively adequate and sufficient food corresponding to the cultural traditions of people to which the consumer belongs, and which ensures a physical and mental, individual and collective fulfilling and dignified life free of fear.”18 The right to food is predicated on the idea that social, economic, and political structures should tangibly support populations and individuals to be able to provide for themselves.19 Thus, the right to food is better understood as the right to expect reasonable opportunities to provide food and good nutrition for oneself.20 A government’s role in ensuring the right to food is to facilitate these opportunities.
Despite the fact that the United States has signed but not ratified these legally binding international treaties, communities can still engage in meaningful public dialogues about fundamental human rights. Despite the lack of governmental willingness to be held accountable for protecting these rights, organizations, corporations, and institutions can participate in rights-related work and can develop programs that seek to respect, protect, and fulfill human rights. In turn, successful programs that actively respect, protect, and fulfill these rights may be adopted as best practices and implemented with federal funding even without a formal rights-based endorsement. Certainly, the US should ratify these conventions so that US citizens can hold their government accountable and can have legal recourse when such rights are violated.21
While the above-mentioned conventions address the structural frameworks of the human rights approach, the Witnesses to Hunger program has moved beyond the structural and legal rhetoric of the rights approach enshrined in the treaties, covenants, general comments, and special reports. It works at a more profound level to enable the audience to engage with the emotional, intimate, lived experiences of the witnesses. By grounding the women’s discussions in their personal experiences and in intimate portraits of their lives, the Witnesses to Hunger photos and voices call attention to the personal dignity that is often forgotten in academic analyses of the health and human rights approach.22
Food insecurity and human rights
The Witnesses to Hunger program does not engage with the right to food simply as a moral issue, but does so because food insecurity is a significant and growing public health problem in the United States. In US-based research, the well-known relationship between food insecurity and health has been proven repeatedly, especially for children. Food insecurity can negatively affect cognitive development, fine and gross motor skill development, educational attainment, and children’s psychosocial disorders.23
Food insecurity is also an indicator of underlying social determinants of poor health, as well as racial, ethnic, and gender discrimination. Racial, ethnic, and gender disparities in food insecurity suggest an overall lack of attention to those individuals who are most vulnerable to it. As stated above, in 2007 female-headed households with children had a prevalence rate of food insecurity that was almost three times the national average (30.2% vs. 11.1%).24 Households with children are at greater risk for experiencing household food insecurity, as the prevalence rates for households with children are one and a half times the national average.25 Nationally, food insecurity among households with children is even more pronounced when race and ethnicity are considered. According to the USDA, in 2007 the prevalence of food insecurity in households with children was highest among black families, with 25.9% of families experiencing food insecurity at some point during the year. In the same year, Hispanic families experienced a food insecurity rate of 23.8%.26 These rates are twice the rate of food insecurity among white households with children (11.7%).27
Because the overall rates of household food insecurity are far from the national Healthy People 2010 target of 6%, and because there has been no significant change in the disparities of food insecurity since the USDA began to measure it in 1995, we previously suggested that the United States adopt a new approach to address food insecurity that openly and explicitly engages a human rights framework.28 One of the most important ways to engage the human rights framework is to ensure the participation of those most affected by rights violations. This must be done not only on a national and legislative scale but also at a deeper level that engages with individual, personal experiences as they relate to human dignity.
Although many advocacy groups seek to eradicate hunger, the people who have directly experienced it, especially parents, are rarely provided an opportunity, venue, or structure to participate in the national dialogue. Moreover, the recent reassessment of the measure of food insecurity carried out under the auspices of the National Academies sought input from scientific experts but did not engage with a single person who had experienced hunger or food insecurity firsthand.29 Even though the USDA hosted public listening sessions on issues related to the Supplemental Nutrition Assistance Program (SNAP) (formerly Food Stamps) for the Farm Bill of 2008 and held other sessions related to the Child Nutrition Reauthorization, there has been little effort to make these opportunities available to the millions of program participants who have a stake in how these programs are administered.
A human rights approach is predicated on the idea that people have the right and the duty to participate in civic life, including the development, implementation, and evaluation of policies and programs.30 To facilitate and ensure participation, there must be administrative commitment to establish and maintain open avenues to legitimate forms of participation by people of all backgrounds, especially those most affected by the relevant policies or programs.31 In the case of low-income families in the US, participation in the development of programs and policies associated with the safety net or “welfare system” should be the primary focus. These programs are meant to help the low-income US population maintain an adequate standard of living. Although the US has one of the most lauded systems of democracy in the world, the participation of the poor in the design, implementation, and administration of welfare programs is practically nonexistent.
