Austerity and the embodiment of neoliberalism as ill-health: Towards a theory of biological sub-citizenship

Development and Validation of an Abbreviated Child and Adult Food Security Scale for Use in Clinical and Research Settings in the United States

BACKGROUND

Food insecurity (FI) prevalence was consistently >10% over the past 20 years, indicating chronic economic hardship. Recession periods exacerbate already high prevalence of FI, reflecting acute economic hardship. To monitor FI and respond quickly to changes in prevalence, an abbreviated food security scale measuring presence and severity of household FI in adults and children is needed.

OBJECTIVE

Our aim was to develop an abbreviated, sensitive, specific, and valid food security scale to identify severity levels of FI in households with children.

DESIGN

Cross-sectional and longitudinal survey data were analyzed for years 1998 to 2022.

PARTICIPANTS/SETTING

Participants were racially diverse primary caregivers of 69,040 index children younger than 4 years accessing health care in 5 US cities.

STATISTICAL ANALYSES PERFORMED

Sensitivity, specificity, positive and negative predictive values, accuracy, and area under the receiver operator curve were used to test combinations of questions for the most effective abbreviated scale to assess levels of severity of adult and child FI compared with the Household Food Security Survey Module. Adjusted logistic regression models assessed convergent validity between the Abbreviated Child and Adult Food Security Scale (ACAFSS) and health measures. McNemar tests examined the ACAFSS performance in times of acute economic hardship.

RESULTS

The ACAFSS exhibited 91.2% sensitivity; 99.6% specificity; 98.3% and 97.6% positive and negative predictive values, respectively; 97.7% accuracy; and a 99.6% area under the receiver operator curve, while showing high convergent validity.

CONCLUSIONS

The ACAFSS is highly sensitive, specific, and valid for detecting severity levels of FI among racially diverse households with children. The ACAFSS is recommended as a stand-alone scale or a follow-up scale after households with children screen positive for FI risk. The ACAFSS is also recommended for planning interventions and evaluating their effects not only on the binary categories of food security and FI, but also on changes in levels of severity, especially when rapid decision making is crucial.

The moral economy of universal public healthcare. On healthcare activism in austerity Spain

Spain has a national health service, universal in access and free at the point of use. The global economic crisis of 2008, with its subsequent austerity policies, has put the universality of public healthcare at risk. This has led to an increase in healthcare activism, whose aim is to fight healthcare cuts and privatization to safeguard the national health service for all. This article addresses such healthcare activism. Drawing on long-term fieldwork with a heterogeneous set of actors ranging from individual activists and unions to ad hoc activist collectives, I will analyze the moral economy of healthcare activists in Madrid, to understand why and in which terms they defend universal healthcare as a common good and challenge its marketization. In Spain, since the democratic transition, struggles around what constitutes a common weal have been highly politicized and affect-laden. The national health system stands as one example here, as it is closely linked to the emergence of the democratic welfare state in the late 1970s, following decades of Franco's dictatorship. This makes Spain a particularly interesting case, as the widely acknowledged understanding of public healthcare as a public and social good is intimately linked to democratization and welfare. Therefore, struggles over the nature of health systems are also struggles over the political, moral and economic organization of society, over (il)legitimate forms of power and over ways of caring for each other. In such struggles, visions of the public, the state and the political economy come to the fore. In Spain, there is ambivalence about the state's role as both protector and provider of the public good, but also as facilitator of capitalism, which this article will address.

