George Isham of the Roundtable on Population Health Improvement introduced the day’s final session, which began with remarks from a two-member “reactor panel” charged with reflecting on how lessons from social movements can inform the field, including those who work to garner public support for, investment in, and policy directed at improving population health and health equity. Lessons learned include basic frameworks or elements of successful movements, ideas for next steps for the field, and potential solutions to address gaps and barriers.
Isham urged other roundtable members to ponder these questions as well, following the presentations by Jeff Levi and Sanne Magnan, members of the Roundtable on Population Health Improvement.1
Although he praised the inspiring insights and examples presented over the course of the day, Levi noted that some discussion on creating social movements struck him as rather abstract, particularly from his perspective as a participant in the AIDS and LGBT movements and as a staff member of the National Gay and Lesbian Task Force. If those movements had deliberately employed framing as an approach, he wondered, “would we have gotten things done better or faster?” The concept of framing is
1 The third scheduled panel member, Pattie Tucker, of the Roundtable on the Promotion of Health Equity and the Elimination of Health Disparities, was absent.
interesting, and theories of change are fascinating, “but the people who are usually in the middle of doing this work are not thinking that way. They’re out there doing what has to be done because of the urgency of now,” he observed. Thus, he urged the audience to focus on “what it’s going to take to get the work done for the people that we are so concerned about,” and, to that end, he offered several observations and suggestions for action.
Organizing is associated with social movements, such as ISAIAH’s efforts toward racial and economic justice, and also with political activism, as practiced by the Log Cabin Republicans, Levi said. The sort of movement that could help achieve the goal of improving the public’s health has to reside “outside the partisan arena,” he said. “There will be those who appropriate it for partisan purposes,” he acknowledged, but he argued that the movement itself “should be able to embrace everyone across the spectrum, if we find the right arguments, and if we find the right evidence.” Argüello questioned this point, asserting that fundamental change in the social determinants of health may require addressing inequities in ways “that have clear partisan implications.” Levi acknowledged that the quest for health equity may spark such debate, but he emphasized that broad, bipartisan support will be needed to achieve necessary change, which does not, he argued, have to involve the direct redistribution of income; for example, he noted, capitalist investments in community redevelopment have allowed people to make profits while improving communities. Levi urged openness to multiple approaches—policy and other—to help reach the desired outcomes.
Levi said that his recent experience at the New York State Population Health Conference led him to question the need to catalyze a population health movement, and he argued that it is already embodied in successful programs and thriving in many locations across the United States. “That work is already happening,” he said, and the audience, including roundtable members, could embrace, support, and connect to efforts already under way. “Too often our conversations are about despair, when there’s all this exciting work happening that we just need to shine a light on.”
The population health movement rightly challenges government policy, Levi said, but many public health professionals work for or are funded by the government and so they cannot lead the movement. Although the government will ideally support change that improves population health, such internally driven reform is necessarily limited. Outside resources, such as from private philanthropy, will be needed to push for more cutting-edge changes to be proven effective.
To the earlier question, “Do we need an enemy?” Levi responded, “I am not convinced about that at all,” and he referred to the decades-long interaction between the HIV community and the pharmaceutical industry,
which was by turns combative and collaborative. That sort of “constructive antagonism” got results, he said, and could serve as a model for the population health movement.
“Do we need a population health movement or do we need a health equity movement? I would argue we need the latter,” Levi said. “Population health is a means for achieving health equity. It is not an end in and of itself.” Moreover, he continued, a movement for health equity will be much easier to catalyze than one for population health, which still lacks a clear definition, even among public health professionals; meanwhile, messages about fairness and equity resonate with the public and fall into a “sweet spot” in the current political debate. He noted, for example, that President Obama had given a major speech on equity the previous day in which he had mentioned economics and social class as a factor in health outcomes. Levi concluded his remarks by suggesting next steps for the field such as illuminating work under way toward population health and health equity so that other groups and communities can learn from and replicate it; helping to build the evidence base for effective interventions and, more generally, to show the value of empowering communities; and comparing the frameworks for population health and health equity presented over the course of the workshop (e.g., by Larkin, Calonge, and Iton) as a source of research questions.
