Health Care as Social Justice Practice

As neoliberalism continues to erode access to a publicly-funded health care system in Canada, people’s health organizers are working to improve the health of working class and marginalized communities. This budding movement seeks to defend and expand upon existing health and medical services. At the same time, organizers are establishing parallel initiatives that bring together workers and participants in health programs to mobilize for their shared interests. For instance, the Vancouver Area Network of Drug Users (VANDU) consists of initiatives ranging from advocacy of harm reduction programs (e.g. safe-injection sites for heroin users), to advocating for housing access for the poor, to seeking increased pedestrian safety in Vancouver’s Downtown Eastside. The health justice movement has also built networks that focus on advocacy and education – including the Alliance for People’s Health, a grassroots organization of progressive health care workers fighting for health for all, and the People’s Health Movement, an international alliance of activists and organizations. These networks have taken on campaigns to influence policy, build coalitions, form international delegations to support peoples’ liberation, as well as consolidate efforts to build community power and democratic control over people’s health through advancing community-based health knowledge and building working-class control over health and health care services.

This movement brings together organizers from diverse backgrounds who seek to extend or challenge prevailing health care models, while also filling the many gaps around professionalized medicine. Some activists in the movement are licensed medical professionals – such as physicians and midwives – who work to develop practices that extend beyond the dominant state-sanctioned biomedical approach to medicine. A biomedical approach defines good health as an absence of disease or infirmity and approaches treatment of disease and infirmity primarily through professionalized clinical treatment based on bourgeois scientific principles combined with pharmaceutical treatment. This approach neglects underlying social and economic causes of poor health, such as inequality, poverty, and community disempowerment. As organizers work to ensure health care access for all, they seek to deepen public understandings of the causes and consequences of poor health by increasing community participation in health programs.

In this roundtable, organizers reflect on Canadian-based people’s health initiatives. This organizing is embedded in much wider international struggles for liberation and justice. The movement has drawn inspiration from initiatives abroad, and collaboration across borders is well underway. In many contexts, the movement is seeking to bring health care into alignment with the broader goals of economic and social justice for all.

Baijayanta Mukhopadhyay is an immigrant who made Montreal home, but is currently working as a rural family doctor in northern Ontario. He is an organizer with the Canadian chapter of the People’s Health Movement and is a co-representative for the North America region on its global steering council.

Aiyanas Ormond is a community health worker and organizer with the Vancouver Area Network of Drug Users (VANDU) and a member of both the Alliance for Peoples’ Health and Red Sparks Union, which supports national liberation struggles.

Martha Roberts is a Registered Midwife with the Strathcona Midwifery Collective and an active organizer with the Alliance for Peoples’ Health, a grassroots organization of health workers and community organizers fighting for health for all.

Tell us about yourselves. What is the health work you are engaged in?

Martha: I’m involved in health work in a number of ways. I’m a midwife with the Strathcona Midwifery Collective in the Downtown Eastside, providing prenatal care to women in our community. I’m also a member of the Alliance for Peoples’ Health (APH), a grassroots organization of health care workers and community organizers who are struggling for health for all through political education, community action, and international solidarity with liberation struggles.

Aiyanas: I work as a community organizer for VANDU, a grassroots organization of current and former drug users, which works to improve the lives of people through user-based peer support and education for people who use illicit drugs. VANDU is an organization with more than 2000 members, mostly very poor people who live in the Downtown Eastside, who are daily users of cocaine, opiates, crystal meth, and other currently illegal drugs. About half of the VANDU membership is Native. VANDU works on harm reduction in relation to consumption of currently illegal drugs, but also takes on broader issues of concern to our membership – including pedestrian safety, welfare rates, access to public toilets, and police violence and harassment in our community. I’m also a member of the APH and have done international solidarity work in the health sector with the Philippines and Palestine through the APH.