Mental health coverage for forced migrants: Managing failure as everyday governance in the public and NGO sectors in England

High-income countries (HICs) which are said to have "reached" universal health coverage (UHC) typically still have coverage gaps, due to both formal policies and informal barriers which result in "hypothetical access". In England, a user fee exemption has in principle made access to treatment for post-traumatic stress disorder (PTSD) and other mental health conditions thought to be caused by certain forms of violence universal, regardless of immigration status. This study explores the everyday governance of this mental health coverage for forced migrants in the English National Health Service (NHS) and NGO sector. Fieldwork was conducted in two waves, in 2015-2016 and 2019-2021, including six months of participant observation in an NGO and 21 semi-structured interviews with psy professionals across 16 NHS and NGO service providers. Further interviews were conducted with mental health commissioners and policymakers, as well as analysis of grey literature. Despite being formally covered for certain types of mental health care, in practice asylum seekers and undocumented migrants were often excluded by NHS providers. Undocumented migrants were also often excluded by NGO providers. Several rationalities linked discursive fields to practices developed by psy professionals and other street-level bureaucrats to govern coverage, in a process of "managing failure". These rationalities are presented under three paired themes which draw attention to tensions and resistance in the governance of coverage: medicalisation and biolegitimacy; austerity and ethico-politics; and differential racialisation and decolonisation. Rationalities were associated with strategies and tactics such as social triage, clinical advocacy, obfuscation, evidence-based advocacy and silencing critique. The concept of "health coverage assemblage" is introduced to explain the complex, unstable, contingent and fragmented nature of UHC policies and programmes. Misrecognition and underestimation of the everyday work of health professionals in promoting, resisting and reproducing diverse rationalities within the assemblage may lead to missed opportunities for reform.

Making morbidity multiple: History, legacies, and possibilities for global health

Multimorbidity has been framed as a pressing global health challenge that exposes the limits of systems organised around single diseases. This article seeks to expand and strengthen current thinking around multimorbidity by analysing its construction within the field of global health. We suggest that the significance of multimorbidity lies not only in challenging divisions between disease categories but also in what it reveals about the culture and history of transnational biomedicine. Drawing on social research from sub-Saharan Africa to ground our arguments, we begin by describing the historical processes through which morbidity was made divisible in biomedicine and how the single disease became integral not only to disease control but to the extension of biopolitical power. Multimorbidity, we observe, is hoped to challenge single disease approaches but is assembled from the same problematic, historically-loaded categories that it exposes as breaking down. Next, we highlight the consequences of such classificatory legacies in everyday lives and suggest why frameworks and interventions to integrate care have tended to have limited traction in practice. Finally, we argue that efforts to align priorities and disciplines around a standardised biomedical definition of multimorbidity risks retracing the same steps. We call for transdisciplinary work across the field of global health around a more holistic, reflexive understanding of multimorbidity that foregrounds the culture and history of translocated biomedicine, the intractability of single disease thinking, and its often-adverse consequences in local worlds. We outline key domains within the architecture of global health where transformation is needed, including care delivery, medical training, the organisation of knowledge and expertise, global governance, and financing.

Biological embedding vs. embodiment of social experiences: How these two concepts form distinct thought styles around the social production of health inequalities

OBJECTIVES

This article compares research on biological embedding and the embodiment of social experiences, two concepts proposed in the 1990s to introduce a new perspective on the social production of health inequalities. We draw on Ludwig Fleck's concept of 'thought style' (1935/2008) to question the possible emergence of a common research program around the processes by which the social becomes biological.

METHODS

We compiled a corpus of 322 articles referring to either biological embedding or to the embodiment of social experiences, identified in the Web of Science core collection and published from 1990 to 2021. We analyzed the articles' use of these concepts using scientometric indicators and qualitative content analysis.

RESULTS

Initial differences between the research agendas associated with biological embedding and embodiment are strengthened as both concepts circulate around scientific communities studying the social production of health inequalities. Thought styles formed around embedding and embodiment differ significantly in terms of shared references, sets of methods and research questions, and policy recommendations. Research on biological embedding forms a thought style shared by researchers in the biomedical and public health sciences. Conversely, the concept of embodiment of social experiences connects perspectives from biomedical, public health, human and social sciences, and gathers three thought styles, one identical to that of biological embedding and two formed in social epidemiology and in medical anthropology.

CONCLUSIONS

Acknowledging the differences between the concepts and divergences in their evolution provides an opportunity for identification of topics where thought styles are either complementary or in tension.

