PUBLIC HEALTH UNDERSTANDINGS OF POLICY AND POWER: LESSONS FROM INSITE. Patrick Fafard February 2011

Transcription

1 PUBLIC HEALTH UNDERSTANDINGS OF POLICY AND POWER: LESSONS FROM INSITE Patrick Fafard February 2011

2 Outline 1. INSITE a brief review 2. INSITE and Knowledge Translation 3. Public health / health equity need a theory of politics and of policy-making to understand the place of: a. Science b. Social Justice 1. The way forward INSITE as a case study of political advocacy / mobilization not conventional KT

3 1. INSITE a brief review 1,2 Crisis in HIV in Vancouver in the late 1980s Coalition building and political pressure the four pillars strategy including harm reduction From harm reduction to a safe injection site INSITE opens in 2003 Conservative Government in Ottawa is elected in 2006 and is opposed to harm reduction and INSITE The matter moves to the courts and will be decided by the Supreme Court of Canada sometime in 2012

4 2. INSITE and Knowledge Translation

5 Phase One KT before INSITE opened Growing interest in harm reduction Safe injection sites in Western Europe A sense of crisis about HIV rates in the Downtown Eastside Community and eventual political leadership to create a safe injection site, notwithstanding the lack of evidence INSITE is launched as a research project to fill the gap

6 Phase Two INSITE as a research project British Columbia Centre for Excellence in HIV/AIDS and others Dissemination in high quality peer-reviewed journals one of the most evaluated health care programs in Canada. 11

7 Phase Three INSITE as a political battle Election of a Conservative government in 2006: tough on crime agenda: cuts funding for research one-year exemption from the Controlled Drugs and Substances Act Health Minister describes INSITE as an abomination BC Centre for Excellence in HIV/AIDS launches a multi-pronged KT strategy 10 Broad definition of KT 10 Media engagement Plain language summaries Oral presentations Political commentaries Increasing appeals based on the health needs of drug users: Appeals to a particular conception of social justice 9

8 Phase Three INSITE as a political battle Conclusion of many in the scientific community: Scientific evidence is trumped by ideology 11 KT approaches do not work in the face of ideological conviction and politics 10,11 Paradox: All policy decisions are based, at least to some extent, on politics and ideology Explanation: (Some) proponents of INSITE do not have an operative theory of policy-making or politics

9 3(a) The need for a theory of politics and of policy-making: science The public health enterprise 21 needs a theory of policymaking and the role politics and ideology play in the policy-making process Absent a robust theory of the policy-making process when considering the role and place of scientific evidence public health falls back on a problem-solving, linear conception derived from clinical medicine

10 The health sciences standard model

11 Policy-making is more that just the application of evidence While policy-oriented researchers may want to speak truth to power the powerful are by no means obliged to listen and often do so when it best suits them. 16 In areas of controversial public policy, offering the valueneutral perspective of technical experts focused solely on evidentiary issues is not enough. 17

12 Policy-making must be more that just the application of evidence - values In public health: as interventions become more complex, as the goal shifts to promoting health equity the inevitable result will be conflicts in values Politics is the means by which we manage and hopefully resolve these value conflicts Thus all policy decisions are, at least to some extent, political

13 3(b) The need for a theory of politics and of policy-making: social justice

14 INSITE and social justice INSITE as a project is a mix of science and social justice Harm reduction s central theses espouse a neutral view of drug use and drug policy based on science, not ideology or morals. At the same time these declare support for rights and social justice - convictions that in no sense can be seen as value neutral. 22

15 Public health and social justice Along with science, social justice is a central animating idea of the public health enterprise. Social justice is often the primary organizing moral principle behind public health arguments, and dialogue about public health policy has been biased towards this perspective. 23

16 Public health, health equity and social justice Promoting health equity means thinking of individual and community health in terms of: jobs/working conditions education housing etc. More broadly: when societal resources are distributed unequally by class/race population health will also be distributed unequally

17 Public health, health equity and social justice Yet, how and why societal resources are distributed is not something that can or will be resolved with reference to science. Deciding what constitutes a just allocation of resources requires both a theory of justice and a theory of politics

18 Public health, health equity and social justice Philosophers have offered a number of theories of justice Some allow for some degree of inequality (e.g., John Rawls 12 ; Robert Nozick 13 ) Others call for a radical redistribution of resources (e.g., G.A. Cohen 14 ; Amartya Sen 15 )