Baj: I work mainly as a rural family doctor in Indigenous communities and mining towns; currently I’m in northern Ontario, but I’ll soon be in Quebec and Saskatchewan as well. I spend a lot of time in acute care settings, including emergency rooms and medical wards, but I am committed to the principle of comprehensive, accessible primary health care, which seeks to provide preventative, community-based medicine.
Over the last two years, I have become increasingly involved in the People’s Health Movement (PHM), which is an international network of health justice activists who are concerned about the impact of neoliberalism on health, although each individual chapter has considerable autonomy in its organising. I have been focused on helping build the Canadian network. Here, we want to work on how resource extraction based economies shape people’s experience of health and illness. We strongly believe that communities mobilize most effectively for health when they take into account the economic and political determinants of people’s well-being.

In your experience, what are the major determinants of health in our communities? Do you think “social determinants of health” is a helpful term or perspective?

Martha: I try to take into account every aspect of the lives of folks in my community, so I see the terrible consequences that years of poverty, alienation, and exploitation have on their health. When we talk about this context at the APH, we try to move quickly from the social determinants of health into deeper roots of ill-health, which we call the structural determinants of health. I think this is an important distinction. The social determinants of health are services, goods, and our social environment, like housing, decent jobs, childcare, and respectful and supportive social relationships. These things are important, but more factors must be addressed. Our health problems are rooted in capitalist exploitation: capitalism makes people sick. For me, addressing the structural determinants of health will require an anti-capitalist movement for social transformation. If we want to be healthy, we need to be able to exercise at least some degree of control over our jobs and our communities, as well as have democratic control over how our collective resources are used. We need to demand an end to reliance on charity. Charity doesn’t improve health. Community power and control do.

Aiyanas: I totally agree with Martha. During four years of working with drug users in the Downtown Eastside, I have observed the consequences of a public health approach to drug use; the safe fixing site run by the Portland Hotel Society and Insite in Vancouver work within a harm reduction framework, which includes needle exchanges, and it has had a definite impact on limiting the spread of HIV and decreasing rates of overdose. However, it hasn’t really improved people’s health or well-being. Poor people who use drugs in our neighbourhood are living longer because they are less likely to either die from HIV or an overdose. Otherwise, they remain as unhealthy as ever, and rates of hospitalization have actually increased.
Certainly that’s partly the result of the social determinants of health. Welfare rates have not increased, so people are poorer than ever. Homelessness has increased over this time. And people still face horrible stigma and discrimination in trying to access health care.

Baj: Like Martha, I prefer to avoid the language of social determinants of health, except when I am inhabiting institutional spaces in which it is required to make myself understood or helps develop common analyses. I prefer to talk explicitly about the political and economic factors that shape people’s experience of illness. A well-known example is northern food supply systems. The twin forces of forced settlement and commodification of food have diminished sustainable food choices over the last few decades, leading to a tremendous increase in the burden of disease. Members of these communities are now making concerted efforts to restore more traditional diets within the constraints of contemporary life. Perhaps we shall see data that shows a change in health outcomes in the coming years as a result. But, essentially, health is determined by decisions made by people for themselves – though not with the unfettered freedom of individual will and whim because that type of libertarianism does not allow for a purposeful, healthy shaping of a shared environment. People who are participants in a particular ecological context should decide how the resources in their region are managed for optimal well-being. Inhabitants should not be pressured by external forces into using resources in ways that do not promote good health.

As a clinician, I try to integrate an analysis of how people experience these factors on a personal, day-to-day level through their illness. Physiological distress makes people vulnerable on many levels, and these vulnerabilities are exacerbated by those distresses that politics, history, economics, and society press upon people. In many ways, humans are like broken vases – we glue ourselves together to be functional on a daily basis but given a certain amount of stress at a certain angle, we crack along all the old fault lines. When the body registers pain, old wounds start to throb, too, as neural pathways formed long ago are triggered once more – every insult, every injury, every injustice shadows every illness. Nazim Hikmet’s poem, “Angina Pectoris,” encapsulates this idea much more eloquently:

If half my heart is here, doctor,

the other half is in China

with the army flowing

toward the Yellow River.