Lockdown under lockdown? Pandemic, the carceral and COVID-19 in British prisons

The relationship between pandemic, or chronic infectious diseases, and the carceral, meaning set-apart spaces of enforced confinement for "wrong-doers," has a long, tangled history. It features in Foucault's inquiries into disciplinary power and its associated spatial formations, not least in the shape of the modern prison. Drawing lightly from Foucault's claims about disciplinary and biopolitical power, as well as on his anti-prison activism, this paper explores three possibilities for penal transformation arising during the early months of COVID-19 in UK prisons (circa March to August 2020). Consulting primary source material, these possibilities are respectively identified as "retrenching," "reworking" or "reducing" the carceral. A chief finding is that under the press of pandemic "emergency," the tilt of emphasis has been towards a retrenched or reworked "carceral state," disappointing any promise of abolition, let alone more humble reduction in carceral conditions. The "biological sub-citizens" of prisons are hence being left especially vulnerable to the press of pandemic, in part precisely because of how carceral spatialities are being intensified.

Competing Responses to Global Inequalities in Access to COVID Vaccines: Vaccine Diplomacy and Vaccine Charity Versus Vaccine Liberty

Global access to coronavirus vaccines has been extraordinarily unequal and remains an ongoing source of global health insecurities from the evolution of viral variants in the bodies of the unvaccinated. There have nevertheless been at least 3 significant alternatives developed to this disastrous bioethical failure. These alternatives are reviewed in this article in the terms of "vaccine diplomacy," "vaccine charity," and "vaccine liberty." Vaccine diplomacy includes the diverse bilateral deliveries of vaccines organized by the geopolitical considerations of countries strategically seeking various kinds of global and regional advantages in international relations. Vaccine charity centrally involves the humanitarian work of the global health agencies and donor governments that have organized the COVAX program as an antidote to unequal access. Despite their many promises, however, both vaccine diplomacy and vaccine charity have failed to deliver the doses needed to overcome the global vaccination gap. Instead, they have unfortunately served to immunize the global vaccine supply system from more radical demands for a "people's vaccine," technological transfer, and compulsory licensing of vaccine intellectual property (IP). These more radical demands represent the third alternative to vaccine access inequalities. As a mix of nongovernmental organization-led and politician-led social justice demands, they are diverse and multifaceted, but together they have been articulated as calls for vaccine liberty. After first describing the realities of vaccine access inequalities, this article compares and contrasts the effectiveness thus far of the 3 alternatives. In doing so, it also provides a critical bioethical framework for reflecting on how the alternatives have come to compete with one another in the context of the vaccine property norms and market structures entrenched in global IP law. The uneven and limited successes of vaccine diplomacy and vaccine charity in delivering vaccines in underserved countries can be reconsidered in this way as compromised successes that not only compete with one another, but that have also worked together to undermine the promise of universal access through vaccine liberty.

Sharing the burden of treatment navigation: social work and the experiences of unhoused women in accessing health services in Santa Cruz

This paper explores the challenges faced by unhoused women in accessing general and reproductive health care services in Santa Cruz, CA. Semi-structured interviews with women experiencing houselessness were conducted in Santa Cruz, CA with a focus on their narrative experiences as patients. The overwhelming majority of participants expressed appreciation for clinics that provided support through longer hours, alternative therapies, and appointment reminders. Overall, the interviews indicated that women who had access to a social worker were much more likely to report improved access to satisfactory treatment. These findings suggest that there is not a tangible lack of healthcare services for unhoused women in the local community, but rather a burden of treatment navigation caused by a dearth of information on how to access care. The interviews suggest that this burden can be reduced with social work interventions and service centers that offer health navigation support. By adapting theories of the "burden of treatment," we argue that additional attention must be paid to overcoming the "burden of treatment navigation." For related reasons, we suggest that increasing the availability of social workers would concretely improve health outcomes for unhoused women.

