Public Health, Movements and Inside-Outside Strategies

As I mentioned last time, I’ve been trying to define ‘inside’ and ‘outside’ in so-called inside-outside strategies. These strategies are increasingly being recognized as fundamental to the pursuit of ‘better health for all’ (before January 20, 2025, this was called ‘health equity’). The argument goes that, although public health departments have had notable successes in improving population-level health, the results have been uneven (formerly known as ‘inequitable’). One remedy is to combine the power of public health with the power of social movements to collectively pursue fairer and more just distribution of resources and opportunities in society (formerly known as ‘social justice’). 

To define ‘inside’ and ‘outside’ you have to be clear on where you’re standing. As this work is part of my Furthering the Narrative project, whose aim is to help professionals in health understand the link between community power and health, what’s ‘inside’ is the health system and what’s ‘outside’ is the movement. Therefore, ‘inside’ work is the work needed to be done within health organizations to prepare to become allied in movements and ‘outside’ work is the work needed to be done to ally. Those are paraphrases of the definitions we’ve drafted for the article we’ll be sending to a public health journal soon. 

We found 10 articles that described real-world work that might now be called inside-outside strategies. We used them to glean the specific practices of inside work and outside work. There were about 30 in each. On the inside, we grouped the practices as follows: understanding history (ie remembering the social reform roots of public health); deepening understanding of key concepts (ie power, narratives, structures); practices to understand and explore (ie base building, community organizing, forms of participation); internal procedures to examine or create (ie defining criteria for when to ally with movements); and preparing for outside work (ie identifying groups to approach and finding funding for the work). 

On the outside, we grouped the practices as follows: engaging and building relationships with movements (ie meeting with community members and developing a shared understanding of unfairness and injustice); finding issues to work on together (ie sharing data on issues to start to understand what could be done); participating in the movement (ie creating and sharing reports, letters and testimony on the issues); helping to build capacity within the movement (ie make the health department’s processes more participatory to help community members better understand how a government agency works); and helping to build capacity within the ecosystem (see below). 

Building Collective Power

The idea of an ecosystem is an important one. Movements (and the campaigns they wage) are created by networks of organizations, such as those that represent the interests of grassroots communities and ones that specialize in advocacy, policymaking, the law, research, and communications. How effectively they work together is key to whether a movement is able to affect the kind of structural changes needed to alter the distribution of resources and opportunities in society. Public health departments have to see themselves as part of this ecosystem and help to build capacity within it by, for instance, explaining to other government agencies why they have embraced an inside-outside strategy. Ultimately, the work is not so much about sharing with or shifting power to communities as building the collective power of ecosystems to bring about change. 

Sometimes, however, I find myself being skeptical in all of this. I wonder why it is that we need ecosystems and inside-outside strategies. Why aren’t public health departments able to deliver better health for all? Isn’t that their job? I appreciate there are many answers to that question but I liked the one discussed by Felicia Wong of the Roosevelt Institute and Deepak Bhargava and Stephanie Luce, authors of the book, Practical Radicals. Their take is that the practice of policymaking is just ill-equipped to deal with our increasingly heterogenous and rapidly changing world. It’s not that government agencies and policymakers are bad, they’ve simply been trained with a set of skills that are increasingly not fit for purpose. 

That explains why think tanks like Demos in the UK are experimenting with new tools for deliberative and participatory policymaking. It’s another way of trying to hear from more community members to better understand the challenges they face and get ideas for the kinds of policies that might make things better. There are some people that think more deliberative and participatory forms of democracy are better per se but in our work to propose policies for the UK government to help communities take back control, my colleague, Oliver Smith, looked at the evidence and found it to be unclear. Demos is doing the hard work of trying to understand if participation and deliberation are valuable, and, if so, under what conditions, in what way and for what segments of society. 

Of course, it’s often the case that the people who’ll be able to use these tools to deliberate or participate are those that already have resources and opportunities in their lives. In that way, perhaps Demos’ experiment will reveal that these new tools advantage the already-advantaged and hence worsen the distribution of resources and opportunities in society by making them even less fair and even less just (formerly known as ‘worsening inequitable’). With some luck, they’re looking out for this in how they evaluate their tools. 

Until next time. 

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The image is by Andrew Baker / Ikon Images