title: Food insecurity, chronic illness, and gentrification in the San Francisco Bay Area: An example of structural violence in United States public policy.
abstract: Food insecurity continues to be a major challenge in the United States, affecting 49 million individuals. Quantitative studies show that food insecurity has serious negative health impacts among individuals suffering from chronic illnesses, including people living with HIV/AIDS (PLHIV). Formulating effective interventions and policies to combat these health effects requires an in-depth understanding of the lived experience and structural drivers of food insecurity. Few studies, however, have elucidated these phenomena among people living with chronic illnesses in resource-rich settings, including in the United States. Here we sought to explore the experiences and structural determinants of food insecurity among a group of low-income PLHIV in the San Francisco Bay Area. Thirty-four semi-structured in-depth interviews were conducted with low-income PLHIV receiving food assistance from a local non-profit in San Francisco and Alameda County, California, between April and June 2014. Interview transcripts were coded and analysed according to content analysis methods following an inductive-deductive approach. The lived experience of food insecurity among participants included periods of insufficient quantity of food and resultant hunger, as well as long-term struggles with quality of food that led to concerns about the poor health effects of a cheap diet. Participants also reported procuring food using personally and socially unacceptable strategies, including long-term dependence on friends, family, and charity; stealing food; exchanging sex for food; and selling controlled substances. Food insecurity often arose from the need to pay high rents exacerbated by gentrification while receiving limited disability income--​a situation resulting in large part from the convergence of long-standing urban policies amenable to gentrification and an outdated disability policy that constrains financial viability. The experiences of food insecurity described by participants in this study can be understood as a form of structural violence, motivating the need for structural interventions at the policy level that extend beyond food-specific solutions.
authors.affiliation: Global Health Sciences, University of California, San Francisco (UCSF), Mission Hall/Global Health and Clinical Sciences Building, 550 16th Street, 3rd Floor, San Francisco, CA 94158-2549, United States. Electronic address: harrywhittle@gmail.com.
authors.forename: Henry J
authors.initials: HJ
authors.lastname: Whittle
authors.affiliation: Division of HIV/AIDS, Department of Medicine, UCSF, United States.
authors.forename: Kartika
authors.initials: K
authors.lastname: Palar
authors.affiliation: Division of HIV/AIDS, Department of Medicine, UCSF, United States.
authors.forename: Lee Lemus
authors.initials: LL
authors.lastname: Hufstedler
authors.affiliation: Center for Vulnerable Populations at San Francisco General Hospital, Division of General Internal Medicine, UCSF, United States.
authors.forename: Hilary K
authors.initials: HK
authors.lastname: Seligman
authors.affiliation: Department of Health Promotion, Education, and Behavior, University of South Carolina, United States.
authors.forename: Edward A
authors.initials: EA
authors.lastname: Frongillo
authors.affiliation: Global Health Sciences, University of California, San Francisco (UCSF), Mission Hall/Global Health and Clinical Sciences Building, 550 16th Street, 3rd Floor, San Francisco, CA 94158-2549, United States; Division of HIV/AIDS, Department of Medicine, UCSF, United States; Center for AIDS Prevention Studies, UCSF, United States.
authors.forename: Sheri D
authors.initials: SD
authors.lastname: Weiser
mesh_terms: D000328:Adult; D000368:Aged; D002908:Chronic Disease / Q000628:therapy*; D005260:Female; D063105:Food Assistance / Q000191:economics; D005523:Food Supply / Q000191:economics*; D015658:HIV Infections / Q000191:economics; D006703:Ill-Housed Persons; D006798:Housing / Q000191:economics; D006801:Humans; D008297:Male; D008875:Middle Aged; D011203:Poverty; D011640:Public Policy; D012495:San Francisco; D012959:Socioeconomic Factors; D014754:Violence / Q000191:economics*
keywords: Chronic illness; Food insecurity; Gentrification; HIV; San Francisco Bay Area; Structural violence