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One Foot In, One Foot Out



*Milton Terris Award of the Socialist Caucus, APHA Nov.6, 2007*


*Richard Levins*


*Harvard School of Public Health*


*Boston, MA 02115     and *


*Cuban Institute of Ecology and Systematics*


*Boyeros, Ciudad Havana, Cuba*


*Most of us entered public health for a mixture of reasons: the urgency

to alleviate the suffering in the world combined with an intellectual

concern for the scientific problems of infectious and chronic disease,

poverty and inequality, and the organization of health service.  We are

professionals. But unlike other professionals we cannot maintain a

detached neutrality about disease (for or against), for or against

hunger, for or against racism and sexism. We are engaged professionals

and in that sense also activists in institutions that profess a formal

neutrality about many of the key issues that affect health.*


*We are also workers. We are hired to create and apply knowledge within

the constraints set by our employers.  But we are a special kind of

worker in that our labor is not completely alienated from us: we are

really concerned with the product of our labor, with what it does in the

world, unlike the employees in an ammunitions factory who do not seek

out that job for the joy of helping to kill people. As workers a major

concern is to keep our jobs and receive reasonable compensation and

benefits.  But as intellectuals we want our work to be meaningful and

effective.  We are terribly frustrated when we lack the resources to do

what obviously needs to be done, when class size or number of patients

to care for guarantees that we cannot do what we entered the profession

to do and when our best ideas are not fundable or not even mentionable,

when our activism is condemned as unprofessional, when our tasks are

constrained by wrong or narrow theories, when we may contribute to deep

studies of the problem but the reports end in banal recommendations such

as "we should pay more attention to questions of equity" or the almost

inevitable "more research is needed."*


*As workers we share the concerns of other workers, questions of salary,

job security, health and safety on the job, workload.  But as

intellectuals we want our work to matter.  We are inspired by the

California nurses, the doctors in Nicaragua and Chile, the teachers of

Oaxaca, and do our own protesting, demanding, educating.*


*We are activists, critical of the way society is run and we work to

change policies in many areas of life. But our activism is not limited

to the correction of today’s abuses. We also stand back from the

immediate to theorize, analyze, contemplate, ask how our present

struggles contribute to or detract from the long haul. Theorizing is a

vital task: it protects us from being swamped by the events of the

moment. We are also activists in relation to our own situation as

workers even where it offends the proud sense that we are professionals

aloof from class conflict.*


*Our triple identity as workers, as activists, and as intellectuals

creates the cauldron in which we live contradictory lives. We may share

with colleagues a curiosity about the origin of new infectious disease

or how racism exhausts the adrenals or the egg-laying behavior of

mosquitoes in polluted environments.  But we may conflict with them

around the need for universal free healthcare, the need for land reform

in the struggle against the ravages of HIV/AIDS in Africa, the priority

given to molecular approaches to disease.  Our institutions may

appreciate our creative ideas yet fear that potential donors may find

out about our criticism of the pharmaceutical and insurance industries,

or that we might be seen as connected to them when we shout slogans in

front of the Capitol. When we participate in collaborative research we

may disagree as to what to include and what to leave out, what

recommendations to insist on and which to edit out of the conclusions.

Our relation with our colleagues and institutions is therefore a mixture

of cooperation and conflict. Our job depends on the balance between the

professional recognition we may receive and the political embarrassment

or offense that we cause. We want to be able to pursue our shared

interests, continue with our social commitment, draw sustenance from our

surroundings but not drown in its special subculture to the point of

sharing its values and timidities. *


*Our triple identity is also a source of strength. We bring to the

activist community the scientific insights of our professions and the

tools to criticize the reports of panels of experts. We also defend the

value of intellectual work, the need to sometimes take detours from

practical problems in order to understand them more deeply.*


*  We learn from our nonprofessional comrades about the richness and

complexity of health problems and about topics such as the reality of

class in America that are subject to interminable debate in academia but

are obvious on the street.  We have the experience of community groups

such as the women of Love Canal and Woburn, the environmental justice

movements, the River Network, the Women's Community Cancer Project

revealing problems of environmental toxicity that academies prefer to

ignore, that they are prone to dismiss as mere statistical clusters, the

panic of the mob.  We know that nonprofessionals who face a problem

often have a deeper understanding of the very specific situation they

live in than the experts whose first commandment is not to create panic

or impose unnecessary costs on the creators of the problems.  *


*At the same time we cannot fall into the sentimentality of assuming

that the less educated people are, the wiser they are and the more

reliable their opinions.  We understand that the direct experience of

people is also limited: it is limited to objects on the scale of

everyday experience, limited to their own immediate surroundings, and

usually limited by the urgency of a short time frame, seen through the

prism of the biases of their own community and lacking in analytical

tools.  But after decades of community organizing there are many

community groups that do have deep understanding, theoretical insight

and great intellectual clarity. We respect human labor, including our

own, and reject the deprecatory, apologetic term “ the real world” to

refer to any place other than where we are, and all work except our own.*


*  Working in communities also helps us understand that what is

happening to us as workers -- job insecurity, proliferation of managers,

loss of autonomy at work, overload -- had already happened in other

industries.  We see the new buzz word “accountability”, which could mean

the insistence on democratic responsibility to our peers and the

communities we serve. But too often it turns into an increase in

managers, supervisors, bureaucratic rules and forms, a vertical

“accountability” that leads to timidity. We have more in common with the

weavers of Lancashire then is obvious when we contemplate our diplomas.

