In the Journals

Special Issue: “Public Health Activism in changing times: relocating collective agency. Part 2”

This special issue of Critical Public Health is part two of a series on “Public Health Activism in changing times: relocating collective agency.” As editors Catherine Campbell and Flora Cornish describe in part one, the papers in this issue “challenge [a] ‘one size fits all’ template for activism” by calling for “greater recognition of how the redistribution of health-related power…may take more quiet, hidden, and slow forms than hitherto recognized.” Part one was previously highlighted by Emmanuelle Roth for Somatosphere, and can be found here. 

Environmental stewardship in austere times: nurturing sustainable socio-ecological relations

Megan Clinch

Like many communities, the people who live alongside the Calder River and its catchment in Yorkshire, UK, are having to face the health and other consequences of climate change, and catastrophic flooding is becoming a frequent event. Through the concept of planetary health, it is claimed the protection of natural and human systems could be achieved, in part, through the stewardship of common pool resources by the communities that know and depend on them. This paper explores, ethnographically, the challenges of enacting stewardship in the context of austerity. It shows how the socially reproductive capacity required for stewardship is limited in the context of austerity, which impinges the wellbeing and agency of stewards and the sustainability of their stewardship work. Building on theories of care, it is suggested that by aligning stewardship work with the ethical principles of permaculture – care for the earth, care for people, and fair share – forms of agency and action capable of addressing the many challenges wrought by austerity and climate change could be enabled.

LOLS@stigma: comedy as activism in the changing times of the HIV epidemic

Sanny Mulubale, Poul Rohleder & Corinne Squire

This paper examines how, in the midst of changing political times, some characteristics of HIV activism are changing, and suggests the relevance of these shifts for other fields of health activism. Despite the UK achieving UNAIDS’s ‘90–90-90ʹ testing and treatment goals, many in the UK lack up-to-date HIV knowledge and retain stigmatising attitudes, and some areas of testing failure remain. In response, people with HIV and HIV organisations are generating imaginative, collaborative projects that indicate effective contemporary forms of health activism may, as other critical health research suggests, be decentred, participatory, multimodal, affective, and implicit. The paper describes a 2016 HIV NGO-run comedy event directed at HIV awareness which was researched via qualitative pre- and post-measures, and two-month follow-up interviews. Findings pointed to strong effects of comedy, as enjoyment and ‘break’ in HIV thinking, feeling, and action; of a one-off event’s emotionality and particularity; and of performance in generating collectivity and HIV citizenship. The paper discusses the potential transferability of these findings to other health activisms, particularly around stigmatised conditions. It argues that such strategies of emotionality, multi-modality, and solidarity in a performance event can work as implicit activism for changing times, generating social change via a doubled politics of resistance and alterity.

Building collective control and improving health through a place-based community empowerment initiative: qualitative evidence from communities seeking agency over their built environment

Matt Egan, Katherine Abba, Amy Barnes, Michelle Collins, Vicki McGowan, Ruth Ponsford, Courtney Scott, Emma Halliday, Margaret Whitehead & Jennie Popay

Both environmental improvement and collective agency over local decisions are recognised strategies for promoting health and health equity. However, both strategies have been critiqued for their association with policies that emphasise local resources and decision-making while the state disinvests in social and environmental determinants of health. This paper explores the role of place-based community empowerment initiatives in building collective control and improving health. We examined the perspectives of participating communities using qualitative data from interviews and observational fieldwork embedded within an evaluation of a national community empowerment initiative: Big Local (funded by The National Lottery Community Fund and overseen by Local Trust). We selected five examples of community action to improve and maintain built environments. We found that while academics (including the authors) are interested in mechanisms to health impacts, participants focused on something more general: delivering benefits to their communities and maintaining services threatened by state disinvestment. Participants sometimes used ‘health’ as a pragmatic justification for action. We posit that systemic pathways to health impact are plausible even when communities themselves do not forefront health goals. For example, ‘quick wins’ and ‘quick losses’ resulting from early community action have potential to galvanise or undermine collective agency, and so affect communities’ capability to deliver future improvements to social and environmental determinants of health. However, structural limitations and unequal access to resources limit the potential of communities to make health-promoting change, as some participants acknowledged. Collective agency may improve socio-environmental determinants of health but systemic barriers to empowerment and equity persist.

