Tuesday, February 25, 2014

Expert Insight: Dr. Mohan J. Dutta on Questions for Health Communicators: Tackling Income Inequality, Poverty, and Economics

Professor, Director, CARE

Department of Communications and New Media
National University of Singapore

February 18, 2014 Singapore
“His body
had fallen
to the ground
some sixty five feet
crushed into
piles of concrete.”
A gentle nudge from Elaine reminds me that I am running late with turning in this thought piece I promised her on “Future directions for health communication.”
I have been thinking through a recent story I read in the Guardian that documented more than 500 deaths since 2012 among Indian construction workers building the infrastructure for the 2022 World Cup in Qatar (Gibson, February 18, 2014 at http://www.theguardian.com/world/2014/feb/18/qatar-world-cup-india-migrant-worker-deaths), and considering the relevance of this story to our work as health communicators. I am familiar with existing scholarship within our discipline that points toward workplace safety practices, but am not quite convinced that this framework with an emphasis on encouraging individual safety practices among workers through communication offers a meaningful interpretive frame for understanding the complex structural intersections that constitute these deaths. As I struggle to find coherence in my writing, it strikes me that perhaps it is my inability to comprehend, to make sense of, to fit into a pre-existing framework the 500 deaths of Indian workers in Qatar that points toward possibilities for health communication scholarship in the future tense.
The relevance of taking communication seriously is most salient in these interstices where meaning becomes impossible, stories are disrupted, and sense making is so deeply buried in the violence of the context that it becomes inaccessible.  I am reminded of the (im)possibility of communication as I count the 500 Indian workers dead at construction sites, the 400 Nepali workers dead reported in an earlier story in the Guardian (Doward, February 15 2014 at http://www.theguardian.com/football/2014/feb/16/qatar-world-cup-400-deaths-nepalese ), and another Guardian projection of around 4000 workers dying at the construction sites in Qatar building infrastructure for the 2022 World Cup (Booth, September 16, 2013 at http://www.theguardian.com/global-development/2013/sep/26/qatar-world-cup-migrant-workers-dead). The context of horror is marked by the absence of the voices of the many dead workers whose bodies must now be counted.
And yet the context is also material, written into the mangled up bodies of the workers thrown off the crane reaching toward the sky to celebrate the achievement of civilization. The steel and concrete, the low wages, and unpaid for labour, these are all material. The materiality of context bears inscription of the inequalities in everyday life that we take for granted. The materiality of context, unarticulated and erased from our formalized conversations in journals, is integral to the health experiences, health negotiations, and health outcomes of communities that are disenfranchised by the excesses of global capitalism. The everyday lived experiences of culture are constituted amid the materiality of worker abuse, difficult work conditions, poor wages, lack of payment, and lack of dignity.
With three decades of free market reforms carried out across the globe in the form of structural adjustment programs and the contemporary forms of poverty reduction strategies, the financialization of the global economy, and the recent global financial crises accompanied by the material effects on many communities across the globe (from Malawi, Nigeria, and Bangladesh to US, UK, Ireland, and Greece), large sections of populations are without access to basic health resources such as food and shelter, and the basic forms of health care, even as wealth has been consolidated into the hands of the global elite. After the mortgage collapse in the US in 2008 for instance accompanied by the economic collapse, large numbers of families within the US found themselves without a shelter. Our own fieldwork in the US with the “Voices of Hunger” projects joining in chorus with voices of anthropologists and sociologists documenting the evictions, job loss, food insecurity and homelessness in US families in the backdrop of the financial crisis (see snippets from our field notes at http://culture-centered.blogspot.sg/2012/03/communication-and-seasonality-of-hunger.html). From the boardrooms of financial transnationals to power lunches of lobbyists to the policy circles of political elites to the closed door conversations among academics, the global economy has been redone to concentrate resources in the hands of the elite.
Even as global capital fosters deep inequalities at the sites of growth in the metropolitan centers (New York, London, Hong Kong), it works its imperial logic through the exploitation of material resources in the global South. Global patterns of inequalities are created and reified through large scale urbanization, mining, and industrialization projects in the global South that are accompanied then by large migrations out of the global South to the industrialized economies at cosmopolitan centers of production that utilize migrant workers as labour on urbanization, industrialization, and growth projects. As depicted in the stories shared above, migrant workers become collaterals in a global economy that works through the very erasure of their stories of pain, suffering, and subjugation. There are no labor regulations and labour rights in these spaces of capital. The news reports documented earlier share for instance stories of the number of workers who work in slave-like conditions, not even being paid the dirt cheap salaries they are promised by recruitment agents. They lack proper access to food and shelter. And in multiple cases, the workers lack access to any health care. News stories report cases of workers who have been left untreated after a fall at a construction site.
