[TLDR (too long didn’t read): If you are reading this, chances are this has aroused your interest. This Reader explores what has hampered more sustainable impacts of public health the world over. For a quick overview, just read the bolded text]. Traducir/traduire los/les Readers; usar/utiliser deepl.com
—Rebuilding the influence of public health requires a strategic shift that builds people power through partnerships with labor and community organizing groups and eventually deploying non-violent disruptive power to protect population health.
The mismatch results in the meagre health outcomes we see the world over
1. Public health has relied primarily on knowledge and moral power, whereas actors advancing policies detrimental to health increasingly wield economic, political, ideological and physical power within a neoliberal political economy. Under conditions of polarization, disinformation and institutional capture shape the rules that currently determine health outcomes. The strategic shifts thus needed include: rebuilding people power through partnerships with labor (especially health workers) and community organization groups, strengthening ideological power through sustained political education and, when needed, joining with others in the use of nonviolent disruptive power. This will require public health to engage more deliberately with power and politics rather than relying on techno-administrative ‘evidence-based’ arguments alone. It will also require exposing the field’s limited ability to reshape the societal rules that ultimately seal the fate of preventable ill-health, preventable malnutrition and preventable deaths.
So, what forms of power can public health develop to more effectively shape the conditions that determine health?
2. Achieving improvements in health requires challenging and reshaping the structural determination of health along with the power dynamics behind it that are creating and maintaining hierarchical patterns of advantage among socially-privileged groups in the conditions and the access aspects that affect health. Ultimately, the distribution of power shapes and plays a central role in influencing which populations are more or less protected in their health.
3. A common misperception is that, through education, the public will understand and act on information about health and policymakers will implement evidence-based policies that advance public health goals. Well, reliance on the power of knowledge alone has just not protected public health. Decision makers simply dismiss the findings; they counter and suppress the data or fund countervailing research. Ideological power and economic power thus override knowledge power. Appeals to enhance knowledge unfortunately resonate a lot with public health professionals who seek to separate science and management from politics. Emphasizing a separation between these obscures the reality that is inherently political. For-profit social media platforms have been amplifying the spread of misleading information. Only people power can counter this. Beneficiaries’ and people’s voices must simply become more influential, beyond just having their voices heard.
4. As for moral arguments
—Moral arguments have also been used by those opposed to a health equality agenda (including by anti-abortion activists).
Moral power cannot be used in ways that stigmatize people for their behaviors (although one can call out the immorality of extreme wealth inequality and the behavior of billionaires in creating it).
What types of power ought public health to build moving forward?
–What strategies need to be employed to build those forms of power?
5. Working with social movements has been central to public health’s early successes in, among other, improving water and sanitation and working conditions for women and other. Picking up from these connections/successes will strengthen people power. Public health workers must show up as allies in this endeavor, building greater trust with beneficiaries and communities, supporting their work and strategizing with them. Work with those organizing the groups most marginalized by society is key. Such partnerships can start with dialogue and listening, but must then move to a deep engagement towards organizing and mobilizing. This approach builds a popular base of support for public health especially when it supports the community’s agenda. In last instance, only in this way will people challenge the power of monied interests and transform the structural determination and determinants of health.
When formal governance systems are inefficient to protect health, disruption becomes a necessary tool (Refer to US activist Michael Moore’s very effective videos: https://en.wikipedia.org/wiki/Michael_Moore)
6. Disruptive power works by interrupting business as usual. It involves challenging institutional arrangements that sustain harmful systems, as well as imposing political costs until change occurs. Strategic disruption creates pressure. Disruptive power involves: a) nonviolent tactics, b) censorship and non-compliance, c) sit-ins, d) boycotts, e) public art. It can include f) interrupting key public health meetings and g) providing health care when it has been made illegal. Effective disruption can also include providing mutual aid. Although these actions carry risks, by acting in solidarity, they also are radical acts of resistance. In short, we will require creativity, coordination, and courage to defend public health and health equality and to prevent harmful policies and repressive responses.
