Always interested, always in motion: shaping discursive practices and material conditions in the pursuit of public health transformation

In this issue of Critical Public Health, we publish a paper from Savona et al. (2021) that documents some of the ways government and commercial actors in the UK have mobilized the discourse of ‘complexity’ to obscure and justify inaction on the structural drivers of poor dietary public health. The concept of complexity has gained significant traction in global public health in the last 20 years as part of a ‘turn’ towards complexity theory, chaos theory, and other complex systems theories that try to better explain how health systems actually operate and evolve over time (Diez Roux, 2011; Rutter et al., 2017). Using a discourse analysis of key government and corporate documents on diet and health as well as interviews with people working on these issues in academic, government, NGO and commercial sectors, Savona and colleagues provide important lessons about how framing diet and health as inordinately complex problems can, perversely, lead to a focus on individual-level behaviour change and offer a ready-made excuse for why more hasn’t yet been done by the major players in the field to address the problem.

Their study focused specifically on how the relatively recent language of complexity – one that emerged from a critical public health context – has been deployed by powerful actors in the food system to reframe, deflect and defer responsibility. Their insights resonate with similar examples in other areas of public health of the refashioning and redeployment of once-critical vocabularies. The calls for ‘partnership’, ‘collaboration’, participation’, and ‘accountability’ that were central to the Primary Health Care project in the 1970s were swiftly coopted by mainstream health and development agencies. Progressive public health activists inspired by Alma-Ata have decried, rightly, the emptying out of these concepts in contemporary global health practice (Carothers & Brechenmacher, 2014; Cornwall & Coelho, 2007). More recently, concepts of ‘survivorship’ and ‘resilience’, rooted in progressive gender, disability and mental health rights activist discourses, have come under fire for the ways they have been used to occlude the ongoing vulnerabilisation of marginalized groups and justify neoliberal, consumerist and individualist answers to the challenges they face (Abimbola & Topp, 2018; Bell, 2014). And just last year, in response to the wave of protests against racialised police violence in the United States, we saw long-standing social justice concepts like systemic racism, anti-racism, equity and inclusion, and allyship appear in a flood of corporate press releases and on TV commercials. These often clumsy and poorly-informed expressions of solidarity functioned to re-position brand identities and protect market shares in response to new social and political pressures (Blair, 2021).

As Savona and colleagues remind us, it is important that we remain vigilant against the reframing and cooptation of our critical vocabularies. I want to offer here, though, two further insights I believe we should keep in mind when defending the terms of our critical discourses. The first is that discourse – any discourse – is always interested. The words we use and the ways we use them are always underpinned by our own ideological frameworks, hidden assumptions, and partial perspectives as well as the effects we are trying to achieve in the world with them. Savona and colleagues point out that complexity theory – as opposed to the single term complexity – is an important effort to more precisely and accurately understand something about the world. Complexity theory has indeed enriched and improved the models we have for understanding how health systems work and how they might be strengthened (though, as we have noted previously in these pages, current applications of complexity theory also have some important limitations (Salway & Green, 2017).

However, complexity theory is not merely an effort to more objectively or validly redescribe the world. It is also an ideologically-informed reaction against rationalist, linear and ‘command and control’ understandings of health systems that imagine health policy and systems as engineering problems that can be solved by powerful, centralized actors through cool, technical reason (Loewenson et al., 2021; Walt, 1994). The other conceptual redescriptions listed above – participation, resilience, equity – are also examples of ideological struggles over language and meaning. They are part of ongoing efforts in progressive public health circles to promote both better knowledge about how the world actually works, but also better values to inform our efforts to improve the world. Acknowledging the inevitable intertwining of knowledge and politics in all of our discourses will help us to avoid the potential cul-de-sac of claiming that we are merely being objective while our opponents are being ideological.

The second insight is that discourse is always and inevitably in motion. Words slip their moorings, meanings shift, are coopted, transformed, sometimes even inverted. These discursive shifts, realignments, and appropriations may be slow and subtle, or swift and dramatic. But there doesn’t appear to be any way around them. While conceptual redescriptions can be powerful tools, we must remain aware of the limits of language as a means of transforming the world. In the last few years, for example, there have been significant developments around gender terminology, developments that have helped to raise awareness, shift social norms and institutional policies, and in general, produce a (slightly) more inclusive environment for people whose gender expressions and identities don’t fall into mainstream categories. These efforts to shift the reigning gender discourses have been an important tool of gender transformation. But these changes were preceded by – and may still require further – decades of gender rights activism, policy advocacy, slow shifts in service delivery guidelines and professional practice, increased funding for gender rights work and gender inclusive changes in work environments, revisions to the legal recognitions of and protections for gender minorities, better access among marginalized populations to communication and social media infrastructure, etc., etc. (England et al., 2020). These changes, however modest, in the material determinants of the lives of gender non-conforming people accompanied and made possible some of the equally important changes in how we now speak and think differently about gender.

We shouldn’t have to choose between idealist and materialist strategies for improving public health. As Savona and colleagues note, the problems we face are wicked in their complexity, and we need all of the help we can get. Remaining vigilant about (our sense of) the meaning of words like ‘complexity’ or ‘survivorship’ or ‘participation’ is a vital tool in promoting both better knowledge and better politics. This effort will always be strengthened, though, by attention to the structural and infrastructural conditions that, in parallel with discourse, produce and reinforce the many complex drivers of ill health around the world.

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The author(s) reported there is no funding associated with the work featured in this article.