Signing Off by Defining a ‘New’ Field of Practice

Were you there at the beginning? I guess I was but I shudder to think about how naïve my early writing was. I began this journey with a vague understanding that social capital was important to health. It caught my attention because I was increasingly convinced that our approach to health – ie public health and health care based on a biomedical understanding of health – was unsustainable. If all you do is look for sickness in order to treat it, you’ll just get better and better at finding it, especially when ‘treating it’ makes you money. I felt we needed a new way to understand health, and social capital seemed to offer that.

I didn’t stick with social capital for long. I got intrigued by sense of coherence and control over destiny. Coherence and control brought me to agency. Community activists and advocates told me to stop hiding behind technical words like ‘agency’ and just say power. I started to, and didn’t like it at first. And then I did.

I doubled down. I summarised the evidence linking community power to health, showed how it could overcome policy-based inequity, described how voting was a key conduit for it, unpacked how it’s partly made up of narratives that are created through infrastructures and how those narratives can actually be violent and cause harm, and proposed how governments might embrace community power as part of a new, more balanced relationship with the people.

But I have, for some time now, been looking for an off-ramp. Not from the work, as such, but from the self-inflicted obligation to ‘think out loud’ through these posts and my website.

I believe our new article offers that, and I’m taking it.

The Off-Ramp

Community power is key to health, not just because it can be an instrument for making structures fairer and more just (and hence reduce inequities in health) but because its mere presence fosters health. If so, how do public health and health care work with it? The answer for public health is in our new article in The Milbank Quarterly on inside-outside strategies. To quote the ‘policy points’ at the start of the article:

• Health departments can advance health and racial equity by partnering with movements for fairer and more just social arrangements that often emanate from civil society through the work of community power-building organisations
• This requires health departments to adopt an inside-outside strategy, which consists of practices needed internally to effectively participate in movements and practices needed externally to become allied in them

The article has two detailed examples of recent inside-outside strategies run by public health departments. In this regard, what we’re describing is not ‘new’ but we have done the (incredibly) hard work of poring over the grey literature to list the practices that have been documented as part of inside-outside strategies (see Table 1 in the article). We hope the article aids the wider adoption of inside-outside strategies across public health (once some of its leaders stop performing leadership and actually start leading).

But what of health care? How might it work with community power? I think the answer is it won’t. Health care is not interested in health; it’s interested in sickness. That’s what it focuses on, after all. When it comes to health care, community power might actually be the counterforce that pushes back against its inexorable growth. Does endless diagnosis and treatment lead to a good life? To some extent, yes, but not if its costs starve schools, policing, welfare systems, and even governments of resources. No politician will ever have the backbone to say no to health care but communities just might. At some point, the absurdity of having a shiny hospital but poor schools, insecurity, and no safety net will dawn on people.

The Work Goes On

When I started this work, I wanted to build a field of practice. At the time, it was about community-oriented innovation. But by learning as I went, I realised that it was really about building and wielding community power for a fairer and more just society. Of course, that field already exists but its influence on health is only just starting. Through our work and the work of allied scholars and practitioners over the last five-to-ten years, there is greater conceptual clarity, more tangible strategies, and more actionable tactics. Further work is always needed but the case for taking community power seriously in health is well and truly made.

My work on community power and health is continuing; I just won’t be posting about it here anymore. I’m currently finishing up a piece of research exploring what community-led system change looks like in practice (a set of interim structural changes that are fragile is the answer) and an article proposing that if public health wants to improve population-level health it needs to start adopting an ‘ecosystem strategy’ (and accept that it’s not necessarily the centre of that ecosystem). Once those articles get published, I’ll write about them on LinkedIn.

As of now, my website has become an archive of thirteen years of work. All of my projects, publications and posts are here. Archiving the work has been a real labour of love. And, while there are way, way, way too many people to thank, I do want to say thank you to Richard De Angelis, my partner in design-crime from the very beginning.

See you on LinkedIn.

Dr Pritpal S Tamber MBChB

The image below the title is by Daniel Liévano / Ikon Images.