When the personal is not political: experiences of collective agency amongst participants in the domestic violence response in London, UK

Catherine Campbell

How are changing times impacting on the possibility of collective agency by actors and agencies responding to domestic violence against women in London? The struggle against the domestic abuse of women was grounded in the 1970s women’s liberation movement under the rallying cry of ‘the personal is the political’. Over time, the domestic violence (DV) response has become professionalised and mainstreamed, located in public sector agencies and charities, with small feminist groups challenging gender inequalities in different settings. These combined efforts are having no impact on the incidence of DV, and recent years have seen dramatic cuts in DV services. A snowball sample of 25 professionals, policy makers and activists across the DV response engaged in semi-structured interviews exploring their work experiences, particularly experiences of ‘multi-sectoral collaboration’, the professional instantiation of collective agency. Thematic analysis depicted an exhausted and divided sector. Nearly all informants saw DV as rooted in gender inequalities, and viewed collaborative working as essential for tackling its interlocking individual and social drivers. However, contemporary feminism was seen as completely irrelevant to the daily realities of professionals’ work. The paper explores how the current economic, political and cultural contexts of interviewees’ work experiences were hostile to the practice of multi-sectoral collaboration. Such contexts actively militated against collaborator solidarity, the inclusion of survivor voices and a social change orientation – preconditions for effective collective agency in tackling such a complex and multi-level social problem.

‘Grenfell changes everything?’ Activism beyond hope and despair (open access)

Flora Cornish

The horror of the devastating Grenfell Tower fire, and the shock that ‘it could happen here’, in 21st century Britain, led politicians, professionals, and community workers to proclaim that ‘Grenfell changes everything’. Affected people, turned into activists by the disaster, committed to ensuring that such a disaster could never happen again, by demanding changes to regulations and policy. Whereas public health literature addressing activism focuses on strategies and conditions for ‘successful’ collective action, the experience of activism after Grenfell has been characterised by frustrating partial wins, inertia, delay, and setback. This paper seeks to theorise the activist condition of seeking change that is refused and to do so in a way that values the agency and care of (thwarted) activism. Inspired by Haraway’s ‘staying with the trouble’ and critical scholarship on hope, and drawing on three years of knowledge exchange and ethnographic engagement with the community response after Grenfell, I explore the trajectories of six activist change efforts: a fire safety campaign, engagements with a Public Inquiry, campaigns to preserve community assets, community gardening, silent walks, and provision of support to children at a community centre, each addressing social determinants of health and ‘staying with the trouble’ in different ways. I argue that setbacks do not invalidate a struggle or warrant despair, but that in insisting on caring for others’ lives, activism succeeds in instantiating a caring world. Beyond hope and despair is the staying power of communities who value human life and solidarity and keep fighting for them.

Anthropocentric framings of One Health: an analysis of international antimicrobial resistance policy documents (open access)

A. Kamenshchikova

One Health (OH) is an increasingly popular approach for addressing antimicrobial resistance (AMR) which is often presented as a shared health concern at the interface of human-animal-environment relations. OH is widely adopted as a framework for collaboration between organisations like the World Health Organisation and the World Organisation for Animal Health; furthermore it occupies a central position in international AMR policy documents. Scholars like Craddock and Hinchliffe have raised questions about whether a unified OH understanding of health allows us to comprehend the diversity of practices and knowledge involved in interdisciplinary and interorganisational collaborations. In this article, we aim to explore how the OH idea as a shared health concern is conceptualised in international responses to AMR. Therefore, we conducted a constructivist policy analysis of two types of international policy documents – 11 documents dedicated to AMR and a OH approach to it, and 12 documents with a focus on more general health issues that AMR regulations are built upon. The analysis of this policy arena makes clear that both sets of documents put human health at the centre, while the animal and environmental sectors are primarily framed as a risk for human health. Although human health is, more or less explicitly, considered to be the main problem, the animal and environmental health sectors are assigned responsibility for addressing this problem.

