In 1996, then US Secretary of State, Madeline Albright, appeared for an interview on 60 Minutes where she was asked about the wisdom of US sanctions against Iraq, which withheld food and medicine and resulted in a public health crisis that reportedly killed half a million children. Albright's response revealed the grim calculus of policy decisions affecting public health: “I think this is a very hard choice, but the price—we think the price is worth it.” The fact that children's well-being would be sacrificed to advance a political goal is nothing new. Such has been the fate of millions of enslaved and exploited children long before and since this particular public health disaster.
Today, the ways in which such political priorities influence public health decisions are often overlooked in times of crisis. All political decisions are public health decisions to the extent that they impact health and well-being, and official public health recommendations are themselves deeply political. In modern mass politics involving millions of people, it is rarely the case that a purely non-political health-based decision is made. It is even rarer that a decision with no political trade-offs is even possible. Indeed, public health policies almost always involve processes of “political epidemiology” (Gil-González et al. 2009; Brownlea 1981) that follow the contours of traditional power relations, sacrificing some lives to protect others. From this perspective, public health policy reflects a permanent state of triage (Whitehall 2017) in which some lives are prioritized over others and the privilege of living is invariably afforded to historically dominant groups.
In the context of modern liberal politics, as Achille Mbembé (2003) has contended, those who do not to meet the criteria of inclusion are forsaken, exposed, and defenseless to both natural and man-made misfortunes. The human destruction that results from such marginalization led Mbembé to conceptualize our modern condition as a politics of death: a “necropolitics.” It is difficult to dispute Mbembé's assessment. We find theoretical corroboration in the work of thinkers as diverse as Bernard Williams (1976), Jeremy Walzer (1973), Michel Foucault (2008), and Giorgio Agamben (1998). From these theorists we have learned that there are few if any decisions of scale that avoid trade-offs of life and death. Public policy almost always involves morally significant losses of safety and life, decisions that result in “dirty hands” because expedience or prudence demands that an individual or group be categorized as an exception, or as “bare life” over and against which the lives of fully qualified citizens are valued.
Historically, children and youth represent the perennial sacrificial lambs of public health policy, and we see this reiterated in the political epidemiology of COVID-19. Responses to past pandemics such as polio and Spanish Flu—like liberal responses to poverty, pollution, and war—reflect a set of public health decisions that, for the sake of protecting adults and their interests, have disproportionately placed children at risk of illness and death. Pandemics are often conceptualized as natural disasters with unavoidable losses, but as many observed following the political response to hurricane Katrina there is “no such thing as a natural disaster” (Hartman et al. 2006), there are only natural events that are permitted to become disastrous for particular groups. In the case of COVID-19, we have witnessed an unprecedented global response due to the fact that the virus primarily affects older adults. Unfortunately, the social, economic, ecological, epidemiological, and political fallout of the deals currently being struck to secure the safety and well-being of adults will impose grave consequences on future generations.
Why are children at risk? Within most Western liberal regimes, public health recommendations are viewed as authoritative to the degree that they conform to the standards of reason and rational compromise, which, by their nature, tend to protect those who can lay claim to inclusion by virtue of possessing capacities for reason and rational compromise: adults. This is, however, an anti-democratic outcome of deference to liberal institutions. Due to the overwhelming influence of liberalism and its ideal of rational public discourse, children have been disqualified as democratic participants on the grounds that they do not possess sufficient capacities for reason and speech. “Childism,” as it is sometimes called, is a defining feature of the liberal tradition. Thus, unlike groups such as Black, Indigenous and People of Color (BIPOC), who continue to struggle for formal inclusion through reason and speech while remaining substantively excluded from political decision-making, children are both formally and substantively excluded, positioning them as permanent objects of neglect and erasure. Children have no direct influence on the form and content of political decision-making. They are prohibited from participating as equals in representational governance, let alone challenging the notion that representational governance is an appropriate means of participation for all human beings. It is not surprising, then, that children continue to be the primary victims of global famine and starvation, human trafficking, and forced migration, as well as infectious diseases such as malaria and tuberculosis. Millions of children die each year from preventable conflicts, conditions, and diseases. This fact is rarely acknowledged, let alone regarded as a crisis requiring a radical reconfiguration of social and economic life, as is the threat to adults currently posed by COVID-19.
Why has there been such an unprecedented response to this crisis and not others? Barring some intellectual disability (Simplican 2015) that reduces an adult citizen to the cognitive capacities of a child, all adults are permitted to vote and participate in public deliberations. In the United States, the wealthiest and most politically powerful age cohort are the “baby boomers,” older adults who are currently between the ages of 55 and 75 (Knickman and Snell 2002). Although millennials outnumber the boomer generation, older adults own the majority of the available housing and general wealth (Gonthier 2017; Hoolachan and McKee 2019). Most elected and appointed representatives and officials are older adults and, together with the earlier “silent generation” (born after 1928), older adults vote more consistently and in larger numbers than younger people (Fry 2016). As a result, older adults are the primary beneficiaries of political campaigning and policy decisions. They also exhibit the highest rates of media consumption, and therefore remain the primary beneficiaries of media messaging and marketing.
In early 2020, when the mortality rate of COVID-19 was reported to increase dramatically after the age of 50, there was an immediate response by governments, media, and civil society to center public discourse on the health and safety of older adults. A number of articles were immediately published lamenting an alleged ageism and apparent willingness of society to sacrifice the old for the sake of the economy (see Lloyd-Sherlock et al. 2020). Similar sentiments were found in numerous newspaper headlines. Behind these perspectives was a palpable anxiety over the idea that older adults would find themselves in the same position of vulnerability as do the millions of brown and black children who suffer and die every year from preventable diseases inside and outside the borders of Western liberal democracies.
