The Infrastructure of Narrative Power

In 2010, Baum & Fisher looked at why ‘behavior change’ refused to die as a health improvement strategy, despite decades of evidence that it didn’t work. They proposed four reasons: 

1. In general, health education emerged as a health improvement strategy in the early 20^th century and at the time medicine was in its ascendancy. Medicine is an individual pursuit – it’s administered patient by patient – and this created the impression that that’s how health improves. 
2. In the early 1980, the belief was growing that societies ran better when governments were small and markets were created to cater to individuals’ needs. What underlay this belief was the idea that the choices of individuals would, collectively, regulate markets. The power, it was felt, was in individuals, not groups. 
3. There is a simple and powerful logic to focusing on people’s behaviors. If non communicable diseases are the burden, and if they’re largely brought about by tobacco use, unhealthy diets, the harmful use of alcohol, and insufficient physical activity, it seems to make sense to tell people to stop doing those things. 
4. Corporations – especially Bog Tobacco and Big Food – were spending huge sums of money on ‘research’ and lobbying to show that it’s not the supply of unhealthy products that’s the issue but the over-consumption of them – hence interventions needed to target the consumers, not the suppliers (corporations). 

In the final paragraph of the article, they suggest that “public health researchers should pay more attention to ways of discussing their research evidence with people at the grassroots”. The idea was that the profession needed to talk to people about the social determinants of health so that they created the demand for politicians to adopt more population-based approaches to health. 

What all of the bold words point to is the importance of narrative. Impressions, beliefs and what seems logical all come from something, some underlying understanding of the way the world works. Those are narratives. When corporations ‘research’ and lobby, they are trying to shift social narratives in their favor. When Baum & Fisher suggested discussing the social determinants of health with people, they were edging towards a narrative strategy. 

In our recent NEJM article, we illustrated how narratives are, in fact, so powerful that they can directly harm health. To work out what to do about that, we have now published a Perspective in The Milbank Quarterly that describes theinfrastructure required to build and sustain narratives.

It’s hard to write about community and health right now without nodding to the craziness in the US. Let me get that out of the way. There is an argument out there that what’s happening in the US is the consequence of a ‘memo’ written in 1971 by a lawyer called Lewis F Powell Jr. The story goes that he was part of a group of people that were appalled at how American enterprise was being undermined by the consumer movement. They saw it as a step towards socialism, America’s perennial bogeyman. Powell’s memo put forward the idea that corporate America needed to become more aggressive in molding society’s thinking. That memo became the blueprint of the American conservative movement, created and sustained by a network of influential right-wing think tanks. Some say the memo was the basis of The Heritage Foundation’s Project 2025, which is said to inform President Trump’s political agenda. 

What’s relevant here is the role of the right-wing think tanks. Similar to the Big Tobacco and Big Food corporations mentioned above, they were conducting research and lobbying politicians to mold society’s thinking. In essence, they were creating a narrative based on how they see the world. Many of the narratives out there are detrimental to health. The two we pull out in our Milbank Quarterly article are ‘rugged individualism’ and ‘deservingness’. Both focus on individuals, rather than the social conditions that influence those individuals. Both inform social values and political decisions that continue to harm people – like continuing to focus on ‘behavior change’ as a health improvement strategy. 

How do we counter this? If the theory about Powell’s memo is right, we first have to accept that whatever we start doing today needs to be part of a medium-to-long term strategy – Powell to Trump 2.0 is 53 years. We then have to accept that responding to harmful narratives is not about writing a clever blog [sic] or social media post – it’s about taking a step back and thinking about what entities might support a more science-based, health-beneficial narrative and how you bring them together into some kind of network or alliance so that, over time, their communications build new social narratives that crowd out the current, harmful ones. 

In our article, we define narrative infrastructure as “the institutions, actors, organizational networks, and systems of cultural production and reproduction that collectively engage and organize to establish broad yet complementary actions that, taken together, build and maintain the narratives that people use to make sense of the world”. In an accompany table we look at how that was achieved for tobacco control and how it might be achieved in combating racism. 

Our hope as co-authors is that the leaders of institutions read our article and think hard about whether their communications efforts might be more effective if they were somehow part of a network. Although we’ve laid out what happened – and is still happening – in the tobacco control movement, it’s not a playbook. More, it’s a framework to help leaders think about their narrative strategy beyond communicating what their organization is doing. 

Baum & Fisher were right in 2010 to suggest that public health leaders need to discuss their research evidence with people at the grassroots. But 2010 is a long, long time ago. The media landscape is larger, siloed and more antagonistic these days. What it means to discuss something with the public has fundamentally changed. But we hope our new article provides a framework for leaders to organize their strategy and tactics. 

Pritpal S Tamber

The image below the title is by Nick Lowndes / Ikon Images