And, every morning, doctor,

every morning at sunrise my heart

is shot in Greece.

And every night, doctor,

when the prisoners are asleep and the infirmary is deserted,

my heart stops at a run-down old house

in Istanbul.

And then after ten years

all I have to offer my poor people

is this apple in my hand, doctor,

one red apple:

my heart.

And that, doctor, that is the reason

for this angina pectoris -

not nicotine, prison, or arteriosclerosis.

I look at the night through the bars,

and despite the weight on my chest

my heart still beats with the most distant stars.

What seem to be trivial concerns to bring to a doctor are often surface symptoms of deeper unease, old worries, half-forgotten pain, and more profound insecurities. In the context of patriarchy, I do not think it is an accident that women seek care for their health more than men do. So much damage is absorbed by women that only emerges later in conditions that may have no name. Unpacking this life narrative in a busy emergency room is not always easy – and sometimes, abdominal pain is not a repressed trauma bursting forth, but really just a burst appendix. Developing this sense of what the range of real discomforts may be compels me to engage in medical education in a way that trains healers, instead of technicians of biomedicine.

Aiyanas: But “social determinants of health” also says to me that no health policy exists that addresses the underlying causes of ill health in our community. These causes include addiction, which stems from colonization, displacement, the structural violence of capitalism, and a society that isolates, marginalizes, and ignores people’s suffering from individual experiences of trauma and grief. These structural determinants of health need to be addressed through organizing and political struggle.

Does the health work we do address injustice in the social structures and contribute to struggles for social justice? How can we address injustice through health work?

Martha: My academic research looks at how women often decline prenatal care because the content is geared towards risk screening and some degree of social control, especially for working class and systemically-marginalized women. The class and ideological divides between petty bourgeois or bourgeois professionals and working class and marginalized women is profound. Many prenatal programs for poor moms (like Healthiest Babies Possible) are designed to address the “special” needs of poor women. These programs have charitable components, coupons, and so on, and they treat clients like they are stupid and want to live in unhealthy situations. It feels horrible to be treated that way. When I was pregnant, I decided that contact with that kind of health care harmed me more than it helped and I steered clear of prenatal programs.
We’re trying to do it differently at the Strathcona Midwifery Collective. Our model approaches pregnancy and birth as times when women start to exercise some form of power and control over their lives. Supporting that process means spending a lot more time with the families in our care, providing good information and being with women as they make their decisions, and respecting their choices even if we might have made different ones. As a small collective of midwives, we recognize that we don’t have the ability to change the power and control families have over much of their lives, but in our clinic and in our community space, we build reciprocal relationships based on respect, friendship, and mutual aid. Finally, we believe that babies and children bring joy to people’s lives; we deeply respect the right of working class and systemically-marginalized parents to raise their own children without interference from the state.
At the APH, we believe not only that communities should have democratic control over local health services, but that working class communities can also have critical insights into our understandings of health and disease, as well as the design of preventative health programs. We also talk a lot about patients’ rights, and these rights include elements of justice, for sure.

Baj: The People’s Health Movement explicitly addresses the issue that health for all cannot be achieved without addressing injustice perpetuated in our societies. What proves to be a greater challenge for me is translating this commitment into the demands of everyday clinical practice. I, along with many other colleagues, struggle to make clinical work political work. Work that interrupts the demands of clinical logic with revolution, as it were. It is not easy. I think I have engaged in truly liberationist medicine only once or twice in my five years of clinical training and work. The great potential for liberation could happen by breaking down the isolation of illness, by connecting people to others in similar sorts of pain, by recognising that pain has patterns, and by realizing they are not alone in their struggles – that poor health is in fact a collective experience borne unfairly and more often by certain people than others. Making these connections goes against the grain of many principles we have come to value in biomedicine –that is, one-on-one care, individualised treatment plans, relationships based on confidentiality, and so on. Trying to be a clinician while challenging the ways in which contemporary healthcare perpetuates unjust distributions of power and resources is difficult – but it is not impossible.