The impact of financialisation on public health in times of COVID-19 and beyond

The substantial literature in political economy and sociology has shown that the increasing importance of financial activities (financialisation) exhibits significant effects on many socioeconomic conditions. While these conditions are relevant to public health, the dominant focus of the literature has been centred on the impact of financial markets on health services and health-care systems. This paper analyses how the financialisation of non-financial corporations, real estate and pensions can worsen public health through the transformation of workplace and living conditions as well as financially dependent social groups' perception of health risk. Our analysis raises several questions which aim to provide the basis of a future research agenda on the effects of financialisation on public and global health.

Limits of neoliberalism: HIV, COVID-19, and the importance of healthcare systems in Malawi

Countries in sub-Saharan Africa have been seriously affected by HIV and now face a new pandemic - COVID-19. How have prior experiences with managing HIV prepared countries for COVID-19? To what extent has the structure of the global health field enabled or constrained countries' ability to respond? Drawing on qualitative methods, this article examines the impact of HIV interventions on the healthcare system in Malawi and its implications for addressing COVID-19. I argue that the historical and continued influence of neoliberalism in global health manifests in the structures and routines of clinical practice. In Malawi's health centres, a parallel NGO system of care has become grafted onto state healthcare, with NGOs managing HIV commodities and providing care to HIV patients. While HIV NGOs do support the work of government providers, it is limited to tasks that align with their programmatic goals. Outside of donor priorities, the conditions of public healthcare are left behind, and government providers struggle with shortages of staff, medical resources, and basic infrastructure. In the context of COVID-19, risks are compounded as public healthcare facilities not only struggle with resources to treat patients, but also become a site of risk itself for COVID-19 infection.

"You have to fight to legitimize your existence all the time": The social context of depression in men with physical disabilities

Little is known about the common experience of depression in men with physical disabilities. To help address this gap, we present findings from a qualitative study situated in the social determinants of health (SDH). Findings describe the detrimental effects of marginalization, economic precarity, restrictive masculine norms, stigma, and the need to resist ableist messages on men's health and well-being. It is our intention to raise awareness of the impact of the SDH on depression in men with physical disabilities and encourage clinicians and policy makers to address the social domain as they seek to improve mental health in this population.

How Neoliberalism Shapes Indigenous Oral Health Inequalities Globally: Examples from Five Countries

Evidence suggests that countries with neoliberal political and economic philosophical underpinnings have greater health inequalities compared to less neoliberal countries. But few studies examine how neoliberalism specifically impacts health inequalities involving highly vulnerable populations, such as Indigenous groups. Even fewer take this perspective from an oral health viewpoint. From a lens of indigenous groups in five countries (the United States, Canada, Australia, Aotearoa/New Zealand and Norway), this commentary provides critical insights of how neoliberalism, in domains including colonialism, racism, inter-generational trauma and health service provision, shapes oral health inequalities among Indigenous societies at a global level. We posit that all socially marginalised groups are disadvantaged under neoliberalism agendas, but that this is amplified among Indigenous groups because of ongoing legacies of colonialism, institutional racism and intergenerational trauma.

COVID-19 and Private Health: Market and Governance Failure

The COVID-19 pandemic has produced mass market failure in global private health, particularly in tertiary care. Low-and-middle income countries (LMICs) dependent on private providers as a consequence of neglect of national health systems or imposed conditionalities under neoliberal governance were particularly effected. When beds were most needed for the treatment of acute COVID-19 cases, private providers suffered a liquidity crisis, itself propelled by the primary effects of lockdowns, government regulations and patient deferrals, and the secondary economic impacts of the pandemic. This led to a private sector response—involving, variously, hospital closures, furloughing of staff, refusals of treatment, and attempts to profit by gouging patients. A crisis in state and government relations has multiplied across LMICs. Amid widespread national governance failures—either crisis bound or historic—with regards to poorly resourced public health services and burgeoning private health—governments have responded with increasing legal and financial interventions into national health markets. In contrast, multilateral governance has been path dependent with regard to ongoing commitments to privately provided health. Indeed, the global financial institutions appear to be using the COVID crisis as a means to recommit to the roll out of markets in global health, this involving the further scaling back of the state.