Participation and US government welfare programs
In the words of Paul Farmer, “Human rights are best understood (that is, most accurately and comprehensively grasped) from the point of view of the poor.”32 While we agree with this fundamental concept of participation, participation in the context of the US political and social system demands serious consideration because the structures of the welfare system make participation challenging. Low-income and minority groups are often isolated from the American political process due to lack of adequate education, lack of access to technology, and structural disenfranchisement.33 There is also evidence of active disenfranchisement through welfare reform. Researchers have found that the Personal Responsibility and Work Opportunity Reconciliation Act of 1996 (welfare reform) not only caused a significant reduction in welfare caseloads but also significantly reduced voter registration.34 Voter registration efforts that were mandated in welfare offices had significantly lower success in registering already-disenfranchised voters.
Since people living in poverty are less likely to vote or to be involved politically, they have little connection to the elected officials who purportedly represent their interests.35 People living in poverty in the US are more directly affected by social services and social programs, given their frequent participation in government-sponsored programs such as the Supplemental Nutrition Assistance Program, Temporary Assistance to Needy Families (TANF), and Medicaid.36 Since the welfare system is usually the common point of interaction between low-income citizens and their government, the structure and functionality of the welfare system can have a profound impact on the knowledge and attitudes of low-income citizens about political engagement.37 Citizen interaction with “street-level” bureaucrats or other low-level government officials has been found to be critically important in the formation of political knowledge and attitudes. In 1999, Joe Soss found that Aid to Families with Dependent Children (AFDC, the precursor to TANF) recipients tended to hold low levels of “external political efficacy:” in other words, they hold low levels of trust in government and lack the belief that they can understand and inform political issues.38 In part, this is because welfare recipients “form their attitudes and impressions about the overall political system based on their experiences with navigating the welfare system and interacting with social service workers.”39
In the Witnesses to Hunger interviews, participants discussed their frustration with the treatment they received from their caseworkers and other staff at the public assistance offices. They described discouraging and discriminating environments at the local County Assistance Office, Housing Assistance Offices, and other locales intended to provide assistance. This frustration carried over to more general discussions about how “the city” or “the system” is failing them. For example, they expressed frustration with political leaders and other key figures, such as the chief of police or the head of the public transportation system, because these officials would offer to help protect or promote public safety or to provide adequate health care but would then create a system that seemingly did not deliver on those promises. They further objected to the way such programs are advertised in media, on official paperwork, and at agency websites. As an example, Samonia H., one of the Witnesses to Hunger participants, explained, “They say ‘sign up for subsidized child care!’ This is supposed to support you getting a job. But then they put you on a waiting list that can be four or five years long.” Currently, the waiting list in Pennsylvania for subsidized child care has over 16,000 families on it at any given time. This backlog means that many families have little hope of receiving child care support.
Despite the American ideal of equal opportunities for all people, the welfare system is one of the most difficult time-worn structures to overcome. Frances Piven and Richard Cloward have demonstrated how the system has worked to keep the poor feeding into the low-paid labor industry and to keep low-income families out of the political arena.40 Others have also shown how the stigma of the “welfare queen,” first made popular by President Ronald Reagan, has been etched into both the structure of the welfare system and the American psyche.41 Qualitative research on welfare assistance and welfare reform also demonstrates that the structure of the welfare system can perpetuate racial and gender discrimination.42
The Witnesses to Hunger participants echo these concerns. They explained how welfare benefits are too small to promote their health and wellbeing, let alone to allow a person to save and become financially independent. Rather, from their perspective, the welfare system serves to hide the true extent of poverty and to keep the poor “quiet” and continuously dependent on welfare. In the words of Crystal S., a mother of three, “It seems they give you just enough to get you into trouble.”
The Witnesses to Hunger program seeks to challenge these orthodoxies by emphasizing an egalitarian, equal-opportunity rhetoric through participatory forums in person, in social settings, in the media, and on the internet.
Counter-narratives of witnesses to hunger
We need to get up and speak for our rights. If we don’t speak up, who will? Are you aware of my hunger, my struggle and my pain? (Whitney H.)43
From the women’s narratives and images in the Witnesses to Hunger project, a number of themes have emerged that, for the purposes of this discussion, can be discussed under two broad headings. The first concerns antidiscrimination, equality, and the right to participation. The second concerns social determinants and trade-offs among basic needs including food and nutrition, housing, utilities (gas, electricity, and water), health, and safety.