In public health, the site of action is just as likely to be at the policy or program drawing board as it is, eventually, to be in the streets
7. Merely discussing the policy-making process without explicitly trying to resist it when it is top-down has no teeth. Mere ‘advocacy’ leaves activists in the public health workforce without a clear direction on how to engage the needed political levers of change. Health workers have to begin to weave elements of explicit knowledge with their own work experience, question assumptions and potential biases and position themselves and their practice within the broader determinants of health and health equality. (Leigh K. Haynes)
Bottom Line
8. Do not forget: The commercial determinants of health are key structural determinants of health. Through deregulation, governmental institutions have increasingly ceded authority to corporations. As a result, government institutions increasingly reflect the priorities of economic interests. Public health must use people power to constrain corporate economic power, for example, through environmental, worker protection and antitrust regulation and through strengthening labor unions especially those of health workers.
9. So, does all this have a chance? This strategy is unlikely to be implemented by current public health leaders within the existing public health structures. Advancing public health and health equality requires engaging directly with power and politics. Without doing so, public health risks further marginalization, continued distortion of health initiatives towards equality, as well as additional harm to the communities ill-served. Public health faces a crucial strategic decision: rely on techno-managerial evidence alone and hope those in power act, or realign the field’s strategies to build the power needed to reshape the rules that determine population health. …But hope is notoriously not enough. (mostly taken from J. Heller)
Claudio Schuftan, Ho Chi Minh City
Your comments are welcome at schuftan@gmail.com
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Postscript/not so marginal
When it comes to global health and humanitarian work, there is no ‘them’…only ‘us’. (Global Health Council)
—Health is not automatically a humanitarian topic. Health, humanitarian, and human rights work are grounded in norms and values that are, however imperfectly, realized through voluntary moral exhortations encouraging people to behave decently. Legislation is largely ineffective and sometimes counterproductive in these areas, except in narrow technical domains. If humanitarians behave as bureaucrats devoid of empathy and political thinking, it drains the heart out of humanitarian work. Unfortunately, increasingly, people enter humanitarian work, not as a vocation, but as a career. Those individuals should not be allowed to climb organizational ladders and to run humanitarian institutions like businesses. Courage, moral instinct (not forgetting political instinct) and compassion cannot be taught in management schools. I do not believe it is possible to produce such ideal leaders through education or careful design. Humanitarian leaders should, therefore, tread lightly and humbly, especially given that their well-paid careers are built upon the misery and misfortune of others. (Mukesh Kapila)
–Humanitarian work has always been framed upon the collective assumption that there are lines that should never be crossed, even in wars. Today, the consensus and meaning behind these laws are gone. Too many governments are no longer consistently defending the rules-based order that they helped create. When it suits them, some are openly disregarding international law. Others are applying it selectively, condemning their adversaries for violations while tolerating the same behaviours by their allies. Many more are simply remaining silent at times when condemnation and action are required. When governments feel that their own geopolitical and domestic interests are more important than their legal obligations, our rules-based humanitarian system becomes diminished and corrupted. Enforcement becomes inconsistent. Tolerance of excessive civilian casualties becomes routine. And anything becomes permissible, including the unthinkable. Today, impunity is being allowed to flourish. Bad actors feel more empowered to break the laws that exist to make us all safer, because they know they w ill not be held to account. This matters, because humanitarian crises do not emerge in a vacuum. Instead, they are the direct results of these kinds of transactional political choices. In this worldview, the protection of civilians and aid, as well as health workers is no longer understood as a universal obligation as much as a commodity –something that can be bargained, withheld or selectively applied. Protection becomes a political investment that demands a political return. But failing protection is not the only challenge humanitarian work faces today. Often, states impose unnecessary restrictions that prevent aid workers from carrying out their duties. Without accountability, action becomes merely a tolerance of the unjustifiable. (Amitaba Behar, Oxfam)