Magnan began her talk with a synopsis of a theory of leadership, known as “Theory U,” which she said resonated with much of what she had heard during the workshop. Discussed in books by Otto Scharmer,2 Theory U is “about leading as the future emerges,” she said, and it provides a model for addressing complex problems. The tendency is to move straight right to find the solution at the upper right top of the U. However, those who are beginning the process—the upper left of the U—are trying to clarify what they hope to accomplish, their goals and values, and what it would look like to have a movement that achieves population health in health equity, Magnan said. From here, according to the theory, they should find common purpose with collaborating organizations (“open heart”) and, on common ground at the bottom of the U, they can progress to new thinking and principles (“open mind”), which in turn will lead to new processes and structures (“open will”), and finally to solutions, at the right-hand top of the U.
Magnan then discussed several considerations, raised in the day’s presentations and discussions, that those seeking to contribute to a movement for health and health equity could address:
2 See http://www.ottoscharmer.com/publications/summaries.php (accessed June 13, 2014).
- Find ways to legitimize and energize the work of organizers and organizations already working toward population health and health equity, whether that is conducting research or simply lending a respected name to their efforts.
- Articulate goals and values and have a clear picture of what is being fought for (or against).
- Recognize and take advantage of health care costs and cost-ineffectiveness in the United States as an opportunity to explain to the public (e.g., through editorials) how these problems can be mitigated by addressing the social determinants of health, which contribute more to an individual’s health and well-being than health care; and the consequences of these problems for the nation’s economy and future (IOM, 2013; Pittman, 2010).
- Find more ways to serve as a connector between grassroots and “treetop” sectors of the movement.
- Find ways to challenge the powers and power structures that skew the health system toward the treatment of disease rather than toward the promotion of health.
- Consider how to educate movement leaders to use appropriate and effective language as a tool to mobilize participants and build broad support for health improvement and equity.
- Draw encouragement from Ganz’s reflections that social movements are inspired by a combination of pain and hope, find effective ways to send the message that there is healing to be done.
Magnan ended by saying that the day’s proceedings could inspire participants to continue to take up, in the words of Ganz, the “mantle of leadership,” to contribute to the “healing that needs to be done in our land” to achieve population health and health equity.
Individual workshop participants, including members of the two roundtables, responded thoughtfully to the three questions posed to the reactor panel. Their remarks are summarized below, by question.
How Do the Day’s Proceedings Change What We Do?
Several participants recognized not only that successful social movements “bubble up” from the grassroots, but that such activity is already occurring and has been occurring for some time. With that understanding as a foundation, several participants identified possible ways that the
organizations such as those represented on the roundtables might become effective participants in a movement already under way.
Argüello suggested that it would be helpful to examine and publicize the evidence base on the social determinants of health and health inequity.
Several individual participants noted that there is a need to bring together experts who can assess the evidence base for existing and potential interventions to then convey the information obtained from such analysis. More specifically Phyllis Meadows of The Kresge Foundation and Melissa Simon of Northwestern University suggested that grassroots practitioners be included in gatherings such as the IOM workshops, and that proceedings be made available to other grassroots groups.
Terri Wright of the American Public Health Association suggested that such efforts be directed by asking movement leaders what kinds of information and evidence they most need. José Montero, president of the Association of State and Territorial Health Officials and director of the New Hampshire Division of Public Health Services, also emphasized the importance of showcasing the evidence on the relationship between income and health. Christine Bachrach suggested that new research models for population health improvement be explored. Cathy Baase underscored the importance of acting with urgency to communicate a vision of a movement for health and health equity to the public and to policy makers.
Other suggestions included
- Taking advantage of public interest in the ACA as an opportunity to raise awareness of the social determinants of health as something missing from the ACA (Argüello).
- Highlighting the interdependence of population health improvement and health equity, as pointed out by Levi and also by Judith Monroe of the CDC. Wright observed that such an alignment needs to emphasize the contribution of population health to general equity, as embodied in the “wheel of promise” developed by the Mission Economic Development Association (described in Chapter 5).
- Laying the groundwork for an IOM consensus study on proposing and testing interventions to address social determinants of health (Calonge).
