I am re-reading, not for the first time, some of the work of legal scholar Catharine MacKinnon.  (I used to refer to her as a feminist legal scholar; I don’t do this any more, since the adjective can be read as a qualifier, or a denigration.  Scholarship is scholarship, full stop.)  Her work has been an inspiration to me for a long time, since she combines impeccable, meticulously documented philosophical argumentation and legal reasoning with incandescent critique of injustice, gender inequality and misogyny.   

But MacKinnon is much more than a hyper-accomplished academic.  Among a host of other achievements, she was co-counsel in the first US Supreme Court case that recognised workplace sexual harassment as a form of discrimination; contributed to the development of Canadian equality law under the country’s Charter of Rights and Freedoms; was co-counsel in the suit that won a landmark US damage award against Serbian warlord Radovan Karadzic, establishing rape as an act of genocide in the context of ‘ethnic cleansing’; and subsequently served as the first gender adviser to the International Criminal Court.  MacKinnon’s advocacy played an important role in generating what is now widespread recognition of rape as a weapon and crime of war.  She has written extensively about these experiences, and much else, in a style I think of as evidence-informed polemic. [1]

The literature on health inequity includes at least a few examples of this style.  For example, in 2013 David Stuckler and Sanjay Basu argued (in The Body Economic) that: ‘The price of austerity is calculated in human lives.  And these lost lives won’t return when the stock market bounces back’.  Immodestly, in 2015 Clare Bambra and I put forward (in How Politics Makes Us Sick) the idea of neoliberal epidemics, specifying neoliberalism as a fundamental cause of health inequalities.  And in 2017, Lancet editor Richard Horton memorably described austerity as ‘a political choice that deepens the already open and bloody wounds of the poor and precarious’.   Outside the academic bubble of citation counts, these interventions (we) have had approximately zero impact in the real world. This post is an effort to start a conversation about how to change that.

One obvious observation is that MacKinnon’s impact results from a combination of advocacy and creative litigation using existing bodies of statute and doctrine.  One of the researchers interviewed by Katherine Smith characterised health inequalities as ‘the most fundamental abuse of human rights in the developed world. [I]f you imagine locking up a substantial proportion of your population for the last five or ten years of their life without any justification at all, well actually this is worse than that, it’s like executing them arbitrarily’.  Stated thus, the point seems obvious, but it’s hard to see avenues for turning it into a basis for litigation.  Maybe concerned academics have simply not connected with the right litigators, but issues of causation might present formidable barriers to success, given courts’ (and many epidemiologists’) tendency to set standards of proof that are often inappropriately high. 

At least in the UK, the deliberate corruption of universities by organising priorities and career paths around generating research income means fewer and fewer academics – mainly those near the end of their working lives, without dependents or with independent wealth – can engage in evidence-informed polemic rather than forelock-tugging before funders without fear of reprisal.  Professionals working in public health in government are likely to be even more limited in their ability to speak out, however sophisticated their private understandings of the origins and politics of health inequality (and in many cases, again in the UK at least, these are very sophisticated indeed).  The tendency of too many health promoters to acquiesce in the popular conception of poor health as somehow the fault of the individual affected does not help. 

Perhaps the most important issue is suggested by Sir Michael Marmot’s call, after the release of the 2008 WHO Commission report, for ‘a social movement, based on evidence, to reduce inequalities in health’.  That movement has yet to materialise.  Writing about 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’.  Crucially, many coalitions that formed to fight sexual harassment connected women who were not otherwise similarly situated in socioeconomic terms.   Another, much more recent manifestation of such a coalition is the powerful anti-violence performance ‘A rapist in your path’, which originated in last autumn’s Chilean protests against inequality and has now gone viral in much of the world.  

Here’s the rub.  As I wrote a decade ago in the Canadian context, effective social movements need not only evidence and coalitions, but also rage, hopelessness, desperation, hope, shared passion, shared vulnerabilities, or some combination of these.  That’s where their energy comes from.  If one adopts a suitably precautionary standard of proof, as suggested by the human rights frame, there is no shortage of evidence – certainly not of the damage done by the past decade’s systematic upward redistribution of resources and opportunity.  What possible coalitions could move the health equity agenda forward, and how can the necessary emotional energy be mobilised?  Let the conversation begin.

[1] A selection of MacKinnon’s earlier work appears in Feminism, Unmodified (1988); somewhat later work in Are Women Human? (2007); and her landmark explication of feminism as political theory in Toward a Feminist Theory of the State (1991).  A very recent open access introduction to her perspective is available here.