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Activism for health
Perspectives
Book Activism for health We live in a time of spectacular opportunity for health. By 2011, life expectancy exceeded 80 years in 26 countries. But with life expectancy below 55 years in another 17 countries, there are also spectacular levels of deprivation. Opportunities for health have grown, but so too have inequalities in access to those opportunities. WHO’s 2008 Commission on Social Determinants of Health attributed health inequalities to “structural conditions that together fashion the way societies are organised—poor social policies and programmes, unfair economic arrangements and bad politics”. The Commission proposed as one pillar of the response to build the power and ability people have to make choices about health inputs and to use these choices towards health. Amartya Sen has similarly identified health outcomes as being a product of different dimensions of functioning and of agency. Whilst health professionals are fairly certain of their role in a biomedical approach to improving health, there is less certain knowledge about whether and how to intervene in unequal power relations or to build people’s agency to achieve wellbeing. Yet as Rudolf Virchow once wrote “all disease has two causes, one pathological and the other political”. In Health Activism: Foundations and Strategies, Glenn Laverack provides both a “why to” and “how to” guide to health activism. He defines activism as an “action on behalf of a cause, action that goes beyond what is conventional or routine”. It can be a way for those without resource or political leverage to influence debate on their health determinants, or to access health care. Laverack synthesises lessons learned on what does and doesn’t work. He provides many examples of the influence of activism on health outcomes, such as in access to www.thelancet.com Vol 381 June 22, 2013
medicines; to healthy foods in urban communities; or to implementing public health standards on smoking. Health activism has a long history. The first Public Health Act in Britain in 1848 is often traced to the cholera epidemic of 1847–48 and Edwin Chadwick’s sanitary report in 1842. It is less well known that the Health of Towns Association, which was established in 1844, was an important source of political action on sanitary reform to back Chadwick and to mobilise middle-class support for the new public health law.
“Glenn Laverack provides both a ‘why to’ and ‘how to’ guide to health activism.” Issues of hard and soft power—or the power “over, with or within people”— that inform a discussion on activism can seem distant to the practice of health and medicine. Yet in my experience all of these forms of power are deeply embedded in the practice of health systems. Health workers often use their authority or expertise to exert power over patients and communities. When such power is internalised and structured into daily lives and in the institutional culture of the health system, it can shut down critical thinking. It can also block other forms of power needed for health, such as the power-from-within that may drive a determination to change harmful dietary or sexual patterns or the shared power of the collective that led the New York City food movement to bring about health-promoting school food policies, or the New Zealand Prostitutes Collective to partner with the health sector to reform the law, improve reproductive health services, and curb the spread of HIV. Laverack thus argues for health workers who interface with the public to play a more enabling part
in the power of communities. Over two decades of work in east and southern Africa, I have seen and measured such gains in health when health workers communicate with, and facilitate action by, organised communities. Laverack makes a persuasive case for how activism has a role in public health policy and practice. Although there are few cases drawn from Africa, reading the book brought to mind many cases that I’ve worked with that confirm the role of activism in health: medics from the liberation movements organising local primary health care services; trade unionists negotiating healthy work; lawyers in organisations like Section 24 in South Africa ensuring accountability on services; treatment activists fighting for access to antiretrovirals; and professionals from EQUINET and the People’s Health Movement mobilising evidence and support for equity in the allocation of health resources. Laverack cautions that the promotion of individualism, privatisation of public services, and a decline in solidarity policies can undermine social processes that address social injustice in health, and he warns of conflict in less open political contexts. However, he also points to opposing trends. People can access information from a wide range of sources, communicate through social media, and are more connected on global shared interests. Avaaz, a global online civil society that promotes activism on issues such as climate change, health, and human rights, has more than 20 million members. The functioning of institutions and policies that affect health are thus becoming more visible and more likely to be questioned. These trends suggest that health systems may need to pay more attention in future to activism as a social determinant of health.
