Building a Social Justice Narrative for Public Health

Public health is the place where science, policy, politics, and activism converge. Each public health issue is a snapshot where we can see the unfolding of the collective processes that define who we are, what we believe, and what we value as a society. For many of us this is exactly what makes public health so engaging, so urgent, and so deeply compelling. As public health professionals we work every day to change the world: not just to wish it was different but to dedicate our lives and our work to make it different, to make it better for all. It is useful to keep in mind Margaret Mead’s observation, “Never doubt that a small group of committed citizens can change the world: indeed, it’s the only thing that ever has.” Though we are idealists, we are also pragmatists. We want to change the world, but we also need to make a difference now. We are confronted with the task of balancing this urgency for meaningful change that can be realized in the short term without losing sight of the longer term need for deep structural change. This is a significant personal and collective strategic challenge. Recently I heard someone say, “If you are working on an idea that you can get done in your lifetime, then you’re not thinking big enough.” Aspiration is a powerful force that drives us. It is a combination of a big idea, a big heart, and a dogged determination to succeed. Obviously, we may have organizations to run, jobs to do, daily tasks to accomplish. But deep down we all have a desire to make a difference that is greater than what any of us can accomplish alone.

If we want different outcomes we will need to ask different questions. When confronted with the wide range of public health problems that challenge our profession our initial response is what can I do, what can my group do, or what can my organization do? This is an automatic and natural response, but it is limiting both in terms of vision and productiveness. The first question we ought to ask is, “What would it take to create the change we need to solve this problem.” Once we take that step back and consider the comprehensive systems aspect of the problem then we can raise the question, “What is my role and the role of my group or organization in contributing to the solution.” Changing the question will change the discussion, and changing the discussion will change the starting point and provide new opportunities for engagement and innovative approaches.

There are three concepts that have guided my career over the past 45+ years. The first is that the primary determinants of the public’s health are social—the level of health inequality is related to the level of social inequality in the larger society. Rudolf Virchow, the father of cellular pathology and one of the founders of social medicine said, “All disease has two causes, one pathological and the other political.” We simply do not have the luxury of ignoring the political, or thinking the scientific will overcome it. We now know that every disease has a biological cause and a social cause and we have come to understand that the social causes may be paramount. Two important aspects of this are that health differences are not just properties of poverty—a rich–poor dichotomy. Rather there is a social gradient and at every level of the gradient those who are higher up have better health outcomes than those who are lower down. This is true even for those at the highest end (Marmot, 2017). In addition, we know that racism, not race, contributes a significant independent effect to these social economic differences (Williams, Lawrence, & Davis, 2019). And we know that racism is deeply embedded in the history and culture of our society (Coates, 2017).

The second concept is that the guiding ethic animating public health policy and program must be social justice because poor collective health is a product of social inequality. To be a more healthy society we must be a more just society; there is no shortcut. Simply put, it is about the collective decisions that we make as a society (reflected in our public policies) that, inadvertently or not, distribute benefits and burdens, risks and opportunities in ways that tend to favor the already advantaged and add to the disadvantage of those less well-off. Sir Michael Marmot, the visionary physician and epidemiologist who helped establish the evidence base for the relationship of social inequality to health inequality argues, “Social Injustice is killing people on a grand scale. A toxic combination of poor social policies, unfair economic arrangements, and bad politics is responsible for most of the inequities we see in the world today, within and between countries” (Marmot, Allen, Bell, & Goldblatt, 2012, p. 181). And the recent report by the World Health Organization’s Commission on the Global Social Determinants of Health (World Health Organization, 2008) begins by stating, “Social justice is a matter of life and death.” We need to introduce to every public policy debate, whether explicitly about health or not, the question, “Will this proposed policy potentially increase or decrease the level of inequality and inequity in our society?”

The third concept is that public health problems are primarily problems of populations, not just individuals. These problems are properties of social, economic, and political systems—not just personal, individual, behavioral factors. Of course, individuals share responsibility for their own health, but we have a social responsibility to create the conditions in which people can be healthy. This requires a focus on public policy that can remedy the conditions that give rise to and sustain inequality that produces unjust and preventable health disparities.

One of the great challenges we face as public health researchers, educators, practitioners, and advocates is to integrate these concepts that are at the core of our profession into a concise and compelling narrative that can convey the urgency of our mission. Sociologist C. Wright Mills (1959) explained, “It is the task of the social scientist—as of any liberal educator—continually to translate personal troubles into public issues, and public issues into the terms of their human meaning . . .” (p. 31). However, in a society where dominant narratives tend to elevate triumphant individuals who rise up to beat the odds, highlighting social barriers and structural inequality is often seen as excusing the shortcomings of individuals. The “odds metaphor” serves to place fault on individuals who just don’t work hard enough rather than focus on structural barriers that reinforce disadvantage. Public health is not a profession that serves as a cheerleader to encourage people to work harder to beat the odds; it is a profession that works to develop public policies that can change the odds so more people can succeed.

Developing a narrative about a systems view of the world tends to run counter to the strong individualism that marks American society. Bellah, Madsen, Sullivan, Swidler, and Tipton (1996) observed in their seminal book, Habits of the Heart, that America has two languages. The first language is that of rugged individualism rooted in self-determination, personal responsibility, self-discipline, and open markets where all are free to pursue their own self-interest. The second language, also deeply established in the culture but less frequently and forcefully articulated, is that of community. This language of community is rooted in values of interconnectedness, mutuality, shared responsibility for the collective good, and a kind of social solidarity. The language of community may be the second language of American society, but it is the first language of public health. And herein lie both our strength and our problem. Our strength is our commitment to community and social justice values, but our weakness is not communicating these values well in an individualistic, market-dominated society. It is this language of community, and the values it represents, that must be the core of the narrative animating a more just and healthier society. Toward this end, an understanding of framing is critical.

