Mass Line & Mass Movement in Health: A Case Study of the Alliance for People’s Health

By Martha Roberts

This article is based on my experiences over the past 9 years of working with the Alliance for People’s Health (APH) as a founding member. I have permission of current APH collective members to post this article and am very grateful for their thoughtful comments and contributions. This is my attempt to sum up the process the organization went through in the development of our political positions, practices, and of nearly a decade of struggle in which over a dozen collective members participated.

logoazar13The APH is an organization of health workers, grassroots organizers and people committed to the struggle for health for all led by a small collective of grassroots organizers in East Vancouver. The APH remains active to this day, advocating for health for, all exposing and opposing the structural determinants of health and connecting health care workers and providers to democratic and people-powered struggles against imperialism, colonialism, and hetero-patriarchy, and struggling for total for social transformation.

In my experience, at times the APH core group consciously applied principles of mass line, and at other times our practices evolved more organically out of our roots in working class communities, primarily communities of colour, and our people-to-people relationships within revolutionary movements.

Looking back over the past 9 years I am impressed and deeply appreciative of our work and of our strong collective analysis. In this short article I am attempting to analyze how the APH conducted mass line practice through cycles of experience, analysis, action toward health for all.

Step One: Identify the Principle Contradiction

“Contradictions in post-revolutionary China after 1949 were the material base of the mass movement,
which in turn is a socialist strategy to resolve these contradictions.” (Ching, p. 61)

When the original APH core group members started meeting in 2006, our first challenge was to identify the main struggle that we wanted to collectively take up. We drew a lot of inspiration from a mass organization in the Philippines called the Health Alliance for Democracy which connects health workers to popular campaigns for social and economic justice. We also drew inspiration from the Council for Health and Development, an institution of People Power that supports the establishment and ongoing development of Community Based Health Programs to provide community-controlled health programs led by Community Health Workers in urban poor and rural communities. Which path were we going to follow? A mass organization of progressive health workers, or an organization leading health programs in working class and marginalized communities? Or both? What was our mass character going to be?

We started by surmising, based on our own personal and organizing experiences, that the “basic requirements for health cannot be achieved for all under a system that oppresses and exploits working class people, women, people of color and Aboriginal people.” If, as our basis of collective unity states, we seek to achieve “a just, liberated and healthy world” for all, what is the main impediment that stands in our way? And how can we organize communities to defend their right to health?

What we needed to do was identify and substantiate the principle contradiction in the social structure which undercuts our experiences of ill-health and prevents communities and individuals from achieving optimal health and well-being. Identifying the principle contradiction forms the basis of our struggle, both as health workers, and as community members, and becomes the overarching ‘call’ of the organization. It is this position that allows us to define the sides of the struggle and digs right into the class dynamic of the issue. This is necessary to identify who’s with us, who’s waffling and can be moved, and who’s against us. It guides us to identify the revolutionary aspect of how to resolve that contradiction.

This process of identifying the principle contradiction and the overarching mass line of the organization necessitates active participation with the masses, for the masses are the drivers of change.

Capitalism is a Disease: the Structural Determinants of Health

The People’s Health Series started in 2008 when APH organizers set about to investigate and struggle to overcome health concerns in our community. We started by selecting what we assessed to be the major health issues in working class communities based on our collective decades of grassroots organizing through the Bus Riders Union, Grassroots Women, the Poverty Action Network, and other mass organizations. These issues included: worker safety, back and neck pain, nutrition, dental care, and access to public health services. We designed popular education workshops that flowed to move people from experiences of ill-health, to analysis of the roots of the health issue, to practical things we could do as individuals, as a group, and as an organization to work towards improvements in our health and the health of our communities.

Over time and through learning from people in our communities, we added mental health, heart health, diabetes and chronic disease prevention, healthy sexuality, migration and health, knowing your health history, patients’ rights, and more. The People’s Health Series expanded to include the Women’s Health Series and the Immigrant and Refugee Health Series. Hundreds of community members participated in these popular education workshops and contributed to our collective understanding of the impacts of capitalism, colonialism, patriarchy, and structural racism on people’s health.

reggaeton to relieve stress

We heard time and time again that the overarching problem people were facing in their health, the thread that connected all of our health problems, was exploitation and oppression under capitalism. What we learned through this constant connection with working class people in our communities was that, while we could implement coping measures or cover up symptoms, the roots of the problem lay in our economic exploitation as workers, in our experiences of institutionalized racism and sexism, and in the limited health and social services within the neoliberal state.

What is food justice

Our mass line became Capitalism is a Disease expressed through our ever-sharpening analysis of the structural determinants of health that we witnessed through every single interaction we had in the programmatic work of the People’s Health Series.

When a worker gets injured due to unsafe workplaces and the boss’s refusal to provide adequate training and safety equipment…

worker health

It is connected to the mother who can’t afford dental care for her children…

dental health

It is connected to the farm worker who suffers malnutrition due to poverty.

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The principle contradiction was clearly capitalism. Capitalism is the social diagnosis and structural change is our common and collective cure.

The lived experience of working class people and communities demonstrated the correctness of this contradiction, and the development of our initial line on the structural determinants of health allowed us to identify who is with us, who can be moved, and who our enemies are.