Aiyanas: VANDU strives to address injustice in existing social structures, so it is grassroots, it is participatory, it is democratic, and it is actively engaged in trying to change the conditions that make the lives of people who use drugs so difficult. This process includes holding five weekly meetings that organize different sectors of the broader VANDU membership (i.e. people on methadone, Aboriginal people who use drugs, and people who drink illicit or non-beverage alcohol); about 150 people participate in these meetings. This mass process, in conjunction with a vigorous and meaningful democratic process, makes the organization genuinely responsive to the needs of the very poor and oppressed people who use drugs.
The result is broad campaigns that take on issues such as the police ticketing and harassment of people in our neighbourhood, the horrible bureaucratic regime surrounding methadone maintenance programs, and access to decent health care without discrimination. At the individual level, it gives people who use drugs a sense of belonging and purpose, and a democratic institution in which they can really exercise power and the chance to take leadership in fighting for meaningful change. We can really see the positive health impact this structure has on people – especially the most active leaders in VANDU, the democratically elected board, but also for active participants in the organization.
That said, this is a very challenging time to do grassroots organizing work. Between the police who use the spectre of the super dangerous Downtown Eastside to justify increasing policing budgets (even though crime is going down), the health people who medicalize and treat “mental health and addictions” but won’t ever deal with the underlying causes, and the federal government that uses the war on drugs and “tough on crime” legislation to distract from the horrible results of three decades of neoliberal capitalism ... Well, it’s really an uphill battle.

What are the limitations and challenges in our work? Although health care in Canada is structured quite differently than in the United States, it is nonetheless deeply embedded in the capitalist economy. Pharmaceutical companies, private insurance companies, medical equipment manufacturers, private biomedical testing companies, etc., all have huge stakes in the Canadian healthcare system, and most doctors’ offices and many other clinics are run for private profit. What are some examples of how this impacts our work and how do we address it?

Baj: Where even to begin? The limitation I find myself thinking about a lot is the public discourse around health justice in Canada. For a long time, the movement for health justice was stymied by equating health justice solely with access to institutionalized biomedical care. The development of universal, single-tier insurance for biomedical care on a massive scale was indeed a great achievement, even though it does allocate immense power to the state. Yet, it raises questions about the justice of distribution – of resources but also of power which allows me to sign off on thousands of collective dollars with little oversight simply because I went to medical school. Also, the equation of health with biomedicine has limited the participation of a more widespread justice approach. Health work is more than just technical tweaking of anatomy and biochemistry. The definition of health justice in Canada is being expanded as people recognize that inequities in health outcomes still exist despite widespread access to biomedicine. More people are now realizing that access is not the only determinant of health, nor is biomedicine the only solution. This dawning realization creates conditions ripe for allowing both health activists and social justice activists to build a truly transformative vision for health justice.

Martha: Some big challenges we face in all of our organizational and clinical work are economic limitations and a lack of income. Our organizational work confronts the same situation that all grassroots organizations face. In terms of clinical work, the situation is a bit more unique. While the midwives in our collective are able to bill Medical Services Plans (MSPs) for providing care to a majority of the folks we deliver babies for, we have a growing number of people in our care who lack MSP coverage due to their temporary or non-status conditions. Further, we’re only able to bill for clinical care, and not for the myriad of other things we do to support the families we work with. Obtaining state funding is fraught with challenges.

Aiyanas: I think the main thing that is holding back VANDU is a lack of connection to a broader movement context. A broader left movement would make coherent demands of the state and project a vision of liberation that deals with the structural issues facing communities – including colonization, poverty and exploitation, racism, and male violence. This would provide VANDU with a political context in which to flourish and also broaden the vision of our members and leaders about what liberation could look like. Without more of this movement context, our concrete struggles at the local level can really feel bogged down and slow, and we also can’t hope to really turn the tide without a broader social struggle.

