Recording artist Lynn Miles sings: “Burn all the bridges down / Move me to another town.” I am not burning any bridges, but I am moving to another town – one on the other side of the Atlantic, in fact. As of June 1, 2013 I will take up an appointment as Professor of Global Health Policy at Durham University. (I cannot resist the observation that Durham County Council is currently the only one in England controlled by the Labour Party, although this may change after the May elections.) The change of scene and the end of provincial funding for the Population Health Improvement Research Network make this a good time to discontinue writing Health as if Everybody Counted. For the immediate future the postings will remain on the CHNET-Works web site, and I hope they will continue to serve as a useful resource for those wanting to advance the health equity agenda. I am also enthusiastic about the possibility of updating, reorganizing and consolidating the postings as an e-book; more news on this as it happens.
As I prepare to leave Canada, I am prompted to reflect on why it is so difficult make change in population health research and practice. Most of us work in institutions like university faculties, government ministries, local public health agencies, or nonprofits. These institutions respond to external priorities like those of granting councils, cabinets and local elected officials – priorities that tend to be shaped by macro-scale political currents like neoliberalism. Our institutions also, with a few exceptions, are strongly hierarchical in their internal structure. Observations of various kinds of organizations show that many individuals working within them adapt with striking facility to the moving target represented by changing requirements for success within the institu¬tion. In an excellent study of the World Bank, Cheryl Payer described “a cage with glass walls. Within this barrier the bureau¬crats and technocrats work, argue, debate, cooperate or fall out with one another, attempting to aggrandize their own position or to defeat opponents. They have the illusion of freedom because the barrier is invisible. The smart or ambitious ones, having once experienced or observed such a collision, remember where the barrier is and avoid it thereafter; those who are slower, stubborn, or angry continue to beat their heads against it until they are bloody. The recruitment and promotion practices naturally favour the smart ones who don't have bloody heads" (p. 353).
Not everyone adapts eagerly to the requirements for advancement within their institution, although eager adaptation is frequent in Canadian university settings. Active resistance is likely to be a career-limiting move in many organizations. Senior managers and external protagonists who set priorities and budgets must at least be comfortable with ideas like health equity if people trying to organize their work around such a concept want to keep their jobs, and the organization’s internal routines must be permeable enough to enable the advocates to make their case. Academics often have more flexibility, but can still be targeted by governments or commercial interests. More routinely, they are vulnerable to being marginalized or excluded through the operation of what can be thought of as organizational filters. For example, if the managers of universities or hospitals (or those to whom they report, like hospital and university boards) decide that securing a permanent teaching or research position requires successful grant applications, then over time the organization becomes populated by people whose research priorities are congruent with those of funding agencies – whether those involve behavioural approaches to health promotion, development of commercial products like new drugs, or military technologies.
Philosopher of science Jon Elster is a master at providing microfoundations for large-scale explanations of social phenomena. In Ulysses and the Sirens, now unfortunately out of print, he wrote that: “If academic personnel apply for military funds in order to be able to conduct the research that they would have done in any case ... the Department of Defence may serve as a filter that selects some applica¬tions and rejects others. The resulting composition of research will be beneficial to the military interests, while wholly unintended by the individual scientist, who can argue truthfully that no one has told him what to do” (p. 30). Those who make it through the filters will in turn have an ongoing influence on the direction of the organization as, for example, they serve on appointments committees or advance into administrative posts, having observed the bloody heads of less accommodating colleagues. The result is a situation in which, as Ken Coates of the University of Saskatchewan has written: “We have self-regulated ourselves into near silence, and our students and the country suffer from the quiet as much as university faculty.” Given granting agencies’ emphasis on biomedical and clinical research and the growing corporate influence in Canadian universities, which has been commented upon even in the Financial Post, it is hard to overstate the importance of this analysis, both for those already ‘in the system’ and for those hoping to make a career in equity-oriented health research.
The experiences of those of us who have worked in such environments are too easily dismissed as anecdotal or otherwise biased; for better or for worse, external validation is needed. Empirical health policy research has not penetrated very deeply into the power structures and organizational routines of Canadian health ministries, university faculties, research institutes and public health agencies. Relevant methodologies and perspectives are suggested by contributors to books like Policy Worlds: Anthropology and the Analysis of Contemporary Power and by the work of scholars like Janine Wedel, whose remarkable analysis of how power operates both through formal organizational structures and the informal networks she calls “flex nets” is especially valuable. It remains to be seen whether those interested in doing this kind of research can make it through the filters, or whether they will find the necessary financial support.