By Kerry Scott
What would French philosopher and social theorist Michel Foucault think about our Third Global Symposium on Health Systems Research in Cape Town? What would please him? Make him laugh? Concern him? Would he warn us of anything?
Okay, I admit it is terribly arrogant to imagine even a moment inside that great mind. However, I do think we could learn from applying his lens on power and knowledge to our objective of building the field of health policy and systems research (HPSR). By participating in the symposium, we are contributing to the conscious development of a field of knowledge. And Foucault offers us some tools to talk explicitly about power and think creatively about what we are doing.
Knowledge is produced when ideas, perspectives, descriptions and arguments are shared and believed. For example, if a US senator thinks abstinence-only sex education should be the primary public health response to HIV, it’s basically meaningless. But once others begin ‘knowing’ this too, with all the associated understandings of health education, global funding, and HIV transmission, it becomes knowledge, which has power. As this example also demonstrates, knowledge systems are not created by individuals or in a vacuum. We need both engagement and collective construction. As interlinked ideas and thoughts gain social acceptance, they begin to constitute a body of knowledge. And the more legitimacy garnered by a body of knowledge, the more powerful it is.
Foucault would tell us that building the field of HPSR involves building legitimacy for our type of knowledge. How do we do this? We coin terms, definitions and acronyms. We organize collectives (such as Health Systems Global or thematic working groups like SHAPES) and meet to share ideas, collaborate and debate. We draw boundaries to help us define what HPSR is and who does and does not practice in it. Perhaps we seek legitimacy by borrowing from pre-existing powerful regimes, structuring our writing to echo accepted formats or adding the word ‘science’ to our ideas and concepts. To what extent do these acts add value and rigour to our work—and to what extent do they mystify our work and promote elitism? And does the former necessitate the latter?
Foucault might point out that HPSR is young and is relatively unique in that the community is engaged in a highly conscious “knowledge building” project. Active discussions around what HSPR is, where it came from and how it will proceed are evidence of this. I think Foucault would like this, because we’re willing to talk about the power relations presupposed and constituted by our field.
Talking about power relations can move them from common sense facts to contested issues. Once you notice a norm, it is possible to de-normalize or problematize it and in the process help construct new ways of ordering society that legitimize—and give power to—previously marginalized perspectives. Indeed HPSR has in part emerged in resistance to other dominant public health approaches. Its embrace of multiple disciplines and multiple truths, for example, resists biomedical and positivist paradigms. But as resistance grows and gains legitimacy as a field of knowledge, it becomes a new form of power, which may be more difficult to detect. And Foucault warns that the most insidious form of power is that which is no longer understood as such; a type of ‘hegemonic’ power, which is dangerous because it comes from within.
What norms can we notice and challenge in the emerging field of HPSR? Heteronormativity? The separation of HPSR from environmental sustainability? And how can we understand resistance in the context of HPSR? Perhaps we can look in the obvious places—epidemiologists who shun qualitative research methods, or medical professionals who wonder why we do not condemn traditional and alternative systems of medicine. But as HPSR, with all our plurality of methods and conceptualizations of health systems, gains legitimacy, this type of critique is fading. So where will resistance lie next? What will it challenge? What will it create?
Kerry Scott (@kerfully) is a social scientist interested in gender, community participation and power in health systems. She holds a Master’s of Health, Community and Development from the London School of Economics (LSE) and is currently a PhD candidate at Johns Hopkins School of Public Health. Kerry is also Research Coordinator in the Public Health Foundation of India’s Health Governance Hub.