Doctoral student of the Global Public Health Unit Sara Marsden writes about the People’s Health Movement (PHM) and a recent event exploring the right to health in Scotland
DEMANDING the right to health in Scotland. It sounds simple, but is it?
On 31 October 2015 in a church hall in Edinburgh we – a collection of activists, healthcare workers, academics, policy-makers, third sector workers and others – gathered to tackle this question head-on at a People’s Health Movement (PHM) event, guided by the chair of PHM Scotland, Dr Anuj Kapilashrami and other members of the Scottish PHM steering group.
Well, it’s as simple and as complex as Robin McAlpine, director of Common Weal, said finishing the event’s keynote speech on the politics of health: “All that matters is everything you do.”
We must stop designing the human environment for corporate profit and start designing it for human living. I think sooner or later most people with an interest in improving public health come to realise this.
We must stop designing the human environment for corporate profit and start designing it for human living. I think sooner or later most people with an interest in improving public health come to realise this, and flounder – where on earth do you start?
How can we, as public health activists/specialists, hope to restructure the way economics and society works? What even IS public health in that case? But we must try. We must claim this territory as ours, as much as any other ‘expert’ because, as the Alma Ata declaration recognised in 1978, health inequalities are not acceptable, morally, politically, socially or even economically. This is urgent.
And this, according to Dr Kapilashrami in the second talk of the day – ‘Building a progressive movement: Organising for health equity’ – is a key inspiration driving the People’s Health Movement, a global initiative launched in 2000 to revitalise the goal of Alma Ata: ‘Health for All’.
As she explained, progress since Alma Ata has been limited and inequalities in global health are rising – something different is required in response.
Health as a human right is at the heart of the PHM philosophy, but so too are a recognition of complex of social determinants of health, and the importance of processes of change. If society needs to change, then society needs to change itself. While government action is fundamental, social movements, equity and participation are key to positive enduring change.
In July 2012 the UK arm of the movement, at its first people’s health assembly, identified a need for local/regional grassroots-led approaches and expressed concern that policy-making in the UK was not adequately informed either by health inequalities or by peoples’ lived realities.
Led by Dr Kapilashrami, PHM Scotland began an extensive, highly participative process seeking to coalesce a movement around action to address these issues in the (devolved) Scottish context.
While government action is fundamental, social movements, equity and participation are key to positive enduring change.
Grown through this process, PHM Scotland’s members themselves are diverse, representing academics, community organisations and health networks, policy advocates, care workers and other individuals.
This movement is creating a collaborative space where common ground can be discovered, in particular between issue-focused campaigns and initiatives, of which there is considerable experience among the membership.
Besides this expanding network, a precious resource in itself, PHM Scotland has achieved a consensus around the broad principles and purpose of a Scottish People’s Health Manifesto. It is a work in progress and an impressive range of people and organisations have participated in its development in a variety of ways.
Over 30 third sector health organisations (health activists, environmentalists, carers, trade union health and safety representatives), 10 academic institutions, and many individuals were involved through online consultations, consultations with community initiatives, public meetings, drop-in story-telling sessions, focus groups with black and minority ethnic women, and more, as well as a larger gathering, 120 strong, at the 2014 Edinburgh people’s health assembly.
This process is ongoing and, as I rapidly came to understand, I had become part of it and was expected to contribute. In its current form, the Manifesto declares 20 key demands within 6 broad categories (see box).
The extent and depth of the collaborative process used to arrive at these gives them considerable credibility as a reflection of both community and ‘specialist’ views of what a right to health looks like.
But for political impact, a better sense of prioritisation amongst these 20 demands is needed, and our task was to address this. This came in two stages – first looking in detail at one of the broad categories in small groups to clarify demands and the specific proposals these would entail, and then voting for our top 10 demands across all the categories.
Although powers devolved to the Scottish Parliament do not give it a full set of policy levers, political representatives – from SNP, Scottish Labour, and Rise – all expressed a willingness to further engage with the manifesto.