Antidiscrimination, equality, and the right to participation
The family photos taken by the Witnesses to Hunger participants are at once profound in their beauty and mundane in their commonality. In many ways, their family photos look like family photos from any family anywhere in America. From the women’s perspectives, their families are equal to all other families and should be viewed as such. This is in spite of the fact that they know, understand, and experience discrimination based on class, race, gender, and social/neighborhood location on a regular basis.
In showing photographs of their children, the women hope that the general public will see their children as equal to all other children and will see the women themselves as equal to all mothers. Ashley O. states this sentiment most comprehensively:
When the public sees our children . . . I just want them to know that we don’t have a label on us. There shouldn’t be a stereotype. We shouldn’t generalize. . . . We’re not a number. I am you. You are me. We’re the same, we’re equals. I’m no different because I’m on welfare. We’re equal. No label. No number. My name is Ashley. Your name is Jennifer. We’re the same.
When asked what they want the public to see, the women expressed a resounding interest in ensuring that others try to understand what it is like to live their lives. “Take a walk in my shoes,” says Imani S., “to see how hard it is.” Or, as Erica S. explains when she describes her photo of her children eating noodles with little nutritional quality:
Come leave your world just for one week and live in my world. Tell me how you’re going to make it and survive; how emotionally, you’re going to keep yourself together. To day-by-day look at your kids and tell them, “I don’t have any money to take you to the store.” Or, “We’re eating Oodles of Noodles today because the food stamps didn’t last.”
The women have a strong desire to demonstrate to the world that they do not deserve to be judged or treated differently than others. They have worked hard to distinguish themselves from the stereotype of the non-working mother who does not care for her kids and who simply “collects her check.” Photovoices such as that of Imani S. demonstrate how much they love their children and want them to go to good schools in order to enhance their opportunities:
I just love my kids. I love ‘em to death. They’re all I got and I’m going do anything and everything that I have to do
. . . to take care of them. I’m not going to sell my body or anything of that nature, but I’ll sell these appliances. I’ll sell anything I have to sell besides my body, to take care of my kids and make sure my food and everything is taken care of.
But the participants are also quick to remind the viewer just how difficult it is to realize these goals given the social and political structures in place and the unhealthy, unsafe environments in which they are raising their children. In addition, the women stress how important it is that they themselves have the opportunity to realize their own career goals so that their children can be exposed to a way of life in which an adult can make a living wage. Erica S., a mother of two girls aged seven and two, explained this desire using a photo of a “one way” sign below a red signal light:
I think I would like to find a stable job, a career. . . . I would like to be able to go back to school and get some more education, further my education a little bit, definitely get out of the inner city. I would definitely like to get out of the inner city so [my daughters] can see a different type of living and a different way of life. This is where they live. I don’t want them to be discouraged as they grow up, thinking this is all there is.
Each woman also emphasized how she intended to do things differently so that her children would grow up to have better opportunities. Shearine M. depicted this concept by taking a picture of her daughter in an open door, commenting,
Just because it was hard for me, to get where I got to be, it’s not going to be hard for her. It’s going to be easier for her to go through the doors than for me. Because I’m going to make sure that her road be easier than mine. I’m just going to make sure that her and [her sister] stay in school and do what they got to do. I’m just going to make sure that all their doors be open.
Recently, Shearine landed a temporary job at a local hospital in her field of training, medical billing. Although the public assistance office helped Shearine attend a training course in medical billing, the office was unsuccessful in helping her find a job. After more than six months, Shearine found her new job on her own. Within the same week of starting this job, Shearine was without child care assistance. Because child care subsidies are provided first and foremost to cash assistance recipients and to those who get their jobs through a cash assistance referral, when she succeeded in getting her new job, she was pushed out of subsidized child care and put onto the waiting list to receive child care subsidies. In Philadelphia, most families on the waiting list never make it back into subsidized care unless they stop working to become eligible for cash assistance again. Though Shearine was able to find a job on her own, she was no longer able to afford to send her children to pre-school, which most national experts suggest is essential for a child’s health, development, and wellbeing.44 “How am I supposed to get ahead?” Shearine asked. “It’s like my children and I are getting punished if I try to better myself and go to work.”
