If imbalances in power are the root cause of health inequities, what can you do about them? Few people in health have grappled with that more than Jonathan Heller, a co-founder of the ground-breaking nonprofit, Human Impact Partners(HIP). The new episode of my podcast series on community power (in collaboration with Ratio) is a conversation with Jonathan.
You can find it on Ratio’s website or Apple podcasts.
Over the last 14 years or so, Human Impact Partners has worked with numerous parts of the public health system in the US to explore how to shift power from those that have it to those that don’t. They have packaged some of their work in a website called the Health Equity Guide.
The Guide contains 15 practices for shifting power – from the obvious (sharing power with communities) to the more subtle (changing the conversation about what creates health). Each practice is accompanied by real-world case studies and actions that organisations in health can take.
It’s important to see these practices as innovations. In health, there is a tendency to think of innovation as embracing new technologies. However, innovation isn’t about technology per se, it’s about changing what we do to get a better outcome. With that in mind, the 15 practices in the Guide are all courageous innovations seeking to achieve health equity. And in that regard, Jonathan (and HIP’s co-director, Lili Farhang) are two of the most innovative people in health.
It’s quite something to take a theoretical concept like power and turn it into a set of practices, each with case studies and concrete actions. As Jonathan tells it in the episode (Ratio/Apple), it requires a clear understanding of what power is and how it works.
The how comes from Steven Lukes’ theory that power has ‘three faces’:
- The visible – people and organisations exercising their influence through political processes operated by formal, transparent bodies
- The hidden – people and organisations using their influence to ensure that only certain issues make it to public (visible) discussion
- And the invisible – people and organisations using their influence to shape narratives, worldviews and ideologies
In the episode (Ratio/Apple) Jonathan spends some time talking about the third face of power – the invisible. As the names suggests, it’s impossible to see and, as a consequence, perhaps the most powerful.
One of the narratives that persists in health is ‘personal responsibility’ – the idea that a person’s health comes down to the choices they make. It stems from the political right and underpins the idea of ‘behaviour change’ as a health improvement strategy. But the idea that someone’s health is simply down to the choices they make flies in the face of overwhelming evidence that our social contexts matter more – much more. The fact that we still see behaviour change strategies focussing on individuals is an illustration of just how powerful the third/invisible face of power is.
Ever practical, Jonathan’s response in the episode (Ratio/Apple) is not just that we need a new narrative on what creates health but that we need to think beyond the communication of that narrative. We need to figure out how the narrative changes what we do, from how we collect data to how we analyse it and how it informs the policy-making process.
Jonathan recently left Human Impact Partners and now splits his time between the University of Wisconsin where he’s a Senior Health Equity Fellow and the National Collaborating Centre for Determinants of Health in Canada where he’s a Visiting Scholar. For the former, he has recently created a short course called ‘Building Power for Health Equity’, the impressive syllabus of which is available at that link.
Towards the end of the episode, Michael Little, the host, asks Jonathan how he’s feeling in the face of the many difficulties in the US right now, health inequity being just one. Jonathan says he feels hopeful quoting the activist Mariame Kaba who says that hope is a discipline. As she explains it, it’s about working every day towards justice in society, knowing that it’s long-term work and keeping going even when the evidence around you suggests that nothing will ever change.
The world needs more Jonathans and I was honoured that he made the time for our podcast series.
The next episode is a conversation with Jennie Popay, a distinguished professor of sociology and public health who’s clear-eyed about how community power has been – and is being – abused. But for now, I’ll leave you to enjoy Michael’s conversation with Jonathan (Ratio/Apple).
See you in two weeks.
Pritpal S Tamber
PS: To learn more about Ratio’s work, sign up for their newsletter or drop them a line: hello@ratio.org.uk.
Further Reading
- In the episode, Jonathan cites what an inequity is using Margaret Whitehead’s seminal paper, The concepts and principles of equity and health [PubMed]
- For a very brief introduction to what power is see the World Health Organisation’s 2010 framework for action on the social determinants of health (page 20)
- Steven Lukes’ book, Power: A Radical View, was first published in 1974 and a new edition was published in 2021
- You can hear Lukes describe the three faces of power in this 14-minute episode of the Philosophy Bites podcast
- For an excellent discussion on why ‘behaviour change’ endures in health promotion despite its failure to reduce health inequities see Baum & Fisher 2014 [PubMed]
- The definition of community power that Jonathan uses was taken from a report on community power, place, and structural change by Pastor and Wander of USC Dornsife Equity Research Institute (see the report at the bottom of this page)
- Jonathan also talks about systemic and structural racism; for an excellent introduction to these terms, see the 2022 article by Paula Braveman [PubMed]
The photograph behind the title is by Yume Photography on Unsplash
