Health inequalities call for advocacy and public engagement

There has now been a consistent stated policy desire to reduce health inequalities for nearly two decades. Yet, despite a mass of research and raft of policy initiatives on the topic of health inequalities in the 19 years since, current indicators suggest either that health inequalities have continued to widen or that progress has been remarkably limited. The failure to reduce health inequalities in the UK has led to some reflection among researchers working in this field, with two distinct explanations both attracting support. For some, the policy failure simply reflects failings in the evidence-base: health inequalities researchers have simply not been able to advise policymakers on ‘what works’ in tackling health inequalities. Others, however, take a much more normative (values-based) view, arguing that the policies put in place to tackle health inequalities were shaped by ideological commitments to national economic growth, limited state intervention in markets and, more recently, a need to reduce the public deficit. In other words, some people think the failure is down to evidence and others to politics, ideologies, and values.

Lots of books and articles have been published about health inequalities (a quick Google Scholar search for the term returns 104,000 hits) and many of these seem to assume that expanding and developing the evidence-base will assist with policy efforts to reduce health inequalities. And perhaps some of this evidence will but, as former policy advisor to Tony Blair, Geoff Mulgan, has noted, in a democracy politicians have every right to ignore evidence, particularly if they think it goes against public preferences. That’s one reason that journalists and some political scientists spend so much time polling people to try to figure out what they think.

What role, then, might evidence play in policy development around health inequalities? Perhaps it’s time to move beyond the idea of evidence-based policy to start focusing on how different kinds of actors employ evidence in policy debates. This includes understanding how interests that can run counter to public health, such as unhealthy commodity producers like the tobacco industry, engage with policy debates about health inequalities. It also means better understanding the relationships between research, policy, and advocacy for tackling health inequalities.

There are two very different ways of thinking about public health advocacy. In Chapman’s terms, it includes (amongst other things) working to place and maintain issues on public and political agendas (and exploiting opportunities to do so), discrediting opponents of public health objectives, and working to frame evidence in persuasive ways (e.g. via metaphors or analogies). In other words, advocacy involves strategically selling public health objectives to a range of non-academic audiences. This way of thinking about advocacy, which has been termed ‘representational’, implies that health inequalities researchers first need to achieve some kind of consensus around the policy (or societal) changes they are trying to ‘sell’ and then work to strategical sell this idea. This involves important work to try to attract political and public attention to the idea, including via the promotion of the research underpinning it.

A rather different way of thinking about ‘advocacy’ is in ‘facilitational’ terms; work akin to Burawoy’s notion of ‘public sociology’. Here, the emphasis is on researchers’ willingness and ability to engage in dialogue with members of the public. It might involve, for example, working with relevant communities to ensure that voices which might traditionally be ignored are given a greater voice in policy debates.

In sum, while commitments to ‘evidence-based policy’ might sound reassuring, they risk: (1) ignoring the realities of policymaking in democracies (and therefore failing); and (2) striving for what is, in effect, an elitist, technocratic approach to decision-making. I find myself agreeing with Max Weber that the role of science is not to tell us (or our political leaders) what we (or they) should do, or how we should live, but rather to make more meaningful choices possible. In practical terms, this means finding ways to ensure that people are able to meaningfully engage with research evidence. And in a democracy, this shouldn’t simply be the people academics often ubiquitously refer to as ‘policymakers’. Rather, we need to get much better at creating deliberative spaces in which researchers, policymakers and members of the public come together to discuss and debate evidence and ideas in ways that acknowledge the role of values and ethics.

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