Step Two: Identify the Process of Change

“Without the opposite or when the opposite is not well focused,
energy created in a mass movement is often diverted to different directions and eventually dissipated” (p.65).

Once we know who’s with us, we need to know where we’re headed, for the mass line not only allows us to understand and analyze society, but it is also the process by which the collectivity of the oppressed and exploited organize in mass democratic formations and then move with unity in the struggle to transform society. We can have an ‘anti’ movement: anti-imperialist, anti-colonial, anti-capitalist, anti-patriarchal. But this is not enough for transformation to occur. If the masses are to be the drivers of change in society there needs to be a clear direction for where that struggle is headed or the struggle will dissipate.

This requires the next step of what Mao called “setting up the opposite” in the contradiction. This requires us to understand the contradiction very deeply and from the perspective of the oppressed and exploited masses. By doing so, we begin to grasp the main impediments to working class power and control. For ultimately, to tackle capitalism as a disease, we need a socialist cure. This is going to require highly organized communities.

As Mao explains, “the other does not exist in the objective world but the material conditions to set it up exist. For example, the waterfall exists in the natural world. Without setting up an opposite, one cannot create something from the waterfall. Building a dam is setting up an opposite to the waterfall. Then energy can be created to generate electricity.”

To set up the opposite is to find the key to building people power, to shift the balance of power so the subordinated becomes the dominant; to generate great energy from the people. This requires a long-term strategy to challenge bourgeois power and harness working class power toward a social system that not only eliminates bourgeois power, but is based in the power of the people.

Contesting Neutrality: What’s a Radical Health Worker to Do?

Our need for healing and medicine exists objectively in the world. But for the masses to really be in the driver’s seat, we can’t just fight for more profit-driven health care based on profit-driven research and profit-driven pharmaceuticals and directed by bourgeoisie capitalist interests and carried out by petty-bourgeois health care professionals. Capitalist medicine reflects bourgeois power.

What we need to do, what our strategy needs to be, is to subordinate that bourgeois power to the power of the people. We needed to set up our opposite, not as amorphous capitalism, but as bourgeois medicine. As working class communities we should no longer buy the ideology that bourgeois medicine is neutral medicine. From there we can start to build health institutions of people power.  Even as we begin to analyze how bourgeois medicine dominates and controls as it heals, we begin to collectively resist by asserting Our Patient Rights within the oppressive institution.

Our line becomes contesting neutrality. Medicine is a major institution of bourgeois and colonial hegemony; there is no such thing as neutral medical research and practice under capitalism. This means that not only as health care providers can we not be neutral and we must decide who we stand with, but even further, the tools we employ in the course of our work are not neutral tools to be used the way we intend. There is bourgeois hegemony embedded in professional institutions, practice structures, and protocols[i].

PIHU 2007

A neutral care provider is one who lacks a critical questioning of their elite petty-bourgeois role in the system, and through their active participation, actually serves to perpetuate bourgeois ideology and practices. A neutral care provider doesn’t ask ‘does the care I provide perpetuate a class-driven and racist ideology of blaming the individual for their illnesses?’ Instead a neutral care provider unquestioningly adopts a reductionist bio-medical framework which fails to strike at the root of the problem, that ultimately capitalism is our main social disease today. This neutrality is what perpetuates a sick system driven by profit and greed.

But even if we do ask those critical questions above, there are no personal solutions to political problems. While some of our skills and knowledge may be useful for healing, much of what we carry in our heads and also potentially much of what we do with our hands might contribute more to harm and the perpetuation of bourgeois hegemony than actually heal. It is not just up to us to decide what harms and what heals. It is impossible to transform ourselves as health care providers until we subordinate ourselves to a movement for economic and social justice led by the oppressed and exploited.

For example, North American health care statistics indicate that somewhere in the range of 26% of women are taking psychiatric medications, and this fact was reflected in the lived experiences of the many women who participated in the Women’s Health Series. We’re pathologized for our experiences of gender oppression, our personality traits, our sexuality, our menstrual cycles and hormonal balances, how we express emotions such as anger or frustration, how we cope with grief, trauma, and abuse, how much food we eat or don’t eat, our experiences of alienation or isolation as mothers, and the list goes on. And when we reach out for help, the attentive health care provider’s first line of treatment usually involves practices such as Cognitive Behavioral Therapies (including mindfulness, etc.). While this may be helpful for some, as an intervention overall it entrenches women’s social experiences in personal failings and ‘wrongful ideas’. The attentive care provider’s second line of defense usually rests in either a) referral to psychiatry for medications, or b) direct prescription of medications, which might address bio-chemical imbalance (or might be harmful), but does not get at the social roots which undercut much of women’s experiences of poor mental health.

WHS SEXUALITY 001

What isn’t talked about are things we can collectively do, together, to support positive mental health for our communities. Like fighting for our collective rights against exploitation and for collaborating, building social networks of resistance against alienation and for unity, and celebrating our beautiful diversity against structural racism and heterosexism.