Nutrition policy-making in Fiji: working in and around neoliberalisation in the Global South

Tarryn Phillips, Amerita Ravuvu, Celia McMichael, Anne Marie Thow, Jennifer Browne, Gade Waqa, Jillian Tutuo & Deborah Gleeson

Many low- and middle-income countries experience a double burden of malnutrition and nutrition-related noncommunicable diseases (NCDs). Existing scholarship highlights adverse impacts of neoliberalism on nutrition, including the influence of laissez-faire economics on reshaping food systems and neoliberalism’s ideological emphasis on personal responsibility for healthy lifestyles. Yet how nutrition policy-makers in the Global South experience and respond to neoliberal pressures remains poorly understood. The aim of this paper is to examine how neoliberal logic is experienced, internalised and resisted by nutrition policy-makers in Fiji. Two Fijian policy analysis case studies were developed in which food marketing regulations were shelved or abandoned: restrictions on marketing of unhealthy foods to children; and restrictions on marketing of breastmilk substitutes. Eleven semi-structured interviews with nutrition policy-makers and stakeholders were conducted in Fiji that focused on these regulations. Data were analysed using Critical Discourse Analysis. Public health policy-makers experienced neoliberalisation as undermining the regulation of food marketing from two directions. From the top-down, politico-economic vested interests were perceived to obstruct effective policy interventions, and from the bottom-up, community decision-making was heavily price-driven and pro-consumer ‘choice’. Participants devised strategies to redress these influences, including rearticulating the NCD problem in economic terms in order to resonate in a neoliberal climate and to empower grassroots ownership of the issue. In the effort to implement nutrition policy, public health policy-makers worked within or around the neoliberal regime, rather than directly challenging it.

Personalized medicine and preventive health care: juxtaposing health policy and clinical practice

Iben Mundbjerg Gjødsbøl, Bo Gregers Winkel & Henning Bundgaard

Health care systems around the globe are currently orienting themselves towards ‘personalized medicine’, a medical care regime aimed at individualizing prevention, diagnosis, and treatment of disease through proliferating amounts and sources of data, including genetic information. In Denmark, national health policies on personalized medicine focus on harnessing the potentials of genomic science and technology to bring knowledge about patient-specific genetic variation into clinical application. A major hope is to improve public health and prevent common diseases by integrating genomic information in health care, yet to act preventively, a temporal path has to be established defining what kind of knowledge to create and to act upon, and when. This paper explores the temporal orderings of medical knowledge in two different areas: health policy and clinical practice. Examining policy papers on personalized medicine issued by Danish governmental and research institutions, and, comparing them with contemporary practices of using genetic information in preventive cardiac health care, we demonstrate that genetic knowledge-making is ordered around two different conceptual views of time: namely the sequential order and the speed with which such knowledge is produced. We argue that the visions of knowledge-making and early intervention through genomic science and technology as conveyed in policy papers on personalized medicine, challenge preexisting practices and understandings of what constitutes timely prevention and actionable knowledge within clinical care. We close the article discussing how prevention through genomics amplifies the significance of the clinical space for public health as a site for sense-making and translation of controversial genetic knowledge.

Representations of Māori in colonial health policy in Aotearoa from 2006-2016: a barrier to the pursuit of health equity

H.A. Came, S. Herbert & T. McCreanor

An integral part of colonisation is the suppression and marginalisation of indigenous knowledges. The indigenous health system within Aotearoa (New Zealand) was supplanted with a colonial infrastructure and praxis which has proven ineffective in addressing systemic health inequities created by the processes of colonisation. This novel study interrogates discursive representations of Māori (Indigenous peoples of Aotearoa) within colonial public health policy between 2006 and 2016. Colonial policy refers to generic or mainstream policy that are designed for ‘all’ New Zealanders. We utilised thematic analysis to examine 106 policies and, after excluding 13 ethnic specific policies, identified 68 policies containing no mention of Māori. The analysis highlights five themes relating to discursive representations of Māori. These were: i) silence about Māori health; ii) Māori as especially at risk; iii) Crown (lack of) responsiveness to te Tiriti o Waitangi obligations; iv) recognition of Māori philosophical approaches to service provision; and v) utilising mātauranga Māori (Māori knowledge). These findings suggest colonial policy presents a barrier to the pursuit of health equity and is poorly aligned to global Indigenous human rights declarations. Within the context of Aotearoa it echoes the sentiments of the key Waitangi Tribunal [WAI 2575] finding that health policy is contributing to health inequities and failing Māori. Health policy must be decolonised to better engage with human rights declarations and te Tiriti o Waitangi obligations in order to achieve health equity.