19 Public health, health equity and social justice The public health enterprise tends to be based on egalitarian theories of justice even while other powerful societal actors do not Moreover, public health often rejects any limit on minority rights that has a negative impact on health even while other powerful societal actors seek to balance individual and community rights

20 Public health, health equity and social justice Thus, promoting health equity will inevitably mean engaging in the conflict between different theories of justice Once again, resolving such conflicts is the stuff of politics and political debate

21 3. The argument in brief 1. The proponents of INSITE wish to juxtapose science and politics/ideology 2. Yet, we know that policy-making is inherently and necessarily a political process 3. The public health enterprise is animated by two broad ideas: science and social justice 4. Therefore, public health needs a theory of the policy-making process that accounts for the role of science and debates about social justice 5. Policy making is not the result of the application of science nor is it the inevitable result of a dominant, egalitarian theory of justice

22 4. Conclusion - the way forward: if public health is inevitably about politics Recall that the story of INSITE can be divided into three phases: 1. Advocacy and community mobilization to Research and KT A return to advocacy (and the courts) 2005 onwards Thus, advocacy and coalition building is at the heart of the INSITE and, I would argue, the public health enterprise The social sciences provide a rich array of theories to explain the success or failure of advocacy and successful examples of coalition building (e.g., Kingdon 20 )

23 Thank you! Patrick Fafard Graduate School of Public and International Affairs University of Ottawa

24 References 1. Dooling K, Rachlis M. Vancouver's supervised injection facility challenges Canada's drug laws. CMAJ. 2010;182(13): Campbell L, Boyd N, Culbert L. A Thousand Dreams: Vancouver's Downtown Eastside and the Fight for Its Future. Greystone Books; Wood E, Tyndall MW, Zhang R, et al. Attendance at supervised injecting facilities and use of detoxification services. N Engl J Med 2006; 354: Kerr T, Stoltz J, Tyndall M, et al. Impact of a medically supervised safer injection facility on community drug use patterns: a before and after study. BMJ 2006;332: Expert Advisory Committee. Vancouver s INSITE service and other supervised injection sites: What has been learned from research? Ottawa (ON): Health Canada, Milloy M, Kerr T, Tyndall MW, et al. Estimated drug overdose deaths averted by North America s first medically-supervised safer injection facility. PLoS One 2008; 3:e Wood E, Tyndall MW, Lai C, et al. Impact of a medically supervised safer injecting facility on drug dealing and other drug-related crime. Subst Abuse Treat PrevPolicy 2006;1: Bayoumi, AM, Zaric, GS. The cost-effectiveness of Vancouver s supervised injection facility. CMAJ 2008;179: Small D. An appeal to humanity: legal victory in favour of North America's only supervised injection facility: Insite. Harm Reduct J. 2010;7: Debeck K, Kerr T. The use of knowledge translation and legal proceedings to support evidence-based drug policy in Canada: opportunities and ongoing challenges. Open Medicine. 2010;4(3):E167-E Hwang SW. Science and Ideology. Open Medicine. 2007;1(2).

25 References (continued) 12.Rawls J. A Theory of Justice: Revised Edition. Revised Edition. Belknap Press of Harvard University Press; Nozick R. Anarchy, State, And Utopia. Basic Books; Cohen GA. Rescuing Justice and Equality. 1st ed. Harvard University Press; Sen A. The Idea of Justice. 1st ed. Belknap Press of Harvard University Press; Burton P. Modernising the Policy Process. Policy Studies. 2006;27(3): Fry C. Applied ethical reflections on the operation of a Geneva drug consumption room: Opportunities for enhanced harm reduction practice. International Journal of Drug Policy. 2006;17(1): Burton P. Modernising the Policy Process. Policy Studies. 2006;27(3): Fry C. Applied ethical reflections on the operation of a Geneva drug consumption room: Opportunities for enhanced harm reduction practice. International Journal of Drug Policy. 2006;17(1): Kingdon JW. Agendas, alternatives, and public policies. Longman; Tilson H, Berkowitz B. The public health enterprise: examining our twenty-first-century policy challenges. Health Aff (Millwood). 2006;25(4): Hathaway AD, Tousaw KI. Harm reduction headway and continuing resistance: Insights from safe injection in the city of Vancouver. International Journal of Drug Policy. 2008;19(1): Alderman J, Dollar KM, Holtz TH. Commentary: Understanding the origins of anger, contempt, and disgust in public health policy disputes: Applying moral psychology to harm reduction debates. J Public Health Pol. 2010;31(1):1-16.