Part of our work at the APH has become engaging health care providers in discussing the implications of the line that there can be no neutrality in medicine and health care. How do health care researchers, students, workers, and providers themselves experience the contradictions that we study and treat the biological origins of what is ultimately social disease stemming from gross exploitation and oppression? How can we support each other to take a stand for social justice in a conservative environment?

As Audrey Lorde once said, the “master’s tools will never dismantle the master’s house”, so it goes that bourgeois medicine is an inherently oppressive tool which serves to perpetuate bourgeois domination and hegemony. This is not to say that that all knowledge and practice contained within bourgeois medicine has no potential value within working class health care, but the point is, it’s not up to bourgeois and petty-bourgeois health care professionals to make the decision about what practices serve to control and which ones have potential to heal.

Step Three: Designing a Long-Term Strategy for Structural Transformation

“Setting up the opposite in a mass movement requires a thorough understanding of the principle contradiction
as well as the skill of translating such an understanding into practice at an operational level. 
It is an extremely difficult task.”

Once we have identified the contradiction, and identified where we need to head to build working class hegemony, then we need to outline our strategy to build the actual mass organization of people power necessary for revolutionary transformation.

What does a strategy for change look like?

who benefits who loses

Community Ownership and Control: New Knowledge and Practice through Democratic People’s Institutions

In order to build “public health care centered on the needs and visions of working-class communities in particular Aboriginal communities and communities of color” we needed to “turn it upside down” and argue that working class people could decide the future of health care for the people. This is the greatest challenge and our most difficult task!

We are not operating in a revolutionary context. My experience in the APH and as a health care provider who dreams of working within an institution of working class power has clarified for me that until we have successfully organized working class and historically-marginalized communities to claim power and control, it will be impossible to subordinate bourgeois knowledge and practices.

Even in advanced movements such as in the Philippines, it is only through the ongoing process of active struggle can bourgeois hegemony in medicine by challenged!

Mocabog CHWs discuss their community concerns

ILPS Workshop12 114

The people must first be organized before power can effectively be exerted. The building blocks of power are mass democratic organizations of the working class.

Developing and then being persistent with a strategy is the only way we’re going to move forward with mass organized resistance. Being persistent means that we learn, we adapt, and we make changes where we need to based on our practical experience, but that we don’t give up on the long-term vision.

The Ongoing Role of the Alliance for People’s Health

The role that the APH plays in building a movement is expressed in our four-point strategy as explained in our APH Primer Spring 2013.

  1. Persistently raising the structural determinants of health and challenging the petty-bourgeois social determinants or bourgeois biomedical frameworks. The leadership the APH demonstrates in advancing an analysis of the structural determinants has been recognized internationally.
  2. Demanding the state provide access to adequate health care, through campaigns such as our dental campaign, and through our ongoing support of the call for Sanctuary Health!
  3. Advocating for community ownership and control of health services, and the development of community roles in health care such as Community Health Workers – reclaiming health knowledge and expertise! Training health care workers in popular education and people-centred techniques, as well as advocating for community members to reclaim control of preventative and curative health services is a major component of our strategy. We share our skills with communities locally and internationally.
  4. Providing concrete support to Liberation Movements across Turtle Island and the world. Supporting mass revolutionary movements for social transformation is in many ways one of our greatest contributions in this moment in the early stages of revolutionary movement building in Canada. Promoting and connecting health care students, workers, providers, and community members to revolutionary movements and struggles, and the comradeship the APH has built in people-to-people solidarity continues to be a beautiful and inspiring practice.

For after all, “only through our united efforts can we make a significant contribution towards a just, liberated and healthy world.”

Recommended readings:

The APH featured on Talking Radical Radio.

Ching, Pao Yu & Hsu, D. (1992). Mass Movement: Mao’s Socialist Strategy for Change. Available in: Revolution and Counterrevolution: China’s Continuing Class Struggle since Liberation.

Anne-Emanuelle Birn, Philanthrocapitalism, past and present: The Rockefeller Foundation, the Gates Foundation, and the setting(s) of the international/ global health agenda. Hypothesis 2014, 12(1)

Feo, O. (2008). Neoliberal Policies and their Impact on Public Health Education: Observation on the Venezuelan Experience. From Social Medicine.

Jardim, C. (2005). Prevention and Solidarity: Democratizing Health in Venezuela. From Monthly Review, January 2005.

De Ceukelaire, W., De Vos, P, & Criel, B. (2011). Political Will for Better Health: a bottom-up process. From Tropical Medicine and International Health.

Krieger, N. & Basset, M. (1986). The Health of Black Folk: Disease, Class, and Ideology in Science. From Monthly Review, July-August 1986.

Mullan, F. (2007). Seize the Hospital to Serve the People. From Social Medicine.

[i] Diabetes diagnosis and treatment in Indigenous and migrant communities is a sharp example of bio-medical reductionism that serves medical profiteering off of the impacts of colonization and forced migration on human biology. The primary problem is the destruction of traditional food systems in the transition to capitalism and forced migration for cheap labour. A de-colonizing approach (or geniune agrarian reform depending on the context) is the only approach that’s going to get at the root of the problem.  I’m not arguing that individuals should not treat their diabetes, or that community-based responses don’t exist. Rather I’m saying that diabetes is a disease of capitalism and colonialism and requires a deeper liberatory response for a true cure.