Elements of a Movement for Population Health and Health Equity
Mary Lou Goeke, executive director of United Way of Santa Cruz County, provided the following comprehensive response to this question:
The movement would be a success if in every local community in America young people, neighbors, civic organizations, faith communities would be gathered together, engaged with each other, setting their goals, their priorities, their strategies with all the other sectors who want to live in healthy communities. They would have skilled professional paid community organizers in strong, stable, backbone organizations that will last. They would use evidence-based practices, grounded in solid research; they would have good success measures; and, they would celebrate publicly their successes and critically analyze their failures. They would be linked to good, strong state and national organizations to magnify their policy work at all levels.
Several participants commented on the importance of narrative to any social movement—narrative that must be sustained to keep a movement viable, noted Antonia Villarruel of the University of Michigan. Monroe emphasized the importance of including youth and senior citizens when mobilizing grassroots support for a movement.
Noting the importance of leadership at all levels in a social movement, Octavio Martinez of the University of Texas at Austin, recommended training community leaders in the skills necessary for shaping policy on issues of concern to them. Montero took up the issue of “constructive antagonism” from his perspective as a member of government. Rather than occurring between the same parties, such conflicts engage different groups at different times, he said, so it is probably unproductive to define an “enemy” for this movement. Moreover, he observed, “regardless of where we sit, we are still members of our community, users of health services, and have families who are in the same position.”
Filling Existing Gaps and Overcoming Barriers
Several individual participants, including David Kindig and Winston Wong, described different areas for future study and discussion, including studying the use of technology and the media—especially social media—to mobilize support for a movement to advance population health and health equity; the use of metrics to illuminate the many facets of health inequity; the development of a deeper understanding of the spectrum of values with regard to health, so as to be able to communicate concepts such as the social determinants and health equity to the public; and the exploration of the potential usefulness of big data in characterizing population health, identifying problems to be addressed, and measuring the impact of interventions. Wong, who discussed the potential of health data, also cautioned about the dangers of privatizing big data and thus favoring profit making over supporting population health and health equity.
After offering some observations that indicated population health and health equity are so closely connected that they may be seen as virtually indistinguishable, Mildred Thompson listed several key concepts and ideas she had gathered from the day’s presentations:
- Democratic self-governance. The work being discussed represents an assertion of democracy, she said, because health is a human right.
- Who is organizing matters. “We’ve got to make sure we’re a part of helping those who are organizing the work,” she advised.
- The importance of access to technology. Although Occupy Wall Street did not succeed as a movement, that effort demonstrated the power of technology in the form of social media to galvanize interest in and support for a movement and its cause. “We could have broader reach and have much more engagement if we were able to figure out these new technologies and make them work for us,” she observed.
- The power of narrative. Thompson noted that a 2008 public television documentary series on health inequality, Unnatural Causes, reached a broad audience and continues to be used along with supporting materials to educate various audiences. She recommended such approaches that require something more active or engaging than simply viewing.
Thompson said that arming a community with information and data can be powerful. To make her case, she described how, as a member of a public health department, she advised and supported a community group in its successful effort to stop a local factory from polluting the air. “We armed them with the data and the resources they needed to make something happen,” she recalled. “That’s a simplistic idea of a small movement, but it shows how it makes a big difference.”
Thompson suggested that roundtable members reach out to new partners with common interests in public health, such as the Federal Reserve Bank. They and other “unlikely partners” could increase both the breadth and depth of a social movement for health equity, she said. Achieving health equity is long-term work, requiring sustained dialogue, she concluded. “This isn’t going to be the only time for it to be discussed,” she said. “There’s going to be layers that we still have to reveal, and I’ll look forward to sharing in that unveiling with everybody else here.”
Kindig echoed the sense of humility expressed by other participants with regard to their role in a movement for improved population health and health equity. However, he also recalled Ganz’s observation that
medical and public health professionals possess a moral authority that can be brought to bear to further this cause. Kindig reminded the audience of the state of the U.S. health care system relative to those of peer countries, and he argued that substantial, sustained changes in resource flows, particularly in the direction of the social determinants of health, are needed—whether these changes result from strategies such as reducing Medicare waste or from some yet unknown solution. Dismantling and reversing current policies of “disinvestment” in public health will be a huge challenge, he acknowledged. “I don’t know if we’re up to it,” he said, “but that’s what we’re about if we’re serious about our goal.”