Last week, we ran a Dean’s Note addressing the Trump administration’s decision to separate families at the US border, and how these separations threatened health, particularly the health of children. They were the latest in a series of actions taken by this administration that have undermined health in the US and around the world. From its reinstatement of the Mexico City Policy, to its move to withdraw the US from the Paris Climate Agreement, to its tolerance, even encouragement, of hate groups, to recent events concerning the Supreme Court, the presidency of Donald Trump has so far done much to dismay those who care about compassion, inclusion, and health. Furthering this calumny, this week the Supreme Court upheld Trump’s travel ban on the grounds that it is within executive powers to create such a ban, even as this ban is clearly founded on xenophobia and Islamophobia, an appeal to the basest instinct of a political base that would keep us back from building a better and healthier world for all of us and for our children.
To talk of silver linings in this context is to risk downplaying the harm that has already been done to the marginalized groups who have felt the sting of these times most keenly. Yet, despite many challenges, it strikes me that there is still cause for optimism, even hope, at this unsettled moment. With the perils of the Trump era comes unique opportunities to build a better world, as public outrage begins to coalesce into powerful social movements capable of creating large-scale progressive change. This process began at the very start of the Trump administration, when millions of people around the world took to the streets during the Women’s March to protest against injustice. It continued during the airport protests against the administration’s travel ban, and, more recently, in the #MeToo movement and the March for Our Lives against gun violence. This momentum his even spread to cultural areas that are often—rightly or wrongly—associated with the politics of President Trump. Last month, the Southern Baptist Convention held its annual gathering, where the denomination elected J. D. Greear as its president, a pastor who has spoken of the need for greater diversity and inclusion among SBC leadership, and the importance of addressing sexual misconduct within the ranks of the faithful. His attitude reflects a generational shift within the denomination, where younger members of the SBC are driving a conversation about the same difficult, necessary issues that have characterized the national debate in recent years.
Social movements often arise in response to unpredictable discontinuous triggers, which catalyze action. All we have seen over the past two years suggests that the election of President Trump has been such a trigger. His actions, combined with the country’s changing demographics, seem to have galvanized a shift towards progressive thinking in the US, opening the door to transformative, generational change. This is, of course, cold comfort to those who are at this moment being actively harmed by the Trump administration. We should therefore have two core objectives, going forward. First, we must do all we can to mitigate the short-term harms caused by the administration. This means speaking out and taking action on behalf of vulnerable populations, keeping focus on how sometimes abstract-sounding political arguments shape the health of these groups. In a recent interview, Professor Monica Wang well expressed the power of speaking out with one voice against injustice; the interview also contains suggestions for how we can mobilize on behalf of the immigrants detained at our southern border. Second, we must work to stoke the social movements that are taking shape around us. From participating in protests and marches, to engaging with the community through our Activist Lab, to generating evidence of the link between socioeconomic conditions and heath through our scholarship, such work has long been core to our values as an activist school of public health, and will remain so after Trump has left office. If we are to recover from the damage done by this administration—and not just recover, but extend progress far beyond the high water mark of earlier eras—we must continue to act in ways that are consistent with our values, as we engage with social movements at the local, national, and global level.
There is little question that thinking about this is germane to the cause of public health. This point is well made in a very good report about the “population health movement,” part of an Institute of Medicine Population Health Improvement Roundtable. Nancy Adler and colleagues point out that “some of the challenges to establishing population health derive from political and social concerns … [and] one of the hallmarks of the field is its attention to the social causes of disease and health.” This draws on the importance of social causes and roots of public health, and by extension social movements. Consonant with our vision for the school, the report argues that research and action must go hand in hand in order to facilitate change, and that new technological developments such as electronic medical records, or “big data” in the form of social media—core elements of translation that we have been discussing as a school community—have the potential to integrate economic or social information into both research and policy change.
There is a good academic literature on this issue to which I would refer the reader. Here I want to comment on a couple of compelling case studies that provide useful thoughts looking forward, and an inquiry into how this applies to two issues of tremendous contemporary salience.