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Open Letter To the Public Health Association of British Columbia

To the Public Health Association of British Columbia (PHABC) Board of Directors,

We are writing to express our concern regarding the PHABC’s promotion of partnerships with the business sector at the conference “Shared prosperity for health and well-being: A collaborative dialogue between business and public health” on December 4-5, 2014.

Although the stated mission of these partnerships is “creating the conditions for health and well-being for all”[1], it is well-documented that markets are incapable of providing health services equitably across and within communities and do not serve the interests of those who cannot afford to pay. Julian Tudor Hart describes this as the inverse care law, where those with the greatest healthcare needs often receive the least adequate healthcare. In 1971, he wrote that, “the market distribution of medical care is a primitive and historically outdated social form, and any return to it would further exaggerate the maldistribution of medical resources.”[2] Over 40 years later his words are more urgent than ever.

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De-funding and privatization of public services have only intensified in the face of neoliberal policies, particularly in health. The private sector cannot fill these service gaps, and detracts from the responsibility of governments to provide public services in our right to health. Similarly, corporate projects of “social responsibility” are part of a growing arena of philanthro-capitalism where health is viewed as a profit-making and corporate investment opportunity.

Partnerships between the health and business sectors are fundamental contradictions: while our primary responsibility in health is to improve the health of our community, the primary aim of business is to serve shareholders in the accumulation of profit. Health care is not a commodity to be bought and sold, and we need only to look to the pharmaceutical industry to see that diseases of the poor receive little attention and monopoly over products (and services) inflates prices to unaffordable levels.

To improve health for all, we need to engage in concrete actions on the social and structural determinants of health[3]. The highly unequal distribution of power and wealth under capitalism are the main drivers of health inequities, which result in differential access to the resources that affect health, such as housing, income, and education. There can never be shared prosperity between health and business, as economic growth and wealth creation occurs at the expense of the politically and economically marginalized. This is particularly salient in British Columbia, where resource extraction is causing innumerable harms to the health of our communities and the environment. We only further entrench health inequities when our prosperity is gained at the expense of others. We can only improve the health of our communities when we work to increase their control and decision-making over their health care, resources, and their lives.

Image from Warrior Publications
Image from Warrior Publications

As health workers, researchers, and students, we urge the PHABC reconsider its direction in seeking partnerships in the private sector and to engage in critical dialogue on meaningful actions towards health equity.

Sincerely,

The Alliance for People’s Health

Jannie Wing-sea Leung, MSc
Leah Diana, RN
Azar Mehrabadi, PhD
Thomas Warren
Martha Roberts, RM, MSc(c)

Endorsed by:

People’s Health Movement – Canada

We invite individuals and organizations to endorse this letter. Action toward equity and justice is urgent. If you or your organization would like to endorse this letter, please contact us at allianceforpeopleshealth@gmail.com

[1] http://phabc.org/files/PHABC_2014_Call_for_Abstracts.pdf
[2] Hart JT. The inverse care law. The Lancet. 1971;297(7696): 405-412.
[3] World Health Organization (WHO). Closing the gap in a generation: Health equity through action on the social determinants of health. Final report of the Commission on Social Determinants of Health. Geneva (CH): WHO; 2008.

International Women’s Day 2013

iwd poster new

Women at the Forefront of Emancipation: Resisting Structural Violence and Exploitation!

Statement by the International Women’s Day Organizing Committee 2013

On March 8th International Women’s Day we raise our fists in solidarity with women struggling for emancipation and we stand united in defense of women’s rights, for genuine liberation for all women.

Women resist colonial occupation!
Today we rally on unceded Coast Salish territory; the traditional territories of the Squamish, Musqueam and Tsleil-Waututh peoples. Indigenous women bear a great burden of colonial occupation and yet across the globe it is Indigenous women who keep the fires of resistance burning in the face of displacement, ethnic cleansing, and genocidal attacks on Indigenous culture, history and traditions.

Indigenous women have never been idle! Palestinian women assert their right to return to the lands from which they were expelled by the Israeli colonial settler state. In India, Adivasi women struggle to protect their ancestral territories despite extreme state violence.

Women resist imperialist plunder of the land and natural resources!
Women lead pivotal struggles for environmental and economic justice in opposition to mining and extractive industries, tar sands, fracking fields, oil and gas pipelines, mono-crop agribusiness, and imperialist military aggression which leads to the destruction and poisoning of the earth.

Former Filipina political prisoner Angie Ipong spent 6 years in prison for joining peasant and Indigenous communities in their land struggles. Freda Huson and women of the Unist’ot’en clan of the Wet’suwet’en are defying pipelines and development aggression on their territories. Wahu Kaara and millions of women across Africa are fighting displacement, development aggression and colonial debt exploitation. These brave women inspire us to protect the Earth and our future generations!

Women resist capitalist exploitation!
Women’s reproductive labour continues to form the basis of capitalist profit as women provide privatized labour in the home and are segregated into ‘women’s work’ such as teaching, nursing, food service, and household management. Women’s work is devalued, and despite decades of struggle, women in Canada continue to be paid only 70% or less of what men earn. In Canada women comprise the vast majority of migrant workers from Asia, forced to migrate by neoliberal economic policies, providing deskilled and cheap labour, privatized health care, and modern-day domestic slavery to the Canadian middle and upper classes.