In the first of the two stages I joined the discussions on reducing exposure to health risks. We touched on a wide range of issues though probably spent most time on the role of work on health and illness.
Our first suggestion was to incorporate strengthened workplace democracy into one of the demands from the democracy/accountability category (not sure that was part of the instructions!). Among other things, we suggested that the demand for an occupational health and safety agency be set in the context of a wider demand for a government commitment to healthy jobs and workplaces.
From the feedback from other groups, I was struck, and not a little saddened, that some of the groups identified the need in today’s Scotland to demand dignity at work, a ban on zero hour contracts, and a right to adequate food.
In one of the wealthiest nations in the world these rights should be a given. I’d assumed we would be aiming higher than this, but I suspect that in our austerity-blighted times, these are wise demands and suggest an unfinished agenda.
Encouraging, however, was the conviction that health can be improved and health inequalities reduced using a range of levers, many (probably most) of which are not recognised specifically as ‘health’.
For instance, a project was described from South Africa which worked with the poorest communities to identify jobs that those communities thought needed doing, and then paying (previously unemployed) people for doing that work.
This was seen as an example of what might be incorporated into a holistic approach to improving health. Positive ideas flowed from this event.
It will be a challenge, however, for both PHM and the politicians to find a way to reconcile diverse perspectives (lifestyle vs structural upstream drivers) and move beyond rhetoric.
The final panel session, chaired by PHM Scotland steering group members Sue Laughlin and Suzanne Fustukian, provided a chance to reflect on the specific political and institutional arrangements in Scotland that might matter.
Although powers devolved to the Scottish Parliament do not give it a full set of policy levers, the political representatives here – from SNP, Scottish Labour, and Rise – all expressed an interest and willingness to further engage with the manifesto, and there was optimism, too, that PHM could influence the Scottish human rights agenda.
It will be a challenge, however, for both PHM and the politicians to find a way to reconcile diverse perspectives (lifestyle vs structural upstream drivers) and move beyond rhetoric.
So my reflections on the event overall? Clearly at play throughout our debate were both ‘downstream’ concerns with improvements in access to good quality services, and more ‘upstream’ concerns with wider structural social, political and commercial determinants of health.
With my public health background, schooled in the importance of population level interventions, I had to work to accept the importance of the ‘downstream’ perspectives. While I might be tempted to argue that this is ‘just’ the symptom of invisible power structures working to shift blame and responsibility to individuals, in a very important sense, this simply isn’t relevant.
These are part of lived realities, and lived realities matter however unjust they might seem to me. An important corollary of this is that the People’s Health Movement’s agenda will always be a work in progress. With its success will come a change in lived realities, and therefore new insights, needs, ambitions and indeed new evidence and new directions.
And as someone who, before coming to academia, has moved between regulation, activism, policy evaluation and government policy-making, this event felt familiar: a collaborative approach to bringing different perspectives and expertise to knotty real-world problems.
Whether you’re a researcher, advocate, local activist, someone seeking improvements in health or simply are interested, I’d encourage you to be involved in this important, innovative and exciting movement.
But this process is much more of a challenge to received wisdom than it might at first appear. PHM Scotland is asking difficult questions, not only about what the government should do to safeguard a right to health for the people of Scotland, but also about the business of doing public health itself: what the role of advocacy and of academics is in policy-making, what information counts as evidence, whose evidence counts, how different types of evidence are balanced/combined/integrated into decision-making, and what the relationship between academic research, lived realities and policy-making is.
But while I’m left wondering again – but in a whole new way – ‘what even IS public health? – I’m also enthused that, whatever the answer to that question is, and it may well not matter, the People’s Health Movement Scotland is asking questions that do matter, and is seeking to ask them of the right people – all of us.
Whether you’re a researcher, advocate, local activist, someone seeking improvements in health or simply are interested, I’d encourage you to be involved in this important, innovative and exciting movement.
The blog originally appeared on the University of Edinburgh website.
Picture courtesy of GotCredit