This is not to say that ageism against older adults is not a genuine prejudice. Older adults can be victims of prejudicial neglect and erasure, yet they do not suffer from the risks of structural domination and erasure. Just as racism is defined as the combination of racial prejudice and institutional power, likewise, childism is distinct from ageism in that children are permanently and structurally subordinated to those who hold exclusive political, legal, and economic power. Indeed, the fact that the main sites and processes of influence in liberal society are expressly denied to children is celebrated as a mark of cultural maturity. To be labelled infantile, childish, or childlike is the ultimate disqualification as it suggests that the target is emotionally and cognitively unqualified to participate in the safe and secure domain of exclusive adult privilege. This logic is then applied to other groups in order to racialize them, leading to the disqualification of black, indigenous, and other peoples as members of the immature and irrational “child-races” (Rollo 2018a, 2018b). Likewise, in the end, it is only once an adult has begun exhibiting the supposedly degrading physical and mental dependency characteristic of childhood that they risk being abandoned and neglected.
The disruptive lockdown and social distancing measures implemented by virtually all states in their efforts to protect adults will likely leave today's children dealing with a legacy of social and physical estrangement, catastrophic economic collapse, the destruction of higher education, abandonment of environmental issues, gaps in vaccination and herd immunity for other diseases, the syphoning off of medicine and healthcare resources, as well as mass sickness and famine that will primarily affect black and brown children in the Global South. Likewise, many of the most serious pandemics in modern history are the result of structural subordinations of the young. Children and youth are disproportionately represented among the poor and it is the poor who are most affected by public health issues. Polio, for example, primarily affected children under the age of six and reached the level of a pandemic because of the poor hygiene that resulted from impoverished conditions. The deadliest pandemic in human history, the 1918 Spanish Flu, primarily affected young adults such as soldiers. It was, of course, the young who were primarily enlisted as soldiers during World War I, and these youth were susceptible to this flu both because of a lack of immunity and because of the catastrophic effect of trench warfare on health and hygiene. Older people benefitted from immunity to this particular strain of influenza, but also from being statistically more wealthy and not being compelled to fight in the war. Public health decisions were designed to protect adults and their political and economic interests from the risks posed by children, who were categorized as primary vectors of infection. The political epidemiologies of polio and Spanish Flu reflect the childist institutional triage according to which adults are protected and youth are sacrificed.
One way to approach this issue is observe how the response to COVID-19 has laid bare the failure of intergenerational justice at the heart of the modern marriage of liberal and democratic traditions. Both liberal and democratic ideals reject the arbitrary exercise of coercion and violence to govern citizens. Liberal justifications for the exclusion of the child center on the child's lack of sophisticated reasoning and communication on norms and collective decision-making. Children, especially very young children, simply do not possess the cognitive capacities to deliberate or consent to be governed, which means they are to be “naturally” governed by others. Democratic traditions are not so restrictive, however. The normative democratic ideal of inclusion, or the “principle of affected interest,” holds that all those affected by a change in collective norms of governance ought to have an opportunity to influence those changes. So long as the means by which individuals affirm, contest, or modify these collective norms are non-coercive, democratic doctrines are rather ambivalent with respect to who and how individuals ought to be included. There are no cognitive qualifications in a strictly democratic ideal of inclusion. This makes the modern alloying of liberalism with democracy somewhat tense when it comes to the question of whether children ought to be regarded as full citizens.
The charge of arbitrary exclusion is nothing new for liberalism, of course. Many critics have argued that the standards of reason and speech necessary that give rise to popular sovereignty have been tendentiously interpreted by wealthy and able-bodied white men so as to exclude the poor, people with disabilities, women, and people of color. The liberal social contract tradition harbors a sexual contract that excludes women (Pateman 1988), and a racial contract that excludes black peoples (Mills 1997). Others have gone so far as to argue that the liberal notions of reason and sovereignty will always be predicated on one or more arbitrary and possibly violent exclusions. Thus, even if the poor, or women, or people of color liberate themselves by proving their capacity for reason, there will be others who are affirmed as ineligible. In this sense, the political epidemiology of COVID-19 reflects a “generational contract” that excludes and sacrifices the young for the sake of those who must be protected: able-bodied adults.
To challenge the hegemony of liberal political epidemiologies that tend to globally situate children as sacrificial lambs, we likely require, among other things, a renewed investment in the theory and practice of democracy. Specifically, it seems that public health decisions would benefit from greater critical attention to the distinctly democratic ideal of inclusion and the rejection of disqualifying and exclusionary liberal standards of reason and communication. A genuinely child-centered democratic approach would benefit not just the young, but also those who are ensnared in the developmental logics of gender, racial, and colonial exclusion. Uday Singh Mehta (1999) observes that colonized peoples have “from the outset been coded as a child” (14) because the child represents “the fixed point underlying the various imperial imperatives of education, forms of governance, and the alignment with progress” (31). It would seem that insofar as liberal ideals of agency and participation are predicated on what decolonial thinker Ashis Nandy (1984) referred to as “the ideology of adulthood,” public health decisions will continue to reflect the current anti-democratic necropolitics.
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)| false . , Gil-González, D. , and M.T. Ruiz-Cantero C. Álvarez-Dardet 2009. “ How Political Epidemiology Research Can Address Why The Millennium Development Goals Have Not Been Achieved: Developing a Research Agenda.” Journal of Epidemiology & Community Health 63( 4): 278– 280.
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