Migrant women in Canada face a triple-burden of racism, exploitation, and patriarchal violence, and yet women are on the frontlines of struggles against austerity and in defense of public services such as healthcare, daycare and public education. Migrant, immigrant and undocumented women workers,
often excluded from the mainstream union movement, defend and assert their rights through community organizations against great odds.

Women resist patriarchal violence!
There are over 600 missing and murdered Aboriginal women and girls in Canada. For decades women’s organizations have known that the police are integrated in a patriarchal justice system which fails to address violence against women, and in fact, forms a part of the problem. Prostitution, trafficking, and the sexual commodification of women is exploitation and violence against women for the purposes of capitalist accumulation, colonial control, and patriarchal power. It is time to decriminalize women in the sex trade and demand an end to the buying and selling of women! Male violence in the family, including in social justice movements, reinforces patriarchy and gives men individual power over women. It is time to hold men accountable for their sexist attacks against women.

We fight for all women to be free from male violence and sexual exploitation. We stand in solidarity with women who resist religious institutions, ideologies, and practices that suppress and govern women’s lives in all aspects: political, economic, and social limitations placed on women by reactionary theocratic regimes. Hands off women’s bodies and lives!

In India tens of thousands took to the streets in militant protests following the rape of women on a public bus, women political prisoners in Iran recently went on hunger strike to resist torture and degrading and inhumane conditions imposed by the Islamic regime, and in Canada Indigenous women lead the struggle for justice for their murdered and missing sisters, daughters, mothers and aunties.

Women Rising for Emancipation and Justice!
Women around the world are at the forefront of struggles for emancipation that ultimately seek to end capitalism, patriarchy, exploitation, and greed. We struggle to build a society based on collaboration, cooperation, self-determination, the fulfillment of human potential, and the survival of our planet.

  • We stand in solidarity with all women who struggle for emancipation!
  • Hands off women’s bodies and women’s lives!
  • Justice for all missing and murdered women!
  • Resist the plunder of our lands!
  • Long Live International Solidarity!

Host organizations:
ILPS-Canada
Iranian Left Alliance-Vancouver
Alliance for People’s Health
Canada Philippines Solidarity for Human Rights
Iranian Centre for Peace, Freedom and Social Justice
Migrante BC
International Federation of Iranian Refugees and Immigrants (IFIRI)

Interview on the Social and Structural Determinants of Health

The following is an excerpt from an interview between People’s Health Radio host Aiyanas Ormond and APH organizer Martha Roberts on the social versus the structural determinants of health.  Transcribed from the original interview done in the spring of 2011 on Co-op Radio.

Aiyanas:  What do we need to be healthy?

Martha: I think that’s an interesting question and we ask ourselves that at the APH on a daily basis, and really my answer to that question is another question:

What do you consider health?

This is one we’ve been exploring at the APH for the past five years because really I think there are a lot of ideas out there in the community about what is health.

If you look at the definition of health as the absence of disease or infirmity, then the answer to the question of “what do you need to be healthy?” would be a functioning body without any disease or discomfort, or pain; without any physical problems.  Of course, very few people actually define health this way, but we’re encouraged by the health messages we see to define health that way.  We need to be thin, we need to eat nutritious food, we need to get enough sleep at night. We need to do these things in order to have a functioning body.

We tend to look at it much more broadly.   If you look at the WHO definition of health, they say it’s a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity.  So then you get more into the nitty gritty of what is the quality of people’s lives, are they satisfied, are they happy, do they have a place to live, do they have enough to eat? We start getting into deeper questions of in our lives do we have our needs met and are we fulfilled as human beings?  We tend to go this way at the Alliance for People’s Health

What do I need to be healthy? I need to have my basic needs met and I need to have something in my life that I do, or a place that I fit, where I’m welcomed and where I feel like I have fulfillment as a human being.

Aiyanas: Which brings me to the next question.  The Alliance for People’s Health makes a distinction between the social determinants of health, which is that idea of having your basic needs met, and the structural determinants of health.  Can you explain what that distinction is and why you think it’s important?

Martha: Our health care system is designed on the biomedical model, which is that first definition of health, that it’s the absence of disease or infirmity. Really if you look back through the history of medicine and the development of medical sciences you’ll see that it’s really founded on this reductionist principle that if there’s something wrong in our bodies and we’re unhealthy or we have a disease that it’s a matter of fixing a tube or a pipe or a chemical process that leads to a malfunction in our body in much the same way that we’d view our car.  If our car breaks down, if the tailpipe starts to smoke, if we hear a rattle, we take it to the auto mechanic, the mechanic puts it up on a lift, looks underneath, runs a few diagnostic tests, and says, “Ah ha, you need a new carburetor”, not that I know what a carburetor is, but it’s an example.  And so we buy a replacement part or we add some oil, or we add some kind of a chemical that makes the vehicle function better.