The global dismantling of labour rights to create favorable climates for transnational capital is evident in the special economic zones (SEZs) that have been created to feed into the global economy. These SEZs, marked as spaces of exception, witness some of the worst forms of labor abuse, with long extenuating hours, low wages, and lack of unionization.  The working conditions in many of the SEZs are highly unsafe. The recent stories of the fire and collapse of Bangladeshi garment factories are one such reflection of the poor and deplorable conditions of work at global sites of production.
What does all this have to do with health communication?
Inequality is a global phenomenon. And it is an overarching challenge for health communicators how to understand these inequalities, how to make sense of them, and how to craft messages, discourses, and social change processes so these inequalities can be addressed at local, national, and global levels. With most of our training on individual-level behavior change and lifestyle modification, health communication has broadly been configured in a narrowly conceived logic of individual action. We need to recognize that this is an ideology that is situated in roots of World Ward II propaganda and subsequent Cold War intervention. The idea that encouraging individuals to adopt healthy behaviors is an accomodationist approach to health, one that is expected to bring about health, wellbeing, and development without rattling the status quo through structural transformations. Structures can be left intact without collective participation in processes of change and transformation. The political and economic elite can continue to extract resources from economies as long as communication reifies messages of healthy eating, exercising, and screening to the poor and the disenfranchised.  Closely questioning the hegemony of individual behavior change interventions pushes us to consider the value of our own work, the impact of the work, the effects sizes and sustainability of the behaviors promoted, the relationship of the behaviors to other health outcomes, and the relevance of the work in the backdrop of the dismal health outcomes of disenfranchised communities.
Change therefore can come through a framework of health communication that turns the persuasive theories of communication toward addressing structural issues. Here, I find the recent work of Jeff Niederdeppe and his colleagues promising as it offers insights into causality attributions made by members of the public and the ways in which message frames can work toward shifting these causality explanations. Yet another excellent example of communication raising awareness about health inequalities is the Unnatural Causes (http://www.unnaturalcauses.org/about_the_series.php) series broadcast on the Public Broadcasting Service in the US. The many toolkits on the Unnatural Causes site offer excellent examples of some advocacy and activism tools.
That health is largely structural is a pivotal acknowledgment that can then work toward a collective politics of structural transformation. How can frameworks of health literacy and message framing be directed toward developing health messages describing the health inequalities and the underlying causes? How can the systematic and growing body of evidence on structural determinants of health be communicated to the public through accessible messages? How can for instance the principles of persuasion be directed toward shifting public opinion, attitudes, and behaviors toward financial and economic structures that underlie the deep health inequalities in societies across the globe? How can the traditional principles of diffusion and entertainment-education be incorporated into communication programs directed at fostering public participation in processes of global social change? How can local and community media be fostered as spaces of participation of disenfranchised communities that turn the power in the hands of communities with a commitment to transformative politics? How can the power of mainstream media and powerful lobbies as mouthpieces of transnational corporations be bypassed through creative health communication strategies? How can locally situated cultural meanings offer spaces for mobilizing participation for social change and structural transformation?
What are the processes of organizing and collective mobilization through which disenfranchised communities come together in challenging the patterns of local, national, and global inequalities? What are processes of communication through which existing political configurations can be transformed? What do the wide diversity of collective organizing in cultures across the globe teach us about alternative forms of economic organizing? How can health organizing foster creative communication strategies of change amid structural configurations that serve the power elite and thwart any opportunity for resistance through the deployment of policies, military force, police, censorship and other forms of violence? How can policy structures that silence the voices of disenfranchised communities be engaged and resisted so spaces for disenfranchised voices can be fostered?
Yet another area for health communication research is in creating spaces of meaning making in academic and policy circles that attend to the voices of disenfranchised communities. Take for instance the meanings around the affordable care act in the US. The many interpretive frames around the ACA sensitize us to the politics of access to health that is constituted amid deeply rooted political and economic agendas. Moreover, these meanings interrogate the individualized logic of commoditized health care through insurance reflected in the ACA even as the reforms offer entry points for acknowledging the large numbers of Americans that now have greater access to health care. Similarly, consider the stories of dramatic growth in Asia that are accompanied by data that document the rising inequalities in Asia. Both China and India, celebrated as poster children of liberalization have demonstrated persistent patterns and pockets of inequalities with continued extreme forms of disenfranchisement. The voices of workers, displaced indigenous communities, migrant laborers from these spaces offer alternative discursive spaces that interrogate the prevailing logics of economic growth. These discursive shifts achieved through the participation of the poor in policy and knowledge platforms are pivotal as they offer completely different frameworks of interpretation. Bringing about shifts in interpretive frames through engagement in meaning making is an invaluable task for health communicators, introducing frames of social justice, equality, and human rights in discussions of global political economy. Health communication scholarship can play pivotal role in understanding the communicative processes in networks of local-global solidarity that are directed toward transformative social change. As my colleague and collaborator Professor Heather Zoller observes, health communication understood as health activism can play a vital role in approaching the politics of resistance to global capitalism as fundamentally rooted in health.
