Power and Public Health.
Last week, I had the privilege of presenting at the Nepal Health Foundation International Conference on Epidemiologic Research. While there, I had a conversation with Pushpa Reddy, health secretary for Nepal. Nepal is going through a transformation of its public health system, in parallel with a transformation of its entire administrative structure, to a federal system devolving power to the states and municipal governments. This creates interesting challenges and opportunities for the country in terms of thinking about how to concentrate power in a way that can best serve the health needs of Nepal. This got me thinking a bit about the role of power in promoting the health of the public. My thoughts were further informed by a tragedy that occurred at the end of last week, when a new pedestrian bridge collapsed in Miami, Florida, killing at least six people. While the cause of the accident is not yet known, a lack of regulatory oversight may have been a factor. The exercise of such oversight is a key function of power, and the polices and institutions that power shapes, creating protections that affect everything from the quality of our food and water, to the cleanliness of our air, to, yes, the safety of our infrastructure. To ensure that these measures are robust, and that systems of governance function with an eye toward promoting health, we must understand, and engage with, power.
In public health, we often allude to power, but we rarely address it explicitly—as something to cultivate for the purpose of improving health, or to mitigate when it is in a position to undermine well-being. Often, our discussions about power are motivated by its misuse. Power imbalances can define, and entrench, conditions of inequality and health gaps between groups. Yet power is not, in itself, inherently good or bad. It is a tool. It can be destructive, or it can be applied to the work of creating healthy populations. In considering power, many of us will likely think of recent examples we have seen of how power can be used destructively, to bully and harass within the context of interpersonal relationships. While I will today focus on how power operates at the population level, it is important to acknowledge the ongoing conversation about how power functions between individuals, as we work to create a culture where power is no longer used by one person to harm another.
What is power? The social theorist Steven Lukes has suggested that there are “three dimensions of power”—overt power, covert power, and the power to shape desires and beliefs. Overt power concerns the decisions made in public by leaders, often with a chosen course of action winning out over the preference of a less-empowered person or group. This power manifests most clearly, perhaps, in the actions of political figures, who are regularly on view performing identifiable acts of power, such as passing laws and issuing executive orders. Covert power is, by definition, less visible. It rests in the capacity to set an agenda, to choose which issues are and are not addressed within the complex systems where decisions are made. It can be at its most effective “behind closed doors,” used by those who structure meetings, chair committees, and oversee parliamentary procedure. The power to shape desires and beliefs is arguably subtler, and, potentially, more influential over the long-term, than other forms of power. It can—through persuasion, dialogue, or even propaganda—nudge the public consciousness towards thinking a certain way or adopting certain values. This is the power that I have often suggested we must harness in helping shape the public conversation. This power has the potential to move society in a positive direction, or make people want what is not necessarily in their best interest. Cigarette companies, for example, capitalized on this power to create demand for their products, pitching their wares as healthy and sophisticated, in order to root their profits in the fantasies and aspirations of consumers. It was a triumph of public health to change the conversation so as to make cigarettes less appealing, shifting the locus of power.
How does power shape the conditions of health? Power shapes these conditions in ways both positive and negative. The upshot of this influence depends on who wields power and what their intentions are, and on the occurrence of unforeseen contingencies. For example, the Affordable Care Act (ACA) represents an effort by the federal government to influence population health for the better through overt power. It has done so by expanding health coverage to millions of Americans, and by mitigating poverty through the reduction of healthcare costs for low-income populations. It also, in its early days, provoked a potent backlash, empowering an energetic opposition that led many states to decline Medicaid expansion under the ACA. This opposition, at the time lacking power at the national level, was able to successfully shape values and beliefs (Lukes’ third axis of power) to motivate widespread efforts to repeal the law. The ACA fight therefore exposed a fundamental liability of overt power—its potential to catalyze sometimes negative unintended consequences when other forms of power, particularly power to shape beliefs and conversations, can ultimately have more influence than the overt power that starts the ball rolling in the first place. It also illustrated how health systems evolve within a federal framework, as conflict and gridlock at the national level catalyzes action in the states, devolving power among the country’s constituent parts. Professor David Jones has written extensively on federalism in the context of the ACA fight, a story with much to teach other countries, such as Nepal, that are attempting to balance transformative health system change with the realities of power in a federal context.
The question then for us might be: How do individuals and groups build power to influence health? Using Lukes’ framework, the answer would appear to be by cultivating those who wield both covert and overt power, while also working to shape political and cultural values. Perhaps here we can learn from the National Rifle Association (NRA). The NRA has successfully blocked meaningful gun reform in the US for decades, even in the face of the majority of Americans who support gun control measures. It has accomplished this by cultivating power on all three of Lukes’ axes. It has built political influence through endorsements, campaign spending, and sophisticated organizing. It has wielded covert power by, as much as possible, keeping gun reform off the political agenda, and by successfully supporting efforts to defund CDC gun violence research. Finally, it has effectively framed its agenda as a question of values, promoting the belief that being an American means being able to access a gun anywhere, at any time. While the goals of the NRA may pose challenges to public health, there is much we can learn from how the organization has successfully built and used power to shape the conditions of health. We have also seen how the survivors of the Parkland shooting have begun to shift the balance of power in this debate, by engaging with lawmakers, organizing the public, and changing the public conversation. At SPH, we have worked to help facilitate this change. Many of our students, faculty, and staff participated in last week’s National School Walk Out; on March 24, members of our community, organized by our Activist Lab, will meet on the steps of the State House to participate in the March for Our Lives, as part of our ongoing efforts to create a country that is free of gun violence.
Given that the promotion of the health of populations depends on improving the social, economic, and cultural conditions that shape well-being, we have little choice but to grapple with how we can engage with the three dimensions of power, with special emphasis on influencing values to promote health. We have the power to place issues on the national and global agenda that were not there before, and to help people see familiar issues through a public health lens. The reach of this power has become clear in the wake of recent mass shootings, as leading voices in the media increasingly advocate a public health approach to solving our gun problem. Our pursuit of healthy populations also connects us with overt power. We work with lawmakers to craft legislation, assist with the implementation of public policy, influence decision-makers in a range of sectors, and assume leadership roles ourselves. Through all this, we aim to nudge values in a healthier direction, inspiring a greater awareness of the factors that shape health, and a deeper collective commitment to improving these conditions.
Finally, a note that our engagement with power includes our engagement with power imbalances. I have written before about how we must pursue economic justice to empower marginalized groups, in order to mitigate power/health gaps. That is no small task, but, it seems to me, a real priority if we are truly interested in creating a healthier world, for all.
I hope everyone has a terrific week. Until next week.
Warm regards,
Sandro
Sandro Galea, MD, DrPH
Dean and Professor, Boston University School of Public Health
Twitter: @sandrogalea
Acknowledgement: I am grateful to Eric DelGizzo for his contributions to this Dean’s Note.
Previous Dean’s Notes are archived at: https://www.bu.edu/sph/tag/deans-note/