Well we’ve pretty much been able to say that’s too reductionist, human beings don’t function that way. So then the new fad, the new trend, is the social determinants of health.  New in the last I’d say three decades, really, spearheaded by the public health movement that says people aren’t just machines, that they’re actually influenced by their environment.  And so if we’re saying health is complete physical, mental and social well-being, what are those social determinants? So we say, well, if you look at people in the community, their biggest determinant, honestly, is economics; do they have money? Do they have money to access to have those things I mentioned before, the things that I need? I need a house, I need food, I need a job so I can pay my rent, I have to send my kids to school, I need childcare for when I’m working. So we say access to money and resources are the social determinants of health.  We need employment, we need housing, we need food, and we need education for ourselves and for our families.

If you look at the Ottawa Charter for Health or if you look at how the Canadian Government defines social determinants of health, we’ll see these things.  It also includes things like access to medical care.  We need to be able to see a physician or go to emergency if we break our arm.  We need these things in our lives in order to function as human beings in society.

Aiyanas: So those are the social determinants of health.

Martha: That’s the social determinants of health.

But really, you dig a little bit deeper than that and say, that still doesn’t make the cut.  We have working class communities where all of their needs are met and they still lead significantly less healthy lives, by any way we counted, than their counterparts in upper and middle class communities. And we say, “Why is that”?  So we have to dig a little bit deeper.

Then you get into the work of someone like Richard Wilkinson who says there’s a social gradient, and people are unhealthy along that social gradient.  At the APH we call that class.   Everyone has a social location in the economy and where that social location is, according to the role they play in society, determines whether they’re going to be healthy or not.

That leads us to a third point. So if we say it’s not just the social determinants of health and it’s not just your social location, then we get into what Vicente Navarro calls the structural determinants of health.  And that’s really the root of our analysis at the Alliance for People’s Health. It’s not just having access to those resources, but actually having control over those resources, that fundamentally makes the difference in people’s health.

So you can give someone food at a food bank, or you can have someone actually possess enough money to go to the grocery store and go shopping and choose their own foods. And you can guess who’s going to be healthier at the end of the day.  It’s the person who has the ability, the money, the control in their lives to decide what they’re going to eat, that actually has better nutrition, and not just nutrition, but sense of self, sense of well-being, sense of control over their lives.

At the APH we say ultimately what we need to be looking at are the structural determinants of health. That’s power in our society to make decisions, not just over your own life, but over the whole functioning of your community, and the control over the resources that you need to make the changes that need to be addressed.  That’s why we see the social gradient. It’s not just happenstance that working class communities suffer less health, they suffer less health because they rely on state services and charity and have to struggle for the things that they need, whereas people in the upper classes have the things they need taken for granted.

Aiyanas: So what’s the strategy at the Alliance for People’s Health for challenging that?  And especially considering that it’s more than just a health gap that’s associated with the wealth gap, but it’s actually about power and control over our communities and our society.  What’s the APH approach in terms of a strategy?

Martha: I think we have two approaches.

One is that we don’t say that the social determinants of health aren’t worth looking at.  We do agree, yes, there is definitely something to the social determinants of health. We start with that.  We have community health projects where we say, you know what, if we need food or we need information about something, we need to know how we can get into social housing, we need to have basic health education about how to take care of ourselves and our families, where to access resources; let’s start with this.  We have community health projects, where as health workers, because many of us are health workers, though some of us are community health organizers and community members passionate about health, let’s spread the knowledge around!  Let’s get together as a community and ask how can we get the things that we need and how can we take care of ourselves?  How can we address the question of the basic needs?

And then the second thing is to actually get involved from there in making changes.  And there are two kinds of changes we want to make at the APH.  There are the changes that demand more access to social services; the government needs to provide us more state services. We need to stop cutting social programs; we need to stop cutting back MSP-insured services. And simultaneously we need to start struggling as working class communities to expand social services again in the context of the expansion of budgets for business and the military.  We need to say these things are unacceptable and we need to struggle for social services.

We actually need to engage people in that struggle.  That for me, as an organizer, is the biggest thing we can do. If you remember back to my answer to the question, what do we need to be healthy, people need something in their lives where they feel they’re exhibiting control, and they have a meaning or a purpose. Being involved in the struggle for the health of your community through political campaigns and community health projects actually improves people’s sense of dignity, it improves their sense of self-worth, it provides them a community that’s supportive, and it improves their own sense of health and well-being.

Contesting Neutrality Part II: What’s a Radical Health Worker To Do?

“Lincoln Hospital Belongs to the People”
From left to right: Dorothea Tillie, Cleo Silvers (seated), Pablo Guzman (seated), Juan Gonzalez (standing), Andrew Jackson (seated, face partially obscured); others unidentified. Collection of Hiram Maristany.
From Social Medicine Vol 2, No 2 (2007)

Monday October 29th
6:30: Movie ‘Diagnosing Poverty: Building Community’ and light meal
(optional)
7:00 – 9:00: Group discussion

Please RSVP if you plan to attend and for directions to the meeting location: allianceforpeopleshealth@gmail.com

In the context of roll-backs in public health services such as essential health care coverage for refugees, attacks against public sector workers, a crisis access to post-secondary education due to rising tuition costs, and the rapidly escalating cost of living, more than ever working class and marginalized communities struggle to make ends meet and still fall short of the basic requirements for health.  How can we achieve health for all when we’re spending all of our time filling in the gaps and healing the wounds inflicted by the injustice of capitalism?