Social determinants and trade-offs among basic needs
The Witnesses to Hunger participants show that caring for their children against the grain of unsafe neighborhoods and the welfare stereotype is a major challenge. They demonstrate how hard it is to survive in a large inner city of the United States. Trade-offs are a common theme in the women’s narratives; that is, sustaining one aspect of their families’ lives on a limited income often comes at the expense of other necessities for a healthy and productive life. Forced to choose between necessities quantified in monetary value, such as food, housing, and heating bills, the trade-offs that low-income women must make speak to a quality of life that is riddled with risk. Even food stamps — which are earmarked specifically for food so that essential food supplies are protected from other costs — are sometimes sold at a loss to a corner store so that a mother can buy diapers or save for a lease on an apartment. A bus ride is a relatively low-cost expenditure, but a single day without bus fare can mean a missed job interview, a lost job, or an absence from a school program — thus closing off opportunities to work one’s way out of poverty.
Less easily quantified are those trade-offs between monetary needs, like food and shelter, and the less tangible concepts of health, safety, and opportunity. Tianna G., a mother of three children, each with serious health problems, speaks of the struggles she and her fiancé face every time a child is hospitalized. Compared to many, Tianna may seem lucky because she and her children have health insurance through Medicaid and are thus able to access top-quality health care at no cost. Yet time spent in the hospital with a sick child is time spent without an income and with added expenses. As Tianna explains,
When one child is sick . . . that means somebody has to stay home and take care of the child that’s not sick. So that means every time he got better and he got sick again their dad had to take off of work. That means that’s money we’re missing. That means . . . do we pay the rent or do we pay the light bill?
The trade-offs between health and work, or between food and transportation, are some of the primary topics that the women discuss.
The need for safety often clashes with the need for financial stability. For instance, mothers will pay for cable television because children cannot safely play outside due to shootings and exposure to violent behavior in the streets. They may also choose to forgo welfare cash benefits to avoid opening the mandatory child support cases. Crystal S., whose three children also have significant health issues, explains how the child support system does little to protect mothers who have been abused by their partners:
If you want your medical coverage and you want to get food stamps for the child, you have to take the child’s father to court for child support. Now, what happens if I was afraid of him? What happens if he beat me up, but my child needs medical coverage? . . . I mean they have restraining orders. They try, but what do you do? It takes the cops so long to arrive. ´Cause the fight I had with my children’s father . . . if he wanted to kill me, he could’ve killed me and then been gone by the time the cops came.
In this case, a mother’s need to protect her own safety and that of her children goes unaddressed by the same welfare system that is designed to protect their health and well-being. In situations where the woman could be in serious physical danger, to require a mother to help identify the father so that the welfare system can enforce child support (and gain some economic returns for the system) may in fact put the woman’s life at risk rather than maintaining and improving her support systems and health care. Many of the participants recognize the cyclical nature of these processes, where suffering continues because of a failure to recognize forces beyond financial and social reality. Crystal continues in her narrative: “I can only testify . . . Being a black man in an urban neighborhood and not being able to find employment, they get angry and they lash out at whoever’s near them. Who is that? You.”
The witnesses’ narratives contain an intrinsically nuanced understanding of the reasons that certain neighborhoods and communities remain not only poor but also violent and drug-ridden. The women are the most acutely aware that the trade-offs they make in attempting to balance their children’s well-being with their own result from many other forces. These include forces of racism, through institutionalized racism such as housing discrimination, discrimination in school systems, and discrimination in job opportunities and job advancement.45 These forces also include classism and overwhelming attitudes about “the poor” by the general public.46 And they include gender discrimination, which manifests in intimate partner violence and misogynist attitudes about women.47 These forces portray a systematic and cyclic “pathology” of the welfare system that has become a racialized, stigmatized, and fragmented system of support for America’s most vulnerable.48
One of the greatest tenets of the human rights framework is that the poor and the underserved must have a clear venue through which to participate in the development and implementation of the policies that most affect them. Although welfare and public assistance programs may be the usual venue for participation by these individuals, these systems can have disillusioning effects on ideas for meaningful participation as well as actively discriminate against and disenfranchise women. The narratives and photos of women in Witnesses to Hunger mark an endeavor to overcome and outdo the orthodoxies of the welfare and income support systems that perpetuate disparities in hunger. Through the public response to their stories, images, and counter narratives, and through the internet, public forums, and local, national, and international media attention, these 42 women may redirect the existing dialogue and policies on poverty and hunger to an effective focus on what is meaningful and true.
The far-reaching impact of this project remains to be seen. In the meantime, we invite feedback from and dialogue with the heath and human rights community.
The authors would like to thank Amber Sterling for helping us research civic participation among low-income families.
