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Hoover’s book is an analysis of the material and psychosocial effects of industrial pollution along the St. Lawrence River, which runs through the Mohawk community of Akwesasne. Hoover focuses on resistance to private and state efforts at land enclosures and economic rearrangements.  Hoover shows how legacy of industrialization and pollution (GM and Alocoa, primarily) ruptured Mohawk relationships with the river, and incurred on tribal sovereignty by disturbing the ability to safely farm, garden, raise livestock, gather, and recreate in ways fostered important connections between and amongst people and the land (“ecocultural relationships”). Hoover describes how confusion about risk and exposure is culturally produced and develops the "Three Bodies" analytic framework to show how individual, social and political bodies are entangled in the process of social and biophysical suffering. 

Hoover also highlights how in response to pollution, Mohawk projects of resistance emerged - a newspaper, documentary films, and  community-based health impacts research. Hoover conducts a comparative history of two research projects tracking the effects on industrial-chemical contamination on Akwesasne people and wildlife: the Mount Sinai School of Medicine’s epidemiological study in the 1980s, which failed to engage Akwesasne people in the production of knowledge or share results meaningfully, and the SUNY-Albany School of Public Health Superfund Basic Research Program study (in the 1990s and 200s), which ultimately began incorporating key theoretical and methodological principles of CBPR.

“Akwesasne residents’ main criticism of the Mount Sinai study was that at its conclusion, the researchers packed up and left, and community members felt they had not received any useful information.” (76) 

“As scholars of tribal health risk evaluation Stuart Harris and Barbara Harper explain, among most tribal people, individual and collective well-being comes from being part of a healthy community with access to heritage resources and ancestral lands, which allow community members to satisfy the personal responsibilities of participating in traditional activities and providing for their families.” (96)

“By placing “race/ethnicity” on a list of diabetes causes without qualifying why it is there, the CDC neglects the underlying root cause—that race/ethnicity is often associated also with class, education, levels of stress, and access to health care and fresh foods.” (231)

“Chaufan argues that to counter the focus on the medicalized aspects of diabetes, which has led to the individualization and depoliticization of the issue, a political ecology framework needs to be applied to the disease, one that is concerned with the social, economic, and political institutions of the human environments where diabetes is emerging.39 Such a framework would highlight how diabetes rates among Mohawk people are influenced more by changes in the natural environment and home environments than by genetic makeup.” (231 - 232)

“Understanding community conceptions of this intertwined “social and biological history” is important because, as Juliet McMullin notes, examining the intersections of health, identity, family, and the environment helps to “denaturalize biomedical definitions of health and moves us toward including knowledge that is based on a shared history of sovereignty, capitalist encounters, resistance, and integrated innovation.”61 The inclusion of this knowledge can lead to the crafting of interventions that community members see as addressing the root causes of their health conditions and promoting better health.” (249)

Katsi Cook, Mother’s Milk Project, collecting samples of breast milk: “Katsi has described this work as “barefoot epidemiology,” with Indigenous women developing their own research projects based on community concerns and then collecting their own data.” (90) - 61? – used a private lab to analyze samples because women did not trust the New York State Health Department

“Barefoot epidemiology” is a concept borrowed from China’s “barefoot doctors”—community-level health workers who brought basic care to China’s countryside in the mid-twentieth century. Hipgrave, “Communicable Disease Control.” According to a “workers’ manual” published by the International Labour Organization, barefoot research is often qualitative, and qualitative research is not the standard approach for conducting health studies, which tend to be based on laboratory experiments and clinical findings. See Keith et al., Barefoot Research” (294)

Civic Dislocation: “In many instances Mohawks experienced what Sheila Jasanoff calls “civic dislocation,” which she defines as a mismatch between what governmental institutions were supposed to do for the public, and what they did in reality. In the dislocated state, trust in government vanished and people looked to other institutions . . . for information and advice to restore their security. It was as if the gears of democracy had spun loose, causing citizens, at least temporarily, to disengage from the state” (118) 

“Dennis Wiedman describes these negative sociocultural changes and structures of disempowerment as “chronicities of modernity,” which produce everyday behaviors that limit physical activities while promoting high caloric intake and psychosocial stress” (235)

Third space of sovereignty: “This tension that arises when community members challenge political bodies while simultaneously demanding that they address the issues of the community has been theorized by political scientist Kevin Bruyneel, who describes how for centuries Indigenous political actors have demanded rights and resources from the American settler state while also challenging the imposition of colonial rule on their lives. He calls this resistance a “third space of sovereignty” that resides neither inside nor outside the American political system, but exists on the very boundaries of that system.” (259)

Elizabeth Hoover is an anthropologist and associate professor of environmental science, policy and management at Berkley, who long claimed to be native (receiving grants and research access under this assumption) but has recently admitted otherwise. She has a PhD in anthropology from Brown University  with a focus on Environmental and critical Medical Anthropology. 

