Thursday, 30 March 2017

Reflections on 'Health promotion discourse' and 'mainstream discourse'

Classified as: reflections, theory and evidence, discourse

Yet are not all modern societies hierarchical? Undoubtedly so, but good evidence suggests that the social gradient can vary in steepness, and its impact on health can be ameliorated, at least in part.
(Martin Tobias 'Social rank: a risk factor whose time has come?' Lancet 25 March 2017 pp1172-1174)
In this article, Tobias refers to evidence showing that social rank (in the study he cites this is an occupational ranking classified as professional, intermediate and unskilled) has an impact on health similar to, or greater than, many of the more commonly discussed 'lifestyle factors'. In addition there is a link between "social rank' and lifestyle factors with low social rank increasing the likelihood of risky lifestyles.

Tobias goes on to say: 
Moreover, upstream interventions (eg, earned income tax credits, universal early childhood education) are likely to be pro-equity, whereas more downstream interventions (eg, smoking cessation assistance, dietary advice) typically favour the privileged (who generally find it easier to access material and social support for behaviour change). 

He present a list of "evidence based strategies", which includes "strengthen local communities" as well as improved regulation, tax and transfer, invest in early life, and many others.

The article is open access and can be seen here 

While I support many of the measures Tobias recommends, what I wish to discuss today is the assumption in the first statement quoted that hierarchy is normal, at least in "modern societies" and that what we in public health should be doing is trying to ameliorate it.

This relates to the question of discourse, and what I am calling the 'health promotion discourse' and the 'mainstream discourse' in this study. My analysis in the first stage of this study suggested that there was a shared 'health promotion discourse' amongst research participants, but that at the same time this discourse existed in the context of an assumed 'mainstream discourse'. Some of the key assumptions or values of the health promotion discourse was that it focused on local communities, it aspired to be inclusive, saw people as having a shared responsibility to care for each other, and supported measures to ensure that disadvantaged or marginalised people had a voice and were included. These values were asserted in opposition to an imagined mainstream discourse that accepted hierarchy and inequality as normal, that saw people as entitled to individual ownership of wealth, and that was top down or centrist in its governance approach.

What was not clear in the research, and is still not clear, is how those operating in the health promotion discourse understood equity. They questioned hierarchy and notions of individual entitlement to wealth, resources and unequal power, but it was not clear whether they wanted a society in which everyone was equal and power and resources were shared on that basis, or whether, like Tobias above, they accepted that hierarchy and inequality were normal features of 'modern societies' and that their aspiration should be to ameliorate this rather than fundamentally change it. In fact this is one of the big questions my thesis will pose.

In the reflective stage of the research, one of the ISEPICH community members contacted me after the workshop to question the way I was presenting these discourses. An excerpt from the participant's comments is below:

"I, like you, think there is a world of difference between two discourses that you have identified in the work you have shown us (that of community development, collectivism etc and the world of the individualist/competitive spirit). They seem like 2 parallel universes. I don't see that they are necessarily in total opposition to each other and i wonder, if in the end your PhD work will be able to contribute any practical effect in both these universes,  if it constructs them in opposition to each other. The PhD needs to include some work on how people in these 2 universes might talk to each other. Indeed, i wonder how it would help in the development of your thesis if you perhaps attempted to enter into dialogue yourself with one or more people from a very different point of view (from the IPA?). What might you learn for your thesis from them?"

In practical terms I responded that I wasn't able to do direct research with organisations like the IPA within the constraints of this thesis, though I certainly read their published material as part of my background research. However the participant's broader suggestion that I was constructing these discourses as being "in opposition to each other" is what I want to discuss here. I think it suggests a kind of equality, two-sides-to every-question type approach.

At one level I can see this - if you think about the discourses very broadly as discourses of cooperation and competition. then you can see them as trends that exist within humans and that need to be reconciled. However this isn't the main point for this study. What I am talking about here are orthodox and heterodox disourses (or mainstream and alternative, hegomonic and subaltern, etc discourses).  In Bourdieu's* terms, the orthodox discourse strives to make itself the 'doxa', that which is taken-for-granted, or 'the universe of the undiscussed'. This is what appears to have happened - many health promoters or public health figures, like Tobias, recognise that inequality and hierarchy causes problems for health and wellbeing, but seem to assume that they can only be ameliorated, rather than replaced with something else (such as egalitarian societies).

So it is not a question of looking at the features of both discourses and trying to have a debate between them, but rather of challenging the primacy of the mainstream discourse, and suggesting that hierarchy and inequality are not inevitable features of human society and that alternative ways of understanding the world are possible. 

In the thesis, I attempt to do this in two main ways: one is by looking at the work of feminist and ecofeminist historians who have studied both the rise of patriarchal, hierarchical societies from about 5000 years ago, and the relatively egalitarian societies they replaced; the other is looking at more recent evidence from Indigenous societies, particularly in Australia, that may have been patriarchal in some ways (this is a strongly debated topic^) but were certainly more egalitarian in the way they shared resources. The suggestion in the thesis is that as well as being more egalitarian, these societies were more sustainable in their relationships with land and ecosystem, and that we can learn from them.

 * Pierre Bourdieu Outline of a theory of practice Cambridge University Press, 1977

^ I found a useful discussion of this topic in: Karen Whitney 'Dually disadvantaged: the impact of Anglo-European law on indigenous Australian women' James Cook University Law Review 4:13-38 

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