What inspires your work?

Martha: I’m definitely inspired by the concept of community-controlled health programs, such as those in the Philippines that are run by people’s organizations and staffed by lay care providers. I’m also inspired by people-powered health care, like Barrio Adentro in Venezuela, which is an important part of the Bolvarian revolutionary process. I’m inspired when I see how national liberation struggles are integrating health into their programming, and the ways in which the health of communities is dramatically improved with democratic control over collective resources like land, agriculture, and production. Health and liberation are so tightly interwoven. So health is a good way to start talking about injustice.

Aiyanas: On a day-to-day basis, I’m definitely inspired by working with people who continue to organize for a better future, despite horrible experiences of social violence and personal trauma. I have seen this first-hand in the Downtown Eastside of Vancouver, as well as in the Philippines and in Palestine. I feel privileged to have met and worked with some of the most heroic and inspiring people in the world. Being a communist also keeps me inspired. If I wasn’t convinced that a better world is possible, that it’s right to rebel, and that revolution is not only desirable but inevitable, I think I would become demoralized pretty quickly.

Baj: I am most inspired by traditions of popular education. I’m also energized by the one-on-one work that happens in the contemporary clinical context, by working with individuals to develop a treatment plan that not only tackles their immediate issues, but links their very private, personal experience with patterns that have persisted for years, decades, and centuries, and how they can engage in dismantling those patterns is all part of making them better. As I previously mentioned, I have only very rarely participated in such phenomenal clinical encounters in the real world, but the ideal of trying to achieve it each and every time keeps me going.

How are struggles for health contributing to broader social movements?

Martha: The concrete example that folks in Canada are talking a lot about is the idea of sanctuary, which is being applied to health services. But I want to be careful not to do what Baj describes by applying biomedical and profit-oriented medicine to our community struggles. There are so many opportunities to use health as a political organizing tool. At the APH, we run a People’s Health Series to develop popular health workshops designed to reframe how we approach health. It offers clinical information and political analysis in a workshop setting. We also do direct solidarity with movements through skill-sharing, or in whatever other form they request.

Aiyanas: There is contradiction in our society in that everyone says they want health – for themselves, for their friends, family, and community – but the underlying logic of capitalism, the profit motive, produces and reproduces ill health for the vast majority of the population. By organizing around health, and by framing our issues in terms of the health of individuals and communities, we can expose and challenge this contradiction.

Baj: Biomedicine has traditionally been very insular, as it has refused to be swayed by broader trends, so I don’t believe it has contributed much at all. Many times, doctors have been on the wrong side of history. The discipline is shifting now, and health struggles outside of biomedicine are gaining prominence. Take for example, the responses to environmental racism and its impact on the health of Indigenous peoples living near the Athabasca tar sands. Still, I’d like to see more of these links made – connecting esoteric topics, like tax law and state surveillance, to the very real implications for health and illness in communities.

What message do we want to send to those who work in other sectors about the importance of addressing health?

Baj: We are struggling for people to live well, to live with the opportunity to become all they can be. The ultimate liberation would involve people no longer needing doctors because the knowledge and the tools for health would be in their own hands. I cannot imagine a world without loss and pain, but I can imagine one where wounds are tended until healed, while scars are celebrated as survival, and grief is held by the warmth of others. Isn’t every struggle about making sure that we are all cared for?

Tom: The health of poor people suffers most acutely under capitalism since a lot of health work is professionalized, therefore the interests of the sick and those providing professional care can be in opposition. This inequality must be challenged, and the concept of liberation medicine, or perhaps liberation healing, should be taken up broadly. We can look to struggles and movements internationally where health care is being reconceptualized to some degree, like Barrio Adentro in Venezuela or the community-based health programs in the Philippines. A lot of fodder for action!

Martha: If our society wasn’t all about profit, wouldn’t we be building healthy people and communities for the sake of full human potential? When we remember what we’re fighting for, then health has to be completely integrated into our vision of the world we want to live in.H