Enhancing citizenship through nursing care in Brazil: Patients' struggle against austerity policies

Interpersonal relations play a critical role in both the conception and dynamics of Brazilian citizenship. Under the influence of neoliberalism, patients must build strategies to access high-quality health care services. This study aimed to analyze the role of interpersonal relations involved in the access to and delivery of health care services in Brazil amid the influence of austerity policies and the role of nurses in enhancing citizenship through nursing care. Thirty-one patients in a public hospital in Rio de Janeiro, Brazil, participated in qualitative interviews. A lexical analysis was conducted to analyze the interview data using Alceste® software, version 2012. The results were interpreted in light of both theoretical constructs of the Brazilian citizenship and biological subcitizenship propositions. Two lexical classes revealed contents about strategies used by patients to access high-quality health care. In the context of budget cuts due to austerity policies, cultural aspects of Brazilian citizenship have influenced access to high-quality health care services by creating two distinct conditions. Some patients acted as super-citizens, while others acted as subcitizens. Nurses across the globe must spearhead the struggle for universal and equitable health care access at all levels, without losing sight of wider sociocultural aspects.

Processes of Sub-Citizenship: Neoliberal Statecrafting ‘Citizens,’ ‘Non-Citizens,’ and Detainable ‘Others’

Increasingly, scholars are exploring the politics of migration and the shifting terrain of citizenship from a critical mobilities perspective. To contribute to these discussions, in this paper, I explore how processes of sub-citizenship occur as nation-states craft immigration, citizenship, and border securitization policies and practices. I argue that complex and shifting processes of sub-citizenship largely occur through the nation-state’s production of ‘insiders’ (‘citizens’) and ‘outsiders’ (‘non-citizens’). As a nascent attempt to introduce sub-citizenship, I draw upon recent high-profile cases of family separation, abuse, and neglect experienced by children with ‘illegal migrant’ status in the United States and Australia. Under the international nation-state system and the neoliberal globalization paradigm, the border policing powers of nation-states are primed to expand and intensify processes of sub-citizenship. Those at lower levels of the sub-citizen hierarchy are at risk of experiencing various forms of state-led violence, including deportation, detention, and torture.

International trade and the neoliberal diet in Central America and the Dominican Republic: Bringing social inequality to the center of analysis

Scholarship on international trade and health analyzes the effects of trade and investment policies on population exposure to non-nutritious foods. These policies are linked to the nutrition transition, or the dietary shift towards meat and processed foods associated with rising overweight and obesity rates in low- and middle-income countries. We argue for expanding the trade and health literature's focus on population exposure through the concept of the neoliberal diet, which centers subnational social inequality as both an outcome of neoliberal agri-food trade policies and a determinant of dietary change. We develop this perspective through a regional analysis of non-nutritious food availability following the implementation of the Dominican Republic-Central America Free Trade Agreement (CAFTA-DR), together with an extended case study, from the late 1990s to the present, of household expenditure and food price changes in the Dominican Republic, the region's largest food importer. Our analysis demonstrates that low-income consumers face increasing household food expenditures in a context of overall food price inflation, in addition to relatively higher price increases for healthy versus ultraprocessed foods. Neoliberal policies not only contribute to restructuring the availability and pricing of healthy food for low-income consumers, but they also exacerbate social inequality in the food system through corporate-controlled supply chains and farmer displacement. Our findings support policy proposals for socially distributive forms of healthy food production to stem the negative effects of the nutrition transition.

A Historical View on Health Care: A New View on Austerity?