Taking cue from those health workers standing up for refugee health, and drawing inspiration from students in Quebec, the APH invites you to participate in a discussion of what a progressive health movement looks like.  Who participates in this movement? Who leads it? What kind of organization would it take to fight back?  What are the demands that unite us? What is our vision of health for all?  Ultimately, we ask ourselves, as radical health workers, what can we do together to transform our system and to struggle long-term for social justice?

Recommended reading “Is Capitalism a Disease: The Crisis in US Health” by Richard Levins. If you only have time to read part of the article we recommend you focus on the section Responses to the Crisis on pages 18-23.  If you don’t have time to read any of the article, that’s OK! Please join us for the discussion!

At 6:30 we will show the 30 minute movie “Diagnosing Poverty: Building Community” about Community-Based Health Programs in the Philippines and share a light meal together.
At 7:00 we will begin our discussion

Check out this article: Seize the Hospital to Serve the People and the video interview with Cleo Silvers who was active in the campaign to Seize the Hospital to Serve the People

MORE ON DIAGNOSING POVERTY: BUILDING COMMUNITY: “This is a story of Baby Jessie, a child from an indigenous community in Bukidnon, Philippines who almost died because of government neglect and wrong priorities. A story of ordinary people’s courage to organize and mobilize themselves to overcome poverty and build a healthy society. Produced in cooperation with Intal. Diagnosing Poverty, Building Community is an official selection to the New York International Filipino Film and Video Festival 2005.”

Cuts to Interim Federal Health, Forced Migration, and Imperialist Globalization

This talk was given by APH organizer Martha Roberts at this recent event organized by No One Is Illegal

Greetings from the Alliance for People’s Health.  I’d like to start by applauding No One Is Illegal for hosting this timely round table and raising the level of the conversation on migration and repression.  I’d like to thank you for asking me to speak today to share our perspective on the cuts to interim federal health and the consequences of imperialism on the people’s health.

1.      Impacts on Health

I work as a Registered Midwife in Vancouver providing prenatal, intra-partum, and postpartum care to new moms and babies until 6 weeks of age.  In plain language, I look after pregnant mamas and deliver babies.

Following the cuts to the IFHP prenatal care coverage for refugees will depend on if their country of origin is listed as a Designated Country of Origin (DCO); the list of DCOs is not yet public.  Prenatal care for women not from DCOs will continue to be covered.  If they are from a DCO (European countries, some speculation re: Mexico and Latin America) prenatal, intra-partum, and postpartum care will not be covered.  Medications will not be covered to any refugee, unless the diagnosed health condition poses a risk to Canadians.  Pregnant women suffering from gestational diabetes, preeclampsia, hypo or hyper-thyroid, or other serious disorders of pregnancy will not have coverage for their medications[i].

On February 27, 2012, the CBC ran a story “Mom without medicare gives birth in hotel: Immigration backlog left pregnant wife of Canadian without status”[ii].  This story caused a flurry of discussion amongst midwives and maternity care providers about caring for women without medical insurance, the potential risks involved for moms and babies, and the high possibility of poor outcomes which have a devastating impact on both care providers and parents.   Women who must self-pay for prenatal care book late into care, are far more likely to decline screening and diagnostic tests, and are forced to balance financial risk with risk of undiagnosed and untreated complications for themselves and their babies.  The mom in the CBC story was a healthy white woman of Scottish descent from a relatively privileged background; what of those whose stories aren`t told?  We know as maternity care providers and in my personal experience as a midwife, working class, marginalized, and racialized women experience poorer birth outcomes, including but not limited to higher rates of hypertension, premature birth, and low birth weight babies.  It is only a matter of time before the impacts of these cuts begin to be realized on a generation of babies born without proper health care.

The cuts to Interim Federal Health are reinforcing and expanding a three-tiered system of health care in Canada.  The first tier is those who can afford privately funded supplemental care over and above what is provided by MSP; the second tier is those who are limited to what the public insurance system will cover; the third tier is those who are denied access to public insurance and segregated as non-deserving; left to fend for themselves in a convoluted maze of bureaucracy, negotiating scraps of piecemeal care.  As immigration requirements continue to tighten, this third-tier will continue to expand.

2.      The Health Sector Response – Petty Bourgeois Politics

Actions from physicians, nurses, midwives, and medical students have been inspiring and at times courageous as they confront Minister Kenney and other Conservative Cabinet Ministers to demand a stop to the IFHP cuts.  As an anti-imperialist and international solidarity activist I am moved by the actions of the professional health sector, which historically has been predominantly a reactionary force.

As a true reflection of its petty bourgeois class position, the Society of Obstetricians and Gynecologists of Canada issued a statement on June 4th supporting the Conservative decision to cut the IFHP, recognizing that “spending from the public purse in support of health services is reaching crisis proportions” and that “products and services must be dispensed in a fair and equitable manner that is consistent with what Canadian tax payers are currently entitled to”[iii].

