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Power - a health and social justice issue

24 Aug 2017 | Andrew Fraser

Power as a fundamental influence on health

In recent years, we have come to realise that there are fundamental influences on health; three are most prominent – income, wealth, and power. Income is fairly straightforward to define; wealth is more complex to the extent that it has a monetary value but is not necessarily expressed in pounds or dollars. And then there is power. Power is often invisible but its effects are not.

All three fundamental influences are inter-linked – the likelihood of being wealthy is driven by income, now or in the past. And power is easier to achieve if, as is usual, wealth ‘buys’ influence. That could be ownership of land or property in getting what we want, but it could equally well be social position or level of education. So power relies on other factors, but is an entity in itself.

The nature of power, as applied to health – key texts

We have relied on two key texts in setting a framework for power in relation to health. First is a WHO framework that breaks down power into four types:

  • ‘Power over’ - where some are able to influence or coerce others – we are very familiar with this type, whether it is the influence of Governments or the coercion of bullying in the workplace. 
  • ‘Power to’ - where individuals are broadly able to organise and change existing hierarchies. Effective democracy might offer this.
  • ‘Power with’ - the collective power of communities or organisations. Effective organisations and their representativeness should ensure this.
  • ‘Power within’ - individual capacity to exercise power – the most difficult to articulate and describe. However, basic feelings such as safety, place in life, and freedom to choose may be elements.

Equally, power may be conditional – perhaps we can understand power in situations when individuals have it, and when they do not. For instance, it cannot be uncommon to be a capable manager at work who experiences domestic abuse at home, or to be a homemaker with a happy family life who feels no sense of control in the workplace owing to poor management or poor working conditions. 

The second text on which we relied was Carnegie UK Trust’s report ‘Power and Making Change Happen’. This helps us put the notion of power in a more practical framework. 

What are the consequences of inequalities in power?

In common with many influences on health, there is rarely a direct relationship between power and health, or inequalities in both. Evidence is lacking in many respects.  ‘Power’ is a concept which includes the ability to do, or to not do, something and to exercise influence or control in a variety of different ways.  So power, or lack of power, can have an important impact on peoples’ circumstances and control over things that affect them, such as housing, food or education, and therefore on their health. 

Power exists in the relationships between people and groups of people.  Through these relationships, some individuals, groups, communities and organisations can have greater power than others and have more opportunities than others to live longer, healthier, more fulfilled lives. Take the example of a family living with insecure housing tenure, with tensions and threats of negative action from their landlord but little sense of control for options to move. Compared with a family who own their own home surrounded by friends and family for support and who are able to relocate for a new job or school.  Now compare the long-term prospects of a child growing up in each household.  

What can we do about it?

There is a great deal of commentary and emerging consensus about the need to tackle inequalities. This intention is often expressed in terms of income or wealth inequality, but themes of fairness and involvement signal a wider agenda. Given the development of our focus as a society on rights, including democratic renewal and social justice, there are examples of work which, if implemented in full, could serve to improve the distribution of power. The Christie Commission espouses such values, the commitment of NHS Scotland to person-centred care, and the strapline of the Social Justice conversation ‘what matters to you’ implies commitment to improvements in allocating power to the individual.

The Community Empowerment Act is an important new piece of Scottish legislation with opportunities to reduce health inequalities through the redistribution of power – but that depends on us really understanding what power is and where power lies.  For there remains a risk, nonetheless, that those most easily able to take the opportunities offered in such circumstances will leave those less able further behind. So the implementation of policy and good intentions must be fair and equally distributed in seeking to ensure power results in better health, and a reduced gradient in inequality.   

What does power look like?

Visualising the concept of power can still be difficult – how best to explain it, give examples and bring power ‘off the page’ or the screen. That is why NHS Health Scotland has collaborated with the Glasgow Centre for Population Health to produce this animation to explain power and why it is important to health and a range of human experiences, for individuals and communities that influence our health and wellbeing.

Power matters to health. If we accept that we could and should do something about it, then how much better would be the quality of people’s lives? Whilst challenging to quantify, the answer is ‘probably significant’.

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