In the best interests of children? The paradox of intensive parenting and children’s health (open access)

Mara A. Yerkes, Marit Hopman, F. Marijn Stok & John De Wit

The family environment and parental guidance are generally considered to be key drivers of children’s health behaviours. Parents, mostly mothers, have become a focal point of policies aimed at preventing children’s health and well-being problems (e.g. childhood obesity). The underlying intensive parenting ideology places significant pressure on parents (notably mothers), requiring them to spend a great deal of time, energy and money on their children’s health and well-being. Yet, the relationship between intensive parenting and children’s health might be paradoxical. While a clear positive relationship exists between parental childrearing styles and children’s physical health, the limited evidence in relation to psychological health suggests intensive parenting may negatively affect children’s wellbeing. Using data from the UK Millennium Cohort Study (MCS) we provide key insights into the relationship between parenting styles and children’s physical and psychological well-being. We analytically distinguish three types of parenting styles (intensive parenting, neglectful parenting, and ‘intermediate’ parenting), and compare children’s self-reported health, well-being and self-esteem by parenting style. The findings show that parenting styles may differentially affect children’s physical and psychological health in nuanced ways. Public health and social policy implications of the role of parenting in children’s health and wellbeing are discussed. The conceptualisation of parenting styles and the relationship with children’s health, however, requires further exploration, which we discuss in the conclusion.

Commentary: Active-offer PrEP for HIV prevention: control, discipline, and public health nursing practice

Patrick O’Byrne, Lauren Orser, Marlene Haines & David Holmes

Whereas public health efforts to prevent HIV transmission used to focus exclusively on HIV diagnosis and reductions in the practices that transmit HIV, they now include the provision of HIV medication to HIV-negative persons before potential contacts when transmission could occur; this is known as pre-exposure prophylaxis (PrEP). To increase PrEP uptake, recent efforts have begun to include the provision of PrEP referrals by public health nurses as part of their mandated follow-up with patients diagnosed with sexually transmitted infections (STIs). This occurred due to research showing high rates of HIV seroconversion among those diagnosed with infectious syphilis and rectal bacterial STIs. In this way, public health practices have incorporated PrEP as part of standard STI follow-up. While this approach of offering PrEP to those at highest risk for HIV acquisition can be considered a public health success, we review it using the works of Foucault and Deleuze, ultimately arguing that what we call active-offer PrEP can also be seen as a combination of discipline and control; that is, as a mechanism of social regulation. As a final point, however, we caution against rejecting active-offer PrEP, arguing that while critique is necessary, ethical practices are as well, which includes providing much needed services, such as PrEP, to those affected by HIV. We assert that critique should not lead to inaction, but should be used to dismantle social inequities and misguided public health practices.

Commentary: We shouldn’t count chickens before they hatch: results-based financing and the challenges of cost-effectiveness analysis

Elisabeth Paul, Garrett W. Brown, Tim Ensor, Gorik Ooms, Remco van de Pas & Valéry Ridde

Results-based financing (RBF) is subject to fierce debate and the evidence-base on its cost effectiveness is scarce. To our knowledge, only one cost-effectiveness study of RBF in a lower-middle income country has been published in a peer reviewed journal. That study – in Zambia – concludes that RBF is cost-effective, which was then uncritically repeated in an editorial accompanying its release. Here we would like to warn against readily accepting the conclusion of the cost-effectiveness study of RBF in Zambia, because its conclusions are not straightforward and could be dangerously misleading, especially for those readers unfamiliar with health economics. After outlining the results from the Zambia’s RBF cost-effectiveness study, we point to important methodological issues related to cost-effectiveness analysis, showing how key assumptions produce particular results. We then reflect on how cost-effectiveness is different from efficiency and affordability – which is important, since cost-effectiveness studies often have considerable influence on national health financing strategies and policy priorities. Finally, we provide an alternative reading of the evidence on RBF in Zambia. Namely, when examined from an efficiency point of view, the study actually demonstrates that RBF is less efficient than the simpler alternative of providing more resources to health facilities, unconditioned on performance, which will be of most interest to a government with tight budget constraints. As a result, existing claims that RBF is cost-effective are overstated, requiring further and more nuanced examination with more adequate research methods.

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