The majority of health professional associations are standing up in defense of refugee rights to access to health care, and I agree with the three basic tenants of their arguments:

1. Spending and budgetary constraints: that cuts will not be a cost savings but will off-load federal spending onto the provinces as more and more folks show up in emergency rooms and health conditions are exacerbated by lack of timely care;

2. Helpless and deserving recipients: that refugees deserve our help as Canadians; here I quote from the Huffington Post, “Dr. Mark Tyndall, a physician in Ottawa, says these “unfair and unethical” cuts would reflect poorly on Canada, by “taking the most disadvantaged and traumatized human beings on Earth and telling them we have been too generous for too long.””[iv]

3. Moral obligations under international law: references to Canadian obligations as a signatory on the Universal Declaration of Human Rights and the legal, moral obligations of states to provide equally for all.

I don’t dispute any one of these popular positions.  What troubles me as an anti-imperialist are the narrow confines of the discussion, reflecting the petty bourgeois class interests of the health professionals, which, unfortunately, based on my personal experiences of discussion in the community of midwives, can be boiled down to whether or not the health care provider gets paid for the work they do.

3.      The Right to Rebel – A Working Class Response

It’s time to blow up these three narrow positions and take a more comprehensive anti-imperialist approach to defending the rights of all migrants, whether refugee claimants, economic migrants, or undocumented workers.  As the health sector, it’s time to oppose war, occupation, and unjust trade as the roots of forced migration, and take a stand on the side not just of more obligations, but of justice.

The health sector needs an anti-capitalist approach.  Let’s broaden the discussion of budgetary constraint and spending and examine the entire federal budget.  Why are we trapped in a discussion of health care spending?  The federal government’s Canada Health Transfer is 29 billion for 2012-2013[v], while Department of National Defence spending has reached $22.5-billion[vi].  The projected cost savings through cuts to the Interim Federal Health Program over the next five years is $100 million or 20 million annually[vii].  And yet on June 8th the Canadian Armed Forces announced a 708.7 million dollar contract to purchase 500 Tactical Armoured Patrol Vehicles (TAPV)[viii].  Further, the Department of Energy and Natural Resources has committed millions in tax credits to support the expansion of the mining and extractive industries which plunder Third World and indigenous territories, and Export Development Canada continues to mitigate financial risk for overseas exploration.

If we’re to move beyond a losing reformist struggle we’ve got to move beyond the arguments of the capitalist states and advance our own positions.

The health sector must stand against national oppression.  It’s time for the health sector to drop the language of “deserving” and stand up against Canadian foreign and military policy; we’re culpable in forced migration.  Canada continues to sign trade agreements with Israel and support the Israeli apartheid.  Canada continues to expand ‘investment defense’; defending capitalist profits at the expense of oppressed nations and peoples.  As a NATO member, the Canadian military is responsible for oppressive occupations and imperialist wars of aggression: currently Canadian Forces are leading Operation Artemis in the Arabian Sea, Operation Attention in Afghanistan, and Operation Calumet in the Sinai Peninsula in Egypt as three examples[ix].  In the recent past Canadian Forces have engaged in operations in Haiti; Canada spent 347 million dollars and engaged in 733 bombing sorties above the North African nation of Libya[x]; and contributed to the training of repressive and murderous counter-insurgency forces in the Philippines.

Now is the time for the health sector to stand up for women`s rights and against patriarchy.   Migrant women have a long history of exploitation under Canadian temporary foreign worker programs.  It is women who will pick up the slack from cuts to health care insurance programs; it is women who bear the greatest economic burden of forced migration, and who bear the greatest burden of reproductive and caring labour.

I`d like to close by stating again that I applaud the professional associations and progressive health workers for standing up for the rights of migrants to access publicly insured health care in Canada.

Let’s build people’s institutions to care for those who lack access to public health insurance; democratic people’s institutions that address the structural as well as the social determinants of health!

Let’s stand in solidarity with the people’s legitimate right to self-defense and movements for national and social liberation!

At the Alliance for People`s Health we call on health workers to take that struggle one step further and hold the Canadian State accountable for the creation of unjust conditions which force migration, and for the exploitation of migrants in Canada.

Thank you

[i] Ontario Association of Midwives public policy analyst email communication, May, 2012

[ii] “Mom without medicare gives birth in hotel: Immigration backlog left pregnant wife of Canadian without status.” By Kathy Tomlinson, CBC News. Posted: Feb 27, 2012 6:58 AM ET: http://www.cbc.ca/news/canada/story/2012/02/24/bc-motelbaby.html

[iii] Society of Obstetricians and Gynecologists of Canada. 4 June, 2012. POSITION STATEMENT: Federal budget cuts to the Interim Federal Health Program.  http://www.sogc.org/documents/medRefugeeHealthBenefitsStatementENG120604.pdf

[iv] Ritika Goel and Naheed Dosani..  No Refuge for Refugees in Health Care.  Posted: 06/11/2012 12:03 pm. http://www.huffingtonpost.ca/ritika-goel/refugee-health-care-canada_b_1579385.html

[vii] Ritika Goel and Naheed Dosani..  No Refuge for Refugees in Health Care.  Posted: 06/11/2012 12:03 pm. http://www.huffingtonpost.ca/ritika-goel/refugee-health-care-canada_b_1579385.html