--submitted by Anne Rucchetto
Public Health work is rarely straightforward. One of the thorniest conundrums that professionals in the field confront is how to address complex health challenges in a manner that produces positive health outcomes at the population level. Many academics, front-line workers, students, and community members devote themselves to continually addressing unresolved issues of public health, facilitating discussions and measuring indicators that reach beyond direct medical care. Instead they choose to look “upstream” (McKinlay, 1975) to issues such as income levels, housing security, citizenship, social connectedness, educational attainment, and the impact of systemic oppressions, such as racism. This work inevitably falls under the title of “advocacy” – which is one of the seven Core Competencies of Public Health in Canada, and defined as “speaking, writing, or acting in favour of a particular cause, policy or group of people – often aims to reduce inequalities in health status or access to health services” (PHAC, 2007).
Yet, it seems that advocacy has, in some ways, fallen out of favour – if not in its aims, then at least in name. Prior to the mid-1970s, public health organizations that addressed areas such as social services worked in tandem with the government to assist in mediating “between differing interests in the pursuit of health and well-being, and facilitate the allocation of resources,” (PHAC, 2007; Shields and Evans, 2010). Many community health centres had specific staff dedicated to advocacy, and this was an accepted, explicit, integral part of public health work. Learning this might surprise those of us new to the field, as one of the lessons we continually learned throughout our education is about the politicization, and, invariably, discrediting of advocacy.
Established researchers and public health workers will admit that, currently, it will not win you prizes to be viewed as an advocate. In the last three decades, there has been a transformation of public health (and third sector non-profit work, more broadly) to pressure academics, front-line workers, students, and community members into representing themselves as “value-free”, peddling the (disproven) paradox that social good will be maximized by bringing complex health issues into the “domain of the market” (Shields and Evans, 2008). This has put intense pressure on organizations that make their advocacy mandates known. Depriving funding and/or forcing the obfuscation of goals to render the aim of “advocacy” a vague, roundabout commitment to serving marginalized populations compromises public health in favour of a very specific kind of political palatability. Several funding bodies—including governmental grants—specifically deny financial support based on the perception that awards may be used for “advocacy purposes” (Schwartz, 2015).
However, the support and presence of advocacy is critical to public health for many reasons. Publicly supported advocacy for health-care providers—from governmental, non-profit, and private sources—facilitates enhanced societal inclusion. “Societal inclusion” can be defined as building shared values across diverse groups, enabling all people to feel they are part of a common goal and engaged in the resolving of shared problems, and that “they are members of the same community” (Judith Maxwell, as quoted in Policy Research Committee, 1996). Advocacy, by definition, prioritizes “team building, negotiation, conflict management and group facilitation to build partnerships”, which the Public Health Agency of Canada recognizes as “essential” skills for the practice of public health. Advocacy has historically provided a platform for “organizations of women, Indigenous people, disabled people, official language minorities, and poor people to be heard among the voice of the economically powerful” (Phillips, 1991). After all, good inquiry asks questions that may necessarily have critical answers. If we measured Canadian health using only the statuses of those with the most privilege and access, there would be significantly fewer questions to ask.
As it stands, there are many questions we must continue to ask about the myriad of unresolved public health issues in Canada. Inevitably, these may lead us to challenge the status quo, in terms of resource distribution, city infrastructure, how and what we teach children in schools, and even the commonly accepted ways of organizing society. The suppression of critical analysis undermines our ability as public health professionals to do our jobs well, and advocacy is a vital part of this. Moreover, it is our responsibility to use the evidence presented to us as an impetus to tackle the complex issues facing us all.
I would like to extend my gratitude to all my fellow students in the Health Promotion Program at the Dalla Lana School of Public Health for providing continual engagement with the ideas discussed above through sharing their own experiences and perspectives with me during the course of our time together. Furthermore, thank you to Richard Elliott, Carol Strike, Karen Yoshida, Valerie Tarasuk, and Frances Tufford for your invaluable support and input as I worked to refine my thoughts.
McKinlay JB. A case for refocusing upstream: the political economy of illness. Applying behavioral science to cardiovascular risk: proceedings of a conference. American Heart Association, 1975;7-17
Philips, Susan D. 1991. “How Ottawa Blends: Shifting Government Relationships with Interest Groups”, in Frances Abele, ed. How Ottawa Spends 1991-1992: The Politics of Fragmentation. Ottawa: Carleton University Press, 183-227.
Policy Research Committee. 1996. Growth, Human Development, Social Cohesion. Draft Interim Report. Ottawa: Policy Research Secretariat, Government of Canada, 4 Oct.
Public Health Agency of Canada. (2008). Core Competencies For Public Health in Canada. Retrieved from http://www.phac-aspc.gc.ca/php-psp/ccph-cesp/pdfs/cc-manual-eng090407.pdf.
Shields, John., & Evans, Mitchell. (1998). Shrinking the State: Globalization and Public Administration ‘Reform’. Halifax: Fernwood.
Shields, John., & Evans, Mitchell. (2010). The Third Sector and the Provision of Public Good: Partnerships, Contracting, and the Neo-Liberal State. In Christopher Dunn, ed. The Handbook of Canadian Administration, 2nd Edition (305-318). Ontario: Oxford University Press.
Schwartz, Robert. “Advocacy and Public Health Policy Change.” Presented at the University of Toronto, November 12, Toronto, ON, 2015.