Social Movements and the Creation of Conditions That Make People Healthy.
It seems like almost weekly now I am commenting on some atrocity that takes the lives of countless people, victims of violence and hate. The latest incident in Mali was brought home even more with the news that one of the victims was a graduate of a peer school of public health. The resonance of this brings the sadness closer. It also reminds us that nearly 2 million people annually die as a result of violence, that five times more are injured in violent incidents, and that there is a long trail of physical and mental health consequences of this violence. Violence is preventable, a challenge to the health of populations that should be in the remit of public health. As our hearts go out to the victims of violence in Bamako, Beirut, Mali, and countless less high-profile places daily, these events should indeed firm up our resolve to engage deeper in the work that aspires to create the cultural, economic, and structural conditions that minimize violence and mitigate its consequences.
Moving on to today’s topic. I have commented frequently in Dean’s Notes that one of the roles of a school of public health is the translation of knowledge to the end of improving the health of populations. We are moving to orient the School towards this vision, where translation stands alongside aspiration to generate knowledge and transmit that knowledge to our students. Our work on an activist public health agenda aims to be the effective arm of that vision, and we will soon roll out a suite of activities through the Activist Lab, run through our practice office and led by our public health practice dean, Harold Cox. As we engage with these questions, I have found myself wondering about how change actually does happen, particularly around social issues.
There is little question that thinking about this is germane to the cause of public health. This point is well made in the very good report about the “population health movement,” part of an Institute of Medicine Population Health Improvement Roundtable. Nancy Adler and colleagues point out that “some of the challenges to establishing population health derive from political and social concerns … [and] one of the hallmarks of the field is its attention to the social causes of disease and health.” This draws on the importance of social causes and roots of public health, and by extension social movements. Consonant with our vision for the school, the report argues that research and action must go hand in hand in order to facilitate change, and that new technological developments such as electronic medical records, or “big data” in the form of social media—core elements of translation that we have been discussing as a school community—have the potential to integrate economic or social information into both research and policy change.
There is a good academic literature on this issue to which I would refer the reader. Here I want to comment on a couple of compelling case studies that provide useful thoughts looking forward, and an inquiry into how this applies to two issues of tremendous contemporary salience.
Perhaps most iconic in public health is the movement to change tobacco consumption that began in the 1950s and continued for the next several decades. This provides useful insights into the phases of change through broad social movements. Professor Constance Nathanson, a former colleague, argued in 1999 that its relative success compared to many other movements had much to do with the persuasive use of information on health risks through grassroots mobilization for nonsmokers’ rights, as well as with the weakness in opposition. Constance A. Nathanson breaks down the movement into three main phases: the first phase, in which the health connection was made between tobacco and lung cancer, primary in the medical press and including the famous Doll and Hill reports and the 1964 Surgeon General’s Report on Smoking and Health; the second phase, the “struggle for regulation” in which Congress excluded tobacco from being regulated under several acts and loopholes were used to create milder warning labels; and the third phase, the “discovery of innocent victims,” in which the nonsmokers’ rights movement was born and the Surgeon General urged the addition of a bill of rights for the nonsmoker to include a ban on smoking in all public spaces in 1971. Nathanson argued that restaurant smoking bans may have been due to nonsmokers’ rights activism in conjunction with greater consumer sensitivity to health risks and media hyperbole. I particularly liked Nathanson’s distillation that “in a society increasingly skeptical of experts and expert knowledge, it is critically important to develop agile institutional mechanisms that link population health science and practice…. [because] research alone will not produce change.” I thought this statement was resonant and agitates for academic engagement in generating content that is broadly accessible and aims to inflect such institutional mechanisms to broader social ends. Of course, the work is not done even on smoking—arguably public health’s greatest achievement over the past century—and there are still many groups with high prevalence of smoking even today, but we have seen great strides over the past half-century, partially due to a social movement.