In his book Gravity’s Rainbow, Thomas Pynchon (1973) explains, “If they can get you asking the wrong questions, they don’t have to worry about answers” (p. 255). A question is a framing device that can limit or expand possibilities and levels of analysis. For example, being concerned with health we might ask the question, “What can people do to live to be 100?” This leads to a discussion of personal habits and behaviors that narrowly focuses subsequent discussion and potential approaches. If we ask the question, “What does a community look like where most of the people live to be 100?” the discussion is freer to move in a much more comprehensive direction. The latter question expands discussion to systems and structures that underlie health such as social and economic factors and related policy alternatives, while the former question narrowly focuses discussion on personal behavior.

Public health has struggled with the empirically established notion that simple dissemination of knowledge is not education, and that even excellent health education is necessary but not sufficient for significant change in the well-being of the population. Much public health communication in the past has been based on the idea that if we could just get the right message to the right person in the right format at the right time then this knowledge would create necessary change. We know, however, that it isn’t about a clever message or a slogan about health habits. Our challenge is to tap into underlying values that can help us grasp the underlying social causes of the problems we face and more fully understand the range of policies to remedy these causes. Significant change requires us to shift from just understanding problems as personal, individual, or behavioral to responding to problems as linked to social, economic, and political structures. Charlotte Ryan (1991) explains, “Every frame defines the issue, explains who is responsible, and suggests potential solutions. All this is conveyed by images, stereotypes, and anecdotes” (p. 59). Frames serve as powerful cues that instantaneously enable people to grasp the meaning of an issue based on their own life experience and values. Most of the decisions we make about the issues that matter most to us, whether personal or political, are made not through careful review and consideration but though “thinking fast” (Kahneman, 2011)—the instantaneous reaction to cues.

The “cueing values” that underlie a progressive view of public health are reflected in the work of Dan Beauchamp (most notably, 1976) who argued that the guiding ethic of public health is social justice. However, dominant American societal values are more rooted in a classical notion of market justice. In short, societal problems, including those of the public’s health, are thought to be best left to be sorted out in the market place rather than through government intervention that can disrupt natural and competitive processes. If everyone just made the right personal health decisions—don’t smoke, good nutrition, daily exercise, don’t use drugs, and so on, then this would add up to a healthy society. Government intervention in a system marked by market fundamentalism, as has famously been said, can be seen as part of the problem rather than part of the solution. In a market system people pursue their own interests unfettered by intrusive government regulation. Rugged individualism characterized by determination, self-discipline, and personal responsibility is rewarded. Economic and social benefits are based solely on individual efforts, and there is an implicit limited obligation placed on people to contribute to the collective good (e.g., through taxes). Behavior is seen as voluntary and moral in nature; thus, rewards for good behavior and accountability for poor behavior are essential. When people are “let off the hook” for poor health behavior, for example, they will simply continue to behave in a way that increases their disadvantage. Thus, government intervention, even though well intentioned, should be as limited as possible because it runs the risk of making people dependent on the service rather than independent through their own efforts.

A public health perspective characterized by social justice argues that public health problems are primarily socially generated. Thus, the solutions to such problems are best understood as a collective responsibility shared across the various levels of society. Problems are not seen as exceptional due to individual failures to adapt or work hard enough but are understood as the predictable outcomes of a system and its policies that favor or disadvantage some groups over others. Contrary to the market justice orientation, social justice emphasizes a strong obligation to the collective good with basic benefits such as living wage jobs, affordable housing, access to education, quality health care, and equal opportunity assured. Furthermore, it is understood that government intervention is necessary to remedy unequal starting positions and provide protections to those disadvantaged by the system through discrimination or other barriers to access.

The debate about social justice versus market justice is a centuries-long argument about how to best balance the role of the state versus the role of the individual. In the United States the pull toward individualism, what some refer to as victim blaming (W. Ryan, 1976), is very strong, almost like a gravitational force—it is our first reactive explanation. However, great advances in public health have come from increasing the regulatory power of the state to support the comprehensive mission of public health to “create the conditions in which people can be healthy” (Institute of Medicine, 1988, p. 1). The public health narrative we seek to create must advance social justice values by understanding the struggle of the individual or group in the context of historical and contemporary policies that continue to contribute to inequities (Wallack & Thornburg, 2016).

As we move toward a public health narrative that can incorporate the complexity of societal explanations but still be rooted in pragmatic applications we must keep several things in mind. First, we need to think and talk about social and public health policy that is rooted in progressive public health values and has a sense of moral urgency. Second, our values require the significant involvement of those most affected by the problems and large-scale community mobilization around potential solutions. Third, we need to increase our ability to communicate, at a deeper level than we currently do, constructing a compelling narrative about community that highlights the social justice values on which our profession stands. When we can do this, ours will be a society that better understands the meaning of public health and responds more appropriately to its challenges. We will then be collectively more effective in better translating our values into caring, and more effective, public policy (Wallack & Lawrence, 2005). This will not be easy but it will be necessary.

As the Vietnamese monk Thich Nhat Hanh tells us,

The problem is whether we are determined to go in the direction of compassion or not . . . . If I lose my direction I have to look for the north star and I will go to the north. That does not mean I expect to arrive at the North Star. I just want to go in that direction.

Our progress depends on