social movements | Health as if Everybody Counted (second edition)

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.

Ten years ago, the World Health Organization’s Commission on Social Determinants of Health released its final report. The authors, led by Sir Michael Marmot, began by stating that the ‘unequal distribution of health-damaging experiences is not in any sense a ‘natural’ phenomenon but is the result of a toxic combination of poor social policies and programmes, unfair economic arrangements, and bad politics’. The unsparing critique proceeded from there. In a generally laudatory review, The Economist wondered whether the Commission was ‘baying at the moon’ when it attacked such ‘global imbalances’.

However, the financial crisis that was spreading across the world even as the report was released made it clear that the Commission’s analysis was spot-on. Against that background Margaret Chan, then Director General of WHO, warned the United Nations General Assembly in October, 2008 that ‘[t]he policies governing the international systems that link us all so closely together …. need to be put to the true test. What impact do they have on poverty, misery, and ill health – in other words, the progress of a civilized world? Do they contribute to greater fairness in the distribution of benefits? Or are they leaving this world more and more out of balance, especially in matters of health?’ As was often the case, Dr. Chan was far ahead of the organisation she led – and as we know, in the decade of counterproductive austerity that followed, her advice was seldom heeded.

Ten years on, where are we? In an article I have just published in Critical Public Health (if you don’t have access through your institution please e-mail me), I argue that – as in many other areas of global health policy and politics – the glass can be considered either half empty or half full. Is the fate of the Commission’s report the tale of a sinking stone …

… or of promise yet unrealised?

On the one hand, the international community has now signed on to at least the rhetoric of the Sustainable Development Goals – a legacy of the World Commission on Environment and Development, which reported not ten years ago, but 31. On the other hand, on most measures and in most contexts economic inequality is rising, and an expanding body of social science research suggests that the reductions in inequality that occurred in the twentieth century, in the context of two world wars that required mass mobilisation and a devastating depression, are an anomaly that is unlikely to be repeated.

As I point out in the article, references to ‘social determinants of health’ in the scientific literature are increasing in number. A PubMed search turned up 75 references in 2008, rising steadily to 1042 in 2017. Research ventures like the LIFEPATH consortium are expanding the already substantial evidence base for acting on social determinants of health. Whether the strength of that evidence matters is ultimately a political issue; getting health equity and the corollary need for redistributive economic and social policies onto mainstream political agendas remains a formidable challenge, but perhaps not an insurmountable one.

The article was finalised before the remarkable primary victory of Democrat Ayanna Pressley in Massachusetts’ 7^th District. Here’s what she had to say about health equity in her ‘equity agenda’ (MBTA is the Massachusetts Bay Transport Authority):

‘Today, when you board the MBTA’s number 1 bus in Cambridge, it’s less than three miles to Dudley Station in Roxbury, but by the time you’ve made the 30-minute trip, the median household income in the neighborhoods around you have dropped by nearly $50,000 a year.^[2]/^[3] As the bus rolls through Back Bay, the average person around you might expect to live until he or she is 92 years old, but when it arrives in Roxbury, the average life expectancy has fallen by as much as 30 years.^[4] …. These types of disparities exist across the 7^th District, and they are not naturally occurring; they are the legacy of decades of policies that have hardened systemic racism, increased income inequality, and advantaged the affluent’.

If the ‘social movement, based on evidence’ that Sir Michael and colleagues envisioned after the Commission’s report is to take shape – it hasn’t, yet – this is the kind of language we need to hear, from political actors and public health professionals alike.