Health Activism: Foundations and Strategies Glenn Laverack. Sage Publications, 2013. Pp 192. £23·00. ISBN 9781446249659 See Perspectives page 2158
Rene Loewenson [email protected]
2157
Book Activism for health We live in a time of spectacular opportunity for health. By 2011, life expectancy exceeded 80 years in 26 countries. But with life expectancy below 55 years in another 17 countries, there are also spectacular levels of deprivation. Opportunities for health have grown, but so too have inequalities in access to those opportunities. WHO’s 2008 Commission on Social Determinants of Health attributed health inequalities to “structural conditions that together fashion the way societies are organised—poor social policies and programmes, unfair economic arrangements and bad politics”. The Commission proposed as one pillar of the response to build the power and ability people have to make choices about health inputs and to use these choices towards health. Amartya Sen has similarly identified health outcomes as being a product of different dimensions of functioning and of agency. Whilst health professionals are fairly certain of their role in a biomedical approach to improving health, there is less certain knowledge about whether and how to intervene in unequal power relations or to build people’s agency to achieve wellbeing. Yet as Rudolf Virchow once wrote “all disease has two causes, one pathological and the other political”. In Health Activism: Foundations and Strategies, Glenn Laverack provides both a “why to” and “how to” guide to health activism. He defines activism as an “action on behalf of a cause, action that goes beyond what is conventional or routine”. It can be a way for those without resource or political leverage to influence debate on their health determinants, or to access health care. Laverack synthesises lessons learned on what does and doesn’t work. He provides many examples of the influence of activism on health outcomes, such as in access to www.thelancet.com Vol 381 June 22, 2013
medicines; to healthy foods in urban communities; or to implementing public health standards on smoking. Health activism has a long history. The first Public Health Act in Britain in 1848 is often traced to the cholera epidemic of 1847–48 and Edwin Chadwick’s sanitary report in 1842. It is less well known that the Health of Towns Association, which was established in 1844, was an important source of political action on sanitary reform to back Chadwick and to mobilise middle-class support for the new public health law.
“Glenn Laverack provides both a ‘why to’ and ‘how to’ guide to health activism.” Issues of hard and soft power—or the power “over, with or within people”— that inform a discussion on activism can seem distant to the practice of health and medicine. Yet in my experience all of these forms of power are deeply embedded in the practice of health systems. Health workers often use their authority or expertise to exert power over patients and communities. When such power is internalised and structured into daily lives and in the institutional culture of the health system, it can shut down critical thinking. It can also block other forms of power needed for health, such as the power-from-within that may drive a determination to change harmful dietary or sexual patterns or the shared power of the collective that led the New York City food movement to bring about health-promoting school food policies, or the New Zealand Prostitutes Collective to partner with the health sector to reform the law, improve reproductive health services, and curb the spread of HIV. Laverack thus argues for health workers who interface with the public to play a more enabling part
in the power of communities. Over two decades of work in east and southern Africa, I have seen and measured such gains in health when health workers communicate with, and facilitate action by, organised communities. Laverack makes a persuasive case for how activism has a role in public health policy and practice. Although there are few cases drawn from Africa, reading the book brought to mind many cases that I’ve worked with that confirm the role of activism in health: medics from the liberation movements organising local primary health care services; trade unionists negotiating healthy work; lawyers in organisations like Section 24 in South Africa ensuring accountability on services; treatment activists fighting for access to antiretrovirals; and professionals from EQUINET and the People’s Health Movement mobilising evidence and support for equity in the allocation of health resources. Laverack cautions that the promotion of individualism, privatisation of public services, and a decline in solidarity policies can undermine social processes that address social injustice in health, and he warns of conflict in less open political contexts. However, he also points to opposing trends. People can access information from a wide range of sources, communicate through social media, and are more connected on global shared interests. Avaaz, a global online civil society that promotes activism on issues such as climate change, health, and human rights, has more than 20 million members. The functioning of institutions and policies that affect health are thus becoming more visible and more likely to be questioned. These trends suggest that health systems may need to pay more attention in future to activism as a social determinant of health.
Health Activism: Foundations and Strategies Glenn Laverack. Sage Publications, 2013. Pp 192. £23·00. ISBN 9781446249659 See Perspectives page 2158
Rene Loewenson [email protected]
2157