It is an axiom of contemporary conversations about austerity and health care that the relationship between the two is essentially direct. Cutting funds damages health care systems and hurts the health of individuals who rely on them. Though this premise has provoked necessary discussion about global politics, the global economy and their impact on individual well-being, it is nonetheless intrinsically problematic. Assigning health and health care as objects of austerity not only obscures the complexity of health care systems and the opacity of health's definitional borders, but also misunderstands austerity, its manifestations and its significance. The ambition of this essay is to bring health care back into the debate, in order to establish the greater dynamism of the contemporary austerity and health care relationship. This historical reconstruction will challenge the significance of our current situating of austerity as health care's bogeyman, press for a reconsideration of our contemporary definitions of the key factors involved here (health, health care and austerity) and finally conclude with some thoughts on how we might more productively approach the problem of health now.

Therapeutic citizens and clients: diverging healthcare practices in Malawi's prenatal clinics

This article examines how HIV policies and the funding priorities of global institutions affect practices in prenatal clinics and the quality of healthcare women receive. Data consist of observations at health centres in Lilongwe, Malawi and interviews with providers (N = 37). I argue that neoliberal ideology, which structures the global health field, produces a fragmented healthcare system on the ground. Findings show two kinds of healthcare practices within the same clinic: donor-funded NGOs took on HIV services while government providers focused on prenatal care. NGO practices were defined by surveillance, where providers targeted pregnant HIV-positive women and intensively monitored their adherence to drug treatment. In contrast, state-led practices were defined by rationing. Government providers worked with all pregnant women, but with staff and resource shortages, they limited time and services for each patient in order to serve everyone. This paper builds on concepts of therapeutic citizenship and clientship by exploring how global health priorities produce different conditions, practices and outcomes of NGO and state-led care.

Navigating HIV citizenship: identities, risks and biological citizenship in the treatment as prevention era

The use of HIV Treatment as Prevention (TasP) has radically changed our understandings of HIV risk and revolutionised global HIV prevention policy to focus on the use of pharmaceuticals. Yet, there has been little engagement with the very people expected to comply with a daily pharmaceutical regime. We employ the concept of HIV citizenship to explore responses by people living with HIV in the UK to TasP. We consider how a treatment-based public health strategy has the potential to reshape identities, self-governance and forms of citizenship, domains which play a critical role not only in compliance with new TasP policies, but in how HIV prevention, serodiscordant relationships and (sexual) health are negotiated and enacted. Our findings disrupt the biomedical narrative which claims an end to HIV through scaling up access to treatment. Responses to TasP were framed through shifting negotiations of identity, linked to biomarkers, cure and managing treatment. Toxicity of drugs - and bodies - were seen as something to manage and linked to the shifting possibilities in serodiscordant environments. Finally, a sense of being healthy and responsible, including appropriate use of resources, meant conflicting relationships with if and when to start treatment. Our research highlights how HIV citizenship in the TasP era is negotiated and influenced by intersectional experiences of community, health systems, illness and treatment. Our findings show that the complexities of HIV citizenship and ongoing inequalities, and their biopolitical implications, will intimately shape the implementation and sustainability of TasP.

When Diabetes Confronts HIV: Biological Sub-citizenship at a Public Hospital in Nairobi, Kenya

This article investigates how international donor policies cultivate a form of biological sub-citizenship for those with diabetes in Kenya. We interviewed 100 patients at a public hospital clinic in Nairobi, half with a diabetes diagnosis. We focus on three vignettes that illustrate how our study participants differentially perceived and experienced living with and seeking treatment and care for diabetes compared to other conditions, with a special focus on HIV. We argue that biological sub-citizenship, where those with HIV have consistent and comprehensive free medical care and those with diabetes must pay out-of-pocket for testing and treatment, impedes diabetes testing and treatment. Once diagnosed, many are then systematically excluded from the health care system due to their own inability to pay. We argue that the systematic exclusion from international donor money creates a form of biological sub-citizenship based on neoliberal economic policies that undermine other public health protections, such as universal primary health care.

