Sir Michael Marmot, who chaired the Commission on Social Determinants of Health and later led a review of influences on health inequalities in England, has called for "a social movement, based on evidence, to reduce inequalities in health" (1) and even claims to identify the beginnings of such a movement. Has such a movement begun to coalesce, and what are the prospects for its success?
In a recent book on women's resistance to workplace sexual harassment in the United States, Carrie Baker defines social movements as "a mixture of informal networks and formal organizations outside of conventional politics that make clear demands for fundamental social, political, or economic change and utilize unconventional or protest tactics" (p. 4) and argues that the resistance she studied fits that definition, even though much of the action took place in courtrooms, administrative hearings, and Congressional committees. Crucially, the coalitions that formed to fight sexual harassment connected women who were not otherwise similarly situated in socioeconomic terms. Restaurant workers, middle managers in banks and federal agencies, and lawyers trying to make partner in their firms were united - sometimes temporarily and precariously – by lack of legal protection from sexual harassment by male colleagues and superiors.
A parallel can be drawn with what is almost certainly the most successful contemporary health-related social movement, that involving treatment and prevention of HIV/AIDS. At the forefront of that movement was the AIDS Coalition to Unleash Power (ACT UP), co-founded in New York City in 1987 by playwright Larry Kramer, who was to become identified as the public face of the movement. ACT-UP quickly adopted the tactic of mounting high-profile demonstrations in places including Wall Street, the US Food and Drug Administration in Washington, DC, and St. Patrick's Cathedral (to protest against Catholic opposition to AIDS education and condom distribution). Some of ACT UP's approaches were controversial, but it "added enterprise and erudition" to confrontation, and the organization and its tactics quickly spread nationally, and even internationally.
In the early years of the epidemic, AIDS was an equal opportunity killer. This is less true today, yet the solidarity forged in the formative years of AIDS activism survives and crosses both class and national boundaries, as seen for example in the transnational support that South Africa's Treatment Action Campaign (TAC) has mobilized. That support was critical in convincing pharmaceutical companies to abandon legal efforts to prevent South Africa's government from buying lower-cost generic antiretrovirals, and TAC continues to appeal to a global audience for maintaining access to AIDS treatment.
Here's the rub.
Effective social movements are not based on evidence. Social movements can use evidence in various creative ways, but they are based on rage, hopelessness, desperation, hope, or combinations of these. That's where their energy comes from. Normally, as shown by the examples of ACT UP and resistance to sexual harassment, their protagonists share a particular vulnerability even though they may otherwise have little in common. If we go farther back in history, the movement for female suffrage and the trade union movement are useful case studies; movements to abolish slavery, in which some protagonists had no personal stake yet were willing to place themselves at considerable risk, provides a partial counterexample.
What shared passions or vulnerabilities (and effective social movements require at least one of these, and often both) will provide the basis for reducing health inequity by way of action on social determinants of health in Canada? What more needs to be known about social movements in order to create an effective one around this agenda? The answers are far from clear, which may be why the agenda is making slow progress.
Public health researchers and practitioners, whatever their level of commitment (which varies greatly), are at minimal risk from many of the conditions of life and work that are most destructive of health: inadequate incomes, precarious employment, hazardous exposures on the job, and the physiologically corrosive levels of stress that go along with all of those. Perhaps that is why the enterprise of health promotion still focuses far too much attention on health literacy, "choosing your sandwich with care," and similar constructs that ignore the quotidian challenges of too little money, too many demands in the workplace (including, for women in particular, the domestic workplace), and too few hours in the day. Prof. Marmot's 2004 book The Status Syndrome is eloquent on the topic of these challenges. Further, few efforts appear to have been made to make common cause and build working relationships with anti-poverty organizations or the trade union movement. (I would love to hear from readers about exceptions to this generalization, in Canada or elsewhere, for future postings.)
Gratifyingly, some health professionals now understand the importance of such alliances. For example, in a special section on advocacy in the March 2012 issue of Canadian Nurse, Joyce Douglas of the Canadian Nurses' Association writes: "Front-line nurses can speak from experience and work with organizations, associations and movements that advocate for wages that people can live on, affordable housing, healthy environments and social inclusion." As Ontario and many other provinces face hard choices about how to reduce their post-recession deficits, let's hope health professionals of all kinds understand the issues and the stakes.
* A conversation with Kumanan Rasanathan helped to clarify some of the ideas presented here, but all blame rests with me.