We may even find allies in our labor struggles among the people in the

communities where we work.  *


*The agendas of affected communities protect us from sinking into the

triviality of much academic debate. It is also a source of hope when our

institutions sink into despair. Therefore our triple identity is a

source of enrichment as well as anxiety.*


*I would now like to explore some of the intellectual constraints on

work that makes the product less than fully satisfying.  *


*1.Problems of misdescription. Although researchers in the United States

recognize the disparities in health outcomes among groups of people,

data describing that inequality is often presented to us in terms of SES

instead of class.  To some extent we can infer class from income,

residence, and occupation.  But it is still unsatisfactory.  It is

common now to see people as deprived of food, housing, education.  That

is, we see them as consumers with insufficient means of consumption.

Remedies are proposed to make good this deficit in consumption.  But the

models generally do not consider restructuring the patterns of ownership

and power in our society.  *


*Common speech in our country describes people as middle-class although

most people work for a living or at least try to.  If we were all middle

class we would have to notice the homeless middle class, the hungry

middle class, the middle class with low education, the imprisoned middle

class.  Or we might be allowed to recognize that virtuous category, the

working poor, so as not to confuse them with a nonworking, unemployed,

or incarcerated middle-class.*


*2. Narrow scope of comparison. When considering alternatives to the

present health care system in the United States, it is respectable to

consider the Canadian experience but not the Cuban.  And this in spite

of the fact that Cuba has the most cost-effective public health system

in the world. It is state run, refutes the common notion that a

state-run system must be stifled by bureaucracy.  It refutes the notion

that innovation is stifled in the absence of the profit motive. In a

time of economic constriction in Cuba it is striking that the trend has

been for increasing and differentiating the types of care rather than

cutting back.  The exclusion of Cuba means that alternatives are limited

to those in which pharmaceuticals are privately developed and owned,

health insurance is a business, and hospitals are encouraged to cut

costs and show profit.*


*3. Narrow posing of problems.  Malaria is seen as a problem of

mosquitoes and bed nets but not of poverty and land use.  The

devastating impact of AIDS on Africa is confronted by proposing the

distribution of medication and the urging of people to practice safe sex

but does not deal with land reform, unemployment, and cultures of

sexism.  Epidemiology is divorced from ecology.  War is still examined

as a disruption of normality rather than an increasingly common

expression of a late capitalist global normality.  Infectious diseases

are approached one at a time without regard either to diseases of other

species or the ecology of our relations with the rest of nature,

particularly with the microbial world.  In the broadest sense public

health is concerned with the relations of our species with the rest of

nature and the relations of social groups within a species. It is part

of our task to insist that health is determined in a much broader arena

than health service or public health programs.  It must go beyond

traditional occupational health to consider the workplace as a habitat

and the structure of work in our society, the organization of work in

our life cycles, and its seasonal and diurnal rhythms.  It must deal

with inequality not simply as a statistical measure but as a structuring

of social conflict.  These are questions that are either simply ignored

or militantly excluded.*


*4. Policy recommendations are limited within the framework of the

existing institutional programs and the social system as a whole. They

have to be within the bounds of the potentially acceptable. Since

consultants and advisers have no capital goods, their only asset is

credibility and therefore the raised eyebrow may be devastating.  It is

taken for granted that health care is private, that insurance is

private, the hospitals are private for the most part, but that the

research conducted directly or indirectly by the pharmaceutical industry

is going in the direction we need. The least that we can do when we work

with policy questions is to make the constraints explicit and then find

ways of challenging the constraints in other venues.*


*Criticism of these constraints opens up not only the particular

question at issue but also more general conceptualization of the nature

of science and scientific research.  This includes a general view of

science as a social product that has areas of profound understanding

interwoven with structured ignorance.  These are not questions which are

normally considered in the seminars and meetings of our professions but

are necessary in order to stand back and evaluate where we are and where

we want to go.  As against the narrow, constrained, mostly reductionist

sciences of our institutional environment we counterpoise a dialectical

view in which:*


*the truth is the whole;*


*things are more richly connected than we imagined. The usual dichotmies

into which we divide the world for purposes both of analysis and policy

are ultimately misleading. Our biology is a socialized biology but no

less biological for that. The psychological is not an alternative

explanation to the physical: *


*things are snapshots of processes that last long enough to earn a name;*


*things are the way they are because they got that way; therefore we

ask, why are things the way they are instead of a little bit different,

and why are things the way they are instead a very different.  These are

the questions of homeostasis and self-regulation on the one hand and of

evolution, development, and history on the other.*


*These considerations also apply to our own disciplines and to ourselves

working within them. Every social location carries with it both insights

and blindnesses. We cannot be free of having a point of view, but we can

recognize it and know where we are most likely to be mistaken. *


*As health professionals we always confront the boundaries of the

permissible. Radical politics is the pushing back of those boundaries.