Social Impact Bonds as a Funding Method for Health and Social Programs: Potential Areas of Concern

Social Impact Bonds (SIBs) represent a new way to finance social service and health promotion programs whereby different types of investors provide an upfront investment of capital. If a given program meets predetermined criteria for a successful outcome, the government pays back investors with interest. Introduced in the United Kingdom in 2010, SIBs have since been implemented in the United States and across Europe, with some uptake in other jurisdictions. We identify and explore selected areas of concern related to SIBs, drawing from literature examining market-based reforms to health and social services and the evolution of the SIB funding mechanism. These areas of concern include increased costs to governments, restricted program scope, fragmented policymaking, undermining of public-sector service provision, mischaracterization of the root causes of social problems, and entrenchment of systemically produced vulnerabilities. We argue that it is essential to consider the long-term, aggregate, and contextualized effects of SIBs in order to evaluate their potential to contribute to public health. We conclude that such evaluations must explore the assumptions underlying the "common sense" arguments often used in support of SIBs.

The effects of neoliberal policies on access to healthcare for people with disabilities

Neoliberal reforms lead to deep changes in healthcare systems around the world, on account of their emphasis on free market rather than the right to health. People with disabilities can be particularly disadvantaged by such reforms, due to their increased healthcare needs and lower socioeconomic status. In this article, we analyse the impacts of neoliberal reforms on access to healthcare for disabled people. This article is based on a critical analytical review of the literature and on two case studies, Chile and Greece. Chile was among the first countries to introduce neoliberal reforms in the health sector, which led to health inequalities and stratification of healthcare services. Greece is one of the most recent examples of countries that have carried out extensive changes in healthcare, which have resulted in a deterioration of the quality of healthcare services. Through a review of the policies performed in these two countries, we propose that the pathways that affect access to healthcare for disabled people include: a) Policies directly or indirectly targeting healthcare, affecting the entire population, including disabled people; and b) Policies affecting socioeconomic determinants, directly or indirectly targeting disabled people, and indirectly impacting access to healthcare. The power differentials produced through neoliberal policies that focus on economic rather than human rights indicators, can lead to a category of disempowered people, whose health needs are subordinated to the markets. The effects of this range from catastrophic out-of-pocket payments to compromised access to healthcare. Neoliberal reforms can be seen as a form of structural violence, disproportionately affecting the most vulnerable parts of the population - such as people with disabilities - and curtailing access to basic rights, such as healthcare.

"The land of the sick and the land of the healthy": Disability, bureaucracy, and stigma among people living with poverty and chronic illness in the United States

Disability benefits have become an increasingly prominent source of cash assistance for impoverished American citizens over the past two decades. This development coincided with cuts and market-oriented reforms to state and federal welfare programs, characteristic of the wider political-economic trends collectively referred to as neoliberalism. Recent research has argued that contemporary discourses on 'disability fraudsters' and 'malingerers' associated with this shift represent the latest manifestation of age-old stigmatization of the 'undeserving poor'. Few studies, however, have investigated how the system of disability benefits, as well as these stigmatizing discourses, shapes the lived experience of disabling physical illness in today's United States. Here we present qualitative data from 64 semi-structured interviews with low-income individuals living with HIV and/or type 2 diabetes mellitus to explore the experience of long-term, work-limiting disability in the San Francisco Bay Area. Interviews were conducted between April and December 2014. Participants explained how they had encountered what they perceived to be excessive, obstructive, and penalizing bureaucracy from social institutions, leading to destitution and poor mental health. They also described being stigmatized as disabled for living with chronic ill health, and simultaneously stigmatized as shirking and malingering for claiming disability benefits as a result. Notably, this latter form of stigma appeared to be exacerbated by the bureaucracy of the administrating institutions. Participants also described intersections of health-related stigma with stigmas of poverty, gender, sexual orientation, and race. The data reveal a complex picture of poverty and intersectional stigma in this population, potentiated by a convoluted and inflexible bureaucracy governing the system of disability benefits. We discuss how these findings reflect the historical context of neoliberal cuts and reforms to social institutions, and add to ongoing debate around the future of public social provision for impoverished and chronically ill citizens under neoliberalism.