The story of change around motor vehicle safety, another great public health achievement of the past century, echoes what I have previously discussed: That what was previously acceptable became unacceptable, and that this was central to improving the health of the public. Health behavior change in populations around this issue was inseparable from denormalization of previously accepted behavior. In particular, this case study provides some perhaps generalizable lessons about the elements of social norm transformation that can be leveraged towards change. Lawrence Green and Andrea Gielen , in a book they co-edited, suggest that three key elements emerged to contribute to these changing norms around seat belt use. First, public health initiatives provoke less controversy when they involve children compared to when similar restraints are advocated for adults. To this point, child car seat use was one of the aspects of vehicle safety that was adopted the most seamlessly compared to others. Second, many sectors, including health, transportation, and law enforcement, came together with community advocates to support legislation and education on car seats in the late 1980s. Third, media and social marketing were paramount in promoting vehicle safety; the National Highway Traffic Safety Administration conducted large public education programs that helped to shape public opinion and gather support to policy change. One of the most successful campaigns that we all recognize is the “Click It or Ticket” slogan. In 1984, seat belt use was only about 15 percent in the United States; in 2007, it had increased to 82 percent, an extraordinary feat.
What are the implications of these observations for two topics of contemporary resonance, for the battles that population health must engage looking ahead towards creating the conditions that make people healthy?
The evidence around the health consequences around racism and the unconscionable and persistent health inequalities in this country is incontrovertible. The Black Lives Matter movement has helped bring to the forefront of public discussion, with the weight of moral urgency, race relations in the country, as instances of racism and injustice in the criminal justice system resound across the US. This movement builds on longstanding racial inequities and has been compared to the Civil Rights movement. Both movements arguably are predicated on the same core injustice, with the Civil Rights movement being catalyzed by voting rights and the current movement focusing on institutionalized racism and treatment of black individuals by the justice system. In an echo of the social change paradigm noted above, in August, a group of Black Lives Matter activists published a set of specific policy recommendations called Campaign Zero, which proposed policing changes and compared the presidential candidates’ positions on related issues with their potential outcomes. This approach aims to mobilize a diverse organizational constituency and bring about a convergence of political opportunities with target vulnerabilities. In a more up-to-date twist than previous movements, social media and technology have played a key role in this movement thus far, both mobilizing and spreading awareness and news of events. Emerging events, including some in our own School and University, have reflected and built upon the momentum around these issues towards changing the public conversation.
There is little doubt that moral urgency also rings true with climate change, at a time when few can deny the urgency of global warming. As the global temperature on the surface of the earth continues to grow, millions are expected to be pushed into poverty in the next 15 years, and extreme weather events will continue to take people’s lives. Eighty two percent of Americans now feel it is their “moral duty” to protect the environment for future generations. The climate change movement has especially gained momentum in the US in the past year, as President Obama rejected the Keystone XL pipeline, as did the United Nations in its 21st Conference of the Parties urged action on climate change. Many have argued that the climate change movement has finally convinced the public of global warming’s dangers, and that the next step is government action, with a plan being articulated at the UN conference. This would then conform to the three phases that Nathanson noted in her analysis of the anti-tobacco movement, moving from a health connection to a struggle for regulation. It would indeed be a pro-social move if success here does not need to wait the discovery of “innocent victims,” in Nathanson’s words, but rather achieves the needed changes in time to ward off adverse health consequences.
In sum, a brief look at two successful social movements—the anti-smoking and the car safety movements—provides some lessons that can have utility for future efforts to make conditions that are currently acceptable, unacceptable. Success in this regard around issues of climate change and racial inequities could serve to create a better, and indeed healthier, world.
I hope everyone has a good week. Until next week.
Sandro Galea, MD, DrPH
Dean and Professor, Boston University School of Public Health
Acknowledgement: I am grateful to Laura Sampson for her work on this Dean’s Note, and to Catherine Ettman and professors Yvette Cozier and Harold Cox for discussions that shaped my thinking on this issue.
Previous Dean’s Notes are archived at: https://www.bu.edu/sph/category/news/deans-notes/
I really like your topic and think it a necessary and critical concept for public health. I would however like to point out that on closer inspection the tobacco and motor vehicle efforts are unlike the kind of social movement that will be needed for social issues that affect vulnerable, marginalized groups for many reasons. There is a lot of literature on that as well.
Thank you for the note. I agree that different causes will require different levers to create social momentum, and that issues that affect vulnerable marginalized populations will require a particular set of circumstances. More on the broader issue of social movements, we are at a particularly interesting time around social movements around firearms, seeing the issue emerge from the ‘progressive activist side’ to the mainstream (as evidenced best by the NY T editorial this weekend). One hopes that this may be a turning point.