We have to make strategic decisions about how to deal with these

constraints.  There are several modalities available.  These are not

mutually exclusive.  In our own work we may challenge the prevailing

dogmas in conversation, seminars, and in writing.  We may push against

the boundaries, raising questions they may not want to hear, encouraging

people to take action that is not part of our job description.  This may

bring us into conflict with our bosses and endanger our jobs. It is a

strategy most accessible to people in relatively secure positions.  The

freedom to challenge what is, is usually associated with rank in the

hierarchy.  For this reason the defense of tenure and job security

generally, along with the expansion of the subject matter for legitimate

discussion, are important struggles for all of us. These battles are

important not only to try to change the framework of public health or of

some of our colleagues, but also to keep our own minds clear.  It is not

always easy to remember that the boundaries of our job description need

not set the boundaries of our minds or our actions. One way to undermine

the constraints is to find ways of bringing people from the community

into the university or agency as active participants.  Recall the slogan

that emerged after hurricane Katrina: “nothing that is about us without

us is for us.”*


*  A second approach is to carry on what we can't do at work in our free

time, using our professional knowledge but going beyond it.  Thus while

our analysis may show that national health systems can have lower costs

of administration than private ones, provide more complete service, and

have medical decisions guided only by the needs of the patient, advocacy

of a national health service may be actively discouraged and certainly

does not fall within the bounds of our research grants.  But in

publications beyond the control of our directors and deans we can carry

our analysis to its obvious conclusion.  Thus we may write about the

problems we have not been allowed to solve and present our ideas in

other communities than the profession.  Here we can make recommendations

that the existing programs could not consider, writing in the

publications of our alternative communities.  We can propose or oppose

legislation in collaboration with community groups.  Working with

community groups is an important means of nourishing our integrity

because at our day jobs we are constantly bombarded with assumptions

that may eventually penetrate our consciousness.  We all appreciate the

good opinions of people we respect and may eventually come to sympathize

with the common sense of our institutions and coworkers. It is a

constant struggle to resist the biases and assumptions of our

professional communities.  It is therefore important to have another

community of validation than that on the job.*


*  In some countries, and in some localities within our country, such

activities may be dangerous and may even have to be carried out

anonymously.  In an increasingly repressive society whistle blowing is

an important but dangerous vocation.*


*A third option is to leave the institutions that are so frustrating and

increasingly demoralized. Then we might seek out community or

union-based organizations where our approach is welcomed and activism

can be our profession. The rest of us have to rally round so that those

who finally can’t stand it any more are not lost in the struggle to



*In the nonacademic activist community the urgent immediate tasks can

prevent us from engaging in the intellectual tasks that both nourish

ourselves and inform the struggle.*


*  In some cases our clash with our institutions may be so sharp as to

make continued work there intolerable, or ethically unacceptable.  For

instance many public health professionals seek employment with USAID. I

would personally would not work for USAID because I consider it a

terrorist organization implicated in efforts to overthrow the Cuban

government, implicated in what in the current double-speak they call

“health system reform”, that is the gutting of national health service,

and in other ways promote a noxious foreign policy. In navigating this

terrain people have to take into account their own location in the

structure, the colleagues who may support them, the degrees of freedom

which they are allowed, their vulnerability to reprisals and their own

self-confidence.  Since I hold a tenured position in a University I have

more freedom to act and more protection from retaliation than in earlier

times in my life.  But others are more subject to the tyranny of

administrators, state legislatures, review panels, or the press.  Here

is where unions are important to defend the intellectual freedom of

public health workers as well as our economic rights, and allies outside

of our institutions are a vital support.  *


*The final option is to leave employment in the public health field,

make a living in some other way, and struggle for the health of our

communities purely as an activist.  In some ways this is the least

desirable of the options because it leaves very little time to pursue

our scientific interests, keep up our networks in the field, and find

outlets where we might be heard.  But it is a fallback option that

combines greater freedom with lower security and access.  Under present

conditions of the job market there are many qualified graduates who do

not find employment in public health, or at least in jobs that are

acceptable to them in public health. Then it is the task of those of us

who are still employed in public health to keep our unemployed comrades

in the networks, notify them of discussions that may be of interest to

them and share publications.*


*Thus our community includes people with many different kinds of

connections to public health institutions and different class

positions.  This is a strength in that it prevents the narrowness of the

academy and the agency from constraining the challenge to carrying out

our mission.  It helps us find people with whom to share different

aspects of ourselves.  With some I can share my love of difference

equations, with others my excitement about the Bolivian revolution, with

some my outrage at the persistence of poverty and preventable disease.

With some go to seminars, with others to picket lines.  This makes for a

rich, exciting, and useful life with marvelous people.*









*Lectures/1 foot in 1 foot out.doc*




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