Mariana Chilton, PhD, MPH, is the Principal Investigator of the Philadelphia GROW Project/Witnesses to Hunger. She is an Assistant Professor in the Department of Health Management and Policy at Drexel University School of Public Health.
Jenny Rabinowich is the Research and Policy Coordinator for Witnesses to Hunger at Drexel University School of Public Health. She has a BA in anthropology and peace and conflict studies.
Christina Council, MPH, was the original Research Coordinator for Witnesses to Hunger at Drexel University School of Public Health.
Jennifer Breaux, MPH, CHES, is the Site Coordinator for Children’s HealthWatch-Philadelphia, and the Research Coordinator for the Philadelphia GROW Project at Drexel University School of Public Health.
Please address correspondence c/o Mariana Chilton, PhD, MPH, 1505 Race Street, 11th Floor, Mail Stop 1035, Philadelphia, PA 19102–1192, email: Mariana.Chilton@drexel.edu.
1. C. Bellamy, “Statement by UNICEF Executive Director to United Nations Security Council on Children and Armed Conflict” (presented in New York, USA, January 20, 2004). Available at http://www.unicef.org/media/media_19030.html.
2. Committee on Economic, Social and Cultural Rights, General Comment No. 12, Right to adequate food, Art. 11, UN Doc E/C.12/1999/5 (1999). Available at http://www.unhchr.ch/tbs/doc.nsf/0/3d02758c707031d58025677f003b73b9?Opendocument.
3. Commission on the Nutrition Challenges of the 21st Century, “Ending malnutrition by 2020: An agenda for change in the millennium. Final report to the ACC/SCN by the Commission on the Nutrition Challenges of the 21st Century,” Food and Nutrition Bulletin 21/3 (2000), Supplement. Available at http://www.iotf.org/php/UNReport.pdf.
4. M. Nord, M. Andrews, and S. Carlson, Measuring food security in the United States: Household food security in the United States, 2007 (Washington, DC: USDA/ERS, 2008), p. 14. Available at http://www.ers.usda.gov/publications/err66/err66.pdf.
5. Committee on Economic, Social and Cultural Rights, General Comment No. 12, Right to adequate food, Art. 11 (see note 2).
6. S. Gruskin, E. J. Mills, and D. Tarantola, “History, principles, and practice of health and human rights,” Lancet 370/9585 (2007), pp. 449–455.
7. J. L. Lawless and R. L. Fox, “Political participation of the urban poor,” Social Problems 48/3 (2001), pp. 362–385.
8. C. C. Wang, “Photovoice: A participatory action research strategy applied to women’s health,” Journal of Women’s Health 8/2 (1999), pp. 185–192.
9. C. L. McAllister, P. C. Wilson, B. L. Green, and J. L. Baldwin, “‘Come and take a walk:’ Listening to early Head Start parents on school-readiness as a matter of child, family, and community health,” American Journal of Public Health 95/4 (2005), pp. 617–625.
10. P. Freire, Pedagogy of the oppressed (New York: Herder and Herder, 1970).
11. C. Wang and M. A. Burris, “Photovoice: Concept, methodology, and use for participatory needs assessment,” Health Education & Behavior 24/3 (1997), pp. 369–387.
12. C. M. Killion and C. C. Wang, “Linking African American mothers across life stage and station through photovoice,” Journal of Health Care for the Poor and Underserved 11/3 (2000), pp. 310–325.
13. McAllister, Wilson, Green, and Baldwin (see note 9).
14. The federal Section 8 program began in 1975 as a way to assist low-income families, elderly people, and people with disabilities to rent decent, safe, and affordable housing. Information on Section 8/Housing Choice in Pennsylvania is available at: http://www.housingresources.info/what-is-section-8-housing.php.
15. Convention on the Elimination of All Forms of Discrimination Against Women (1981). Available at: http://www.un.org/womenwatch/daw/cedaw/cedaw.htm; Convention on the Rights of the Child, G.A. Res. 44/25 (1989), Art. 27.1. Available at http://www2.ohchr.org/english/law/crc.htm; International Covenant on Economic, Social and Cultural Rights, G.A. Res. 2200A (XXI) (1966). Available at: http://www.unhchr.ch/html/menu3/b/a_cescr.htm.
16. Convention on the Elimination of All Forms of Discrimination Against Women (see note 15).
17. Convention on the Rights of the Child (see note 15).
18. J. Ziegler, UN Special Rapporteur on the right to food, Economic, Social and Cultural Rights: The right to food, UN Doc. No. E/CN.4/2004/10 (2004). Available at http://www.unhchr.ch/huridocda/huridoca.nsf/(Symbol)/E.CN.4.RES.2000.10.En?Opendocument.