Creators of the Student Health Index recommend using the tool in combination with qualitative data collection and stakeholder/community engagement (e.g. working with school leaders, local community leaders, and healthcare providers).

A full guide to using the dashboard is available here.

Data sources utilized by the index are not always the most current due to data collection limitations (e.g. covid-19 has caused disruptions in the collection of CDE data).

The Index is limited in that it does not offer data for schools that were not large enough to warrant the construction of a School-based Health Center. Thus, schools that did not meet specific enrollment targets were excluded from the dashboard. This includes rural schools (designed as such by the USDA) with an enrollment under 500 students, urban schools (without a high school) with less than 500 students, and urban schools (with a high school) with less than 1000 students. California had more than 10,000 active public schools in 2020-21. The final dashboard for the Student Health Index includes 4,821 schools.

The lack of available data on health indicators at a school-level restricted the Student Health Index to using proxies for the health outcomes. Some health indicators are included, but they are not school-specific, instead linked to specific schools geographically through the census tract. However, community-level data does not always accurately reflect the characteristics of a school’s population. As a result, school-level indicators in the Index were weighted more heavily than community-level indicators.

Additionally, race was not included as a measure in the Student Health Index because of California’s Proposition 20, which prohibits the allocation of public resources based on race and ethnicity. However, the dataset does contain measures of non-white students at each school. 

The Index has also been limited as a quantitative measure of need, which may overlook the influence of other factors that might be better illuminated through qualitative evidence (e.g. stakeholder engagement, focus groups, interviews, etc.).

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The Student Health Index can produce visualizations that represent data on conditions, school characteristics and risk factors that affect education outcomes and could be improved through access to school-based health care. These visualizations can be used to demonstrate need for expanding school-based health care access in California.

In addition to maps, the index can also be used to generate graphs and visual displays of data (e.g. ratio of highest need schools to all schools, by county).

The visualizations can be used to demonstrate the correlations between final need scores and race, the impact of specific indicators in health, and the concentration of need to certain regions of California (hot spot analysis).

The Student Health Index enables users to identify where SBHCs will have the most impact for students. The index uses 12 indicators, each of which can be scored from 1 to 4 for any given school. These scores are generated using percentiles and represent relative values. The 12 indicator scores are combined into a Need Score, which is calculated using percentiles along a scale of 1 to 4. Schools with a score of 4 (in the 4th quartile) have the highest Need scores relative to other schools in California.

The index is composed of 12 diverse indicators (percentages, rates, and index values) that have been transformed using percentiles in order to enable comparisons on a common scale. These indicators are divided into 3 categories: health indicators, school-level indicators, and socioeconomic indicators.

Health Indicators

1. Diabetes
2. Asthma ED admissions
3. Teen birth
4. Health Professional Shortage Areas (HPSA)

Socioeconomic Indicators

1. Poverty among individuals under 18
2. Uninsured among under 19
3. Healthy Places Index

School-Level Indicators

1. Percent FRPL (students eligible for free or reduced-price meals)
2. Percent English Learners
3. Percent Chronically Absent
4. Percent experiencing homelessness
5. Suspension rate

Other Data

1. Mental health hospitalization rate
2. Percent in foster care

Indicator selection was guided by CDC estimations on the primary contributing factors that shape health (social determinants of health, medical care, and health behaviors). The indicators included in the index are all either directly associated with the absence of health services that could be provided at a school level, act as proxies for health behaviors, or represent social determinants of health that could be addressed through access to school-based health services.

Indicator selection was influenced by recommendations from the Research Initiative of the Campaign for Educational Equity at Columbia Teachers College, which found that seven health disparities affecting school-aged youth could be addressed through school health programs. These disparities include: (1) vision, (2) asthma, (3) teen pregnancy, (4) aggression and violence (including bullying), (5) physical activity, (6) hunger, and (7) inattention and hyperactivity.

More detailed description of the rationale shaping indicator selection is available here.