Perhaps most iconic in public health is the movement to change tobacco consumption that began in the 1950s and continued for the next several decades. This provides useful insights into the phases of change through broad social movements. Professor Constance Nathanson, a former colleague, argued in 1999 that its relative success compared to many other movements had much to do with the persuasive use of information on health risks through grassroots mobilization for nonsmokers’ rights, as well as with the weakness in opposition. Constance A. Nathanson breaks down the movement into three main phases: the first phase, in which the health connection was made between tobacco and lung cancer, primarily in the medical press and including the famous Doll and Hill reports and the 1964 Surgeon General’s Report on Smoking and Health; the second phase, the “struggle for regulation” in which Congress excluded tobacco from being regulated under several acts and loopholes were used to create milder warning labels; and the third phase, the “discovery of innocent victims,” in which the nonsmokers’ rights movement was born and the Surgeon General urged the addition of a bill of rights for the nonsmoker to include a ban on smoking in all public spaces in 1971. Nathanson argued that restaurant smoking bans may have been due to nonsmokers’ rights activism in conjunction with greater consumer sensitivity to health risks and media hyperbole. I particularly liked Nathanson’s distillation that “in a society increasingly skeptical of experts and expert knowledge, it is critically important to develop agile institutional mechanisms that link population health science and practice…. [because] research alone will not produce change.” I thought this statement was resonant and agitates for academic engagement in generating content that is broadly accessible and aims to inflect such institutional mechanisms to broader social ends. Of course, the work is not done even on smoking—arguably public health’s greatest achievement over the past century—and there are still many groups with high prevalence of smoking even today, but we have seen great strides over the past half-century, partially due to a social movement.
The story of change around motor vehicle safety, another great public health achievement of the past century, echoes what I have previously discussed: That what was previously acceptable became unacceptable, and that this was central to improving the health of the public. Health behavior change in populations around this issue was inseparable from denormalization of previously accepted behavior. In particular, this case study provides some perhaps generalizable lessons about the elements of social norm transformation that can be leveraged towards change. Lawrence Green and Andrea Gielen , in a book they co-edited, suggest that three key elements emerged to contribute to these changing norms around seat belt use. First, public health initiatives provoke less controversy when they involve children compared to when similar restraints are advocated for adults. To this point, child car seat use was one of the aspects of vehicle safety that was adopted the most seamlessly compared to others. Second, many sectors, including health, transportation, and law enforcement, came together with community advocates to support legislation and education on car seats in the late 1980s. Third, media and social marketing were paramount in promoting vehicle safety; the National Highway Traffic Safety Administration conducted large public education programs that helped to shape public opinion and gather support for policy change. One of the most successful campaigns that we all recognize is the “Click It or Ticket” slogan. In 1984, seat belt use was only about 15 percent in the United States; in 2007, it had increased to 82 percent, an extraordinary feat.
What are the implications of these observations for two topics of contemporary resonance, for the battles that population health must engage in looking ahead towards creating the conditions that make people healthy?
The evidence around the health consequences around racism and the unconscionable and persistent health inequalities in this country is incontrovertible. The Black Lives Matter movement has helped bring to the forefront of public discussion, with the weight of moral urgency, race relations in the country, as instances of racism and injustice in the criminal justice system resound across the US. This movement builds on longstanding racial inequities and has been compared to the Civil Rights movement. Both movements arguably are predicated on the same core injustice, with the Civil Rights movement being catalyzed by voting rights and the current movement focusing on institutionalized racism and treatment of black individuals by the justice system.
There is little doubt that moral urgency also rings true with climate change, at a time when few can deny the urgency of global warming. As the global temperature on the surface of the earth continues to grow, millions are expected to be pushed into poverty in the next 15 years, and extreme weather events will continue to take people’s lives. Eighty two percent of Americans now feel it is their “moral duty” to protect the environment for future generations. During the Obama administration, the climate change movement gained momentum in the US, and, at the time, many argued that the movement had finally convinced the public of global warming’s dangers. While the Trump administration has done much to hinder progress on this issue, widespread public support for addressing climate change remains a hopeful and sustaining sign for the ongoing movement to protect our earth, and our health, from catastrophe.
In sum, a brief look at two successful social movements—the anti-smoking and the car safety movements—provides some lessons that can have utility for future efforts to make conditions that are currently acceptable, unacceptable. Success in this regard around issues of climate change and racial inequities could serve to create a better, and indeed healthier, world. While the Trump administration may have done much to impede such progress, the movements it has inadvertently helped to create continue to build power and lay the foundations for change that will long outlast the present moment.
I hope everyone has a good week. Until next week.
Warm regards,
Sandro
Acknowledgement: I am grateful to Laura Sampson for her work on this Dean’s Note, and to Catherine Ettman and Professors Yvette Cozier and Harold Cox for discussions that shaped my thinking on this issue.