19. M. Chilton and D. Rose, “A rights-based approach to food insecurity in the United States,” American Journal of Public Health 99/7 (2009), pp. 1203–1211.
20. G. Kent, Freedom from want: The human right to adequate food (Washington, DC: Georgetown University Press, 2005).
21. J. Kasper and P. H. Wise, “The relevance of the United Nations Convention on the Rights of the Child for United States domestic policy: Welfare reform and children in immigrant families,” Health and Human Rights: An International Journal 5/2 (2001), pp. 65–90.
22. M. Chilton, “Developing a measure of dignity for stress-related health outcomes,” Health and Human Rights: An International Journal 9/2 (2006), pp. 208–233.
23. J. T. Cook and D. A. Frank, “Food security, poverty, and human development in the United States,” Annals of the New York Academy of Science 1136 (2008), pp. 193–209.
24. Nord, Andrews, and Carlson (see note 4), p. 10.
26. Ibid., p. 12.
27. Ibid., p. 10.
28. Chilton and Rose (see note 19).
30. Food and Agriculture Organization of the United Nations, The right to food in practice: Implementation at the national level (Rome, Italy: FAO, 2006). Available at http://www.fao.org/docs/eims/upload/214719/AH189_en.pdf). For the report, see Panel to Review U.S Department of Agriculture’s Measurement of Food Insecurity and Hunger, National Research Council, Food insecurity and hunger in the United States: An assessment of the measure (Washington, DC: National Academies Press, 2006). Available at http://books.nap.edu/catalog.php?record_id=11578.
31. Committee on Economic, Social and Cultural Rights, General Comment No. 12, Right to adequate food, Art. 11 (see note 2).
32. P. Farmer, Pathologies of power: Health, human rights, and the new war on the poor (Berkeley, CA: University of California Press, 2005), p. 17.
33. W. Liles, “Challenges to felony disenfranchisement laws,” Alabama Law Review 58/3 (2007), pp. 615–629.
34. D. Muhlhausen, “The impact of welfare reform on declining public assistance voter registrations,” (testimony delivered before the Subcommittee on Elections of the Committee on House Administration of the United States House of Representatives, Washington, DC, USA, April 1, 2008). Available at http://www.heritage.org/Research/Welfare/tst040308.cfm, with full report available at http://www.heritage.org/Research/Welfare/cda08-03.cfm.
35. S. Verba, K. L. Schlozman, and H. E. Brady, Voice and equality: Civic voluntarism in American politics (Cambridge, MA: Harvard University Press, 1995).
36. Lawless and Fox (see note 7).
38. J. Soss, “Lessons of welfare: Policy design, political learning, and political action,” American Political Science Review 93/2 (1999), pp. 363–380.
39. Lawless and Fox (see note 7), p. 364.
40. F. F. Piven and R. A. Cloward, Regulating the poor: The functions of public welfare, updated edition (New York: Vintage Books, 1993).
42. K. Neubeck and N. Cazenave, Welfare Racism: Playing the race card against America’s poor (New York: Routledge, 2004), pp. 215–242.
43. Quotations from Witnesses to Hunger participants are identified here only by first name and last initial. The full gallery of photos is available at www.witnessestohunger.org. Unless otherwise noted, quotes are from the narrative interviews.
44. J. J. Heckman, “Skill formation and the economics of investing in disadvantaged children,” Science 312/5782 (2006), pp. 1900–1902.
45. D. R. Williams, “Race, socioeconomic status, and health: The added effects of racism and discrimination,” Annals of the New York Academy of Science 896/1 (1999), pp.173–188.
46. Piven and Cloward (see note 40).
47. J. Mann and S. Gruskin, “Women’s health and human rights: Genesis of the health and human rights movement,” Health and Human Rights: An International Journal 1/4 (1995), pp. 309–312.
48. Neubeck and Cazenave (see note 42).
Papers in Press
The Cholera Epidemic in Zimbabwe, 2008-2009; A Review and Critique of the Evidence
C. Nicholas Cuneo, Richard Sollom, and Chris Beyrer
Letter to the Editor: Human Rights, TB, Legislation and Jurisprudence
O. B. K. Dingake
UNstoppable: How Advocates Persevered in the Fight for Justice for Haitian Cholera Victims
HIV Criminalization Laws and the Right to Health
Canada’s Mining Industry in Guatemala and the Right to Health of Indigenous Peoples