Finally, addressing the deep-seated structural inequalities that constitute poor health outcomes calls for cross-disciplinary collaborations that engage multiple methods at multiple levels. The silos of provider-patient communication, social support, workplace safety, policy communication, and communication interventions for instance might be too narrow and confining when considering complex intersections that constitute health disparities. Also, we need continued conversations with other disciplines. Conversations with economists can be guided by examination of the meanings of economic policies and the ways in which these meanings constitute health, inequality, and threats to health. Similarly, conversations with geographers on the spatial organizing of health risks offers insights into cartographies of meanings constituted amid inequalities. Sociologists examining the structural organization patterns in societies offer vital entry points for understanding the structural distribution of resources and the ways in which communication is structured amid and in turn structures these social relations and systems of organizing. Anthropologists examining the cultural meanings, frameworks and processes of interactions in deeply unequal societies offer collaborative maps for understanding the ways in which meanings are constituted in cultural narratives and the constitutive role of meanings in shaping disparities. Anthropological work in disenfranchised settings offer narrative frames for understanding lived experiences with inequalities. Policy studies scholars bring their understanding of policy formation processes to the picture, thus creating new entry points for collaboration on understanding the interpretive frames constructed in specific policies, the framing of policies, and the role of communication in engaging public opinion and public support. Collaborations with legal scholars offer potential vantage points for structurally transforming inequalities. In my own work on inequalities, I have increasingly found myself amid a wide variety of scholars who bring diverse viewpoints to the table.
Conversations such as the International Communication Association preconference on Health Disparities organized by the Health Communication division in 2012, the focus on health disparities in the Kentucky Conference in Health Communication, the “Setting the agenda for research on communication about health disparities: Public policy implications” conference organized by the Robert Wood Johnson Foundation Health and Society Scholars Program (RWJF-HSS) and the Annenberg School for Communication at the University of Pennsylvania are some excellent examples of agenda setting work. The recently published Journal of Communication issue on health disparities edited by Nancy Harrington and the book “Reducing Health Disparities: Communication Interventions” that Gary Kreps and I edited for Peter Lang describe some of the collaborations that are starting to take place in health communication for addressing health disparities. These collaborations are starting to draw upon lessons for health activism and health advocacy.
Most importantly, health communication scholars addressing health disparities need to craft spaces of solidarity with underserved communities, with community organizers and activists who are working everyday to fight the injustices that are reproduced by the inequalities. These struggles often take place in the streets and in public forms. This also then suggests new lessons in community collaboration, advocacy, and participation that are not otherwise offered in the disciplinary professionalization of graduate students and faculty. As the commitment to working to change policies calls for a different set of labor that is not usually acknowledged and accepted by the academic structures, vital questions arise regarding what would count toward promotion and tenure, academic success, and professional growth. In my own time commitments to the various facets of my own work, I increasingly find it difficult to carve out the time to write academic pieces. How this is to be negotiated is a challenge for work that wants to straddle the worlds of academic impact and community impact. For instance, one of my advisees Dr. Uttaran Dutta, now an Assistant Professor at Arizona State University worked with the culture-centered approach to build a hospital in an accessible mountainous province in Northeastern India (see his post on the Culture-centered Approach blog at http://culture-centered.blogspot.sg/2013/07/my-dissertation-subalternity-and.html ). I have been amazed at the leadership and labour involved in his work in collaboration with local communities, and yet the challenge that remains ahead of Uttaran is in crafting out how to write about this amazing work in academic journals in ways that would make the work publishable and would count toward his professional success within the University. In thinking through these tensions I am reminded of one of the first Communication Café conversations initiated by then editor Prof. Kathy Miller in which I had an opportunity to participate along with an amazing group of scholars, Sarah Dempsey, Lawrence Frey, Bud Goodall, Soyini Madison, Jennifer Mercieca, and Tom Nakayama (Dempsey, Dutta, Frey, Goodall, Madison, Mercieca, Nakayama, & Miller, 2011). What these conversations depicted are the struggles and negotiations of relationships and expectations in communication scholarship that seeks to work through questions of social justice.
In sum, that there are large sectors of the global population that live without basic access to health care needs to be at the heart of health communication scholarship. That there are dramatic inequalities of health experiences and health outcomes and that this is fundamentally unacceptable needs to be the focus of health communication work, raising questions of meaning about the commoditization of health. Why should fruits and vegetables be out of reach for low income communities? Why should low income communities experience greater burdens of environmental health risks? Why should underserved communities bear disproportionate burdens of disease risks? Why should health care not be accessible to all? Awareness, instead of its narrow focus on behavior modification, needs to shift its lens onto global patterns of health inequalities and the economic logics and assumptions that produce these health inequalities, turning our work toward advocacy and activism.  
The story of Mohsine narrativized as a poem in the opening of this piece draws us to the challenges ahead of us as health communicators. The story of Mohsine asks us to consider seriously, “What is the value of what we do?”
Mohan J.Dutta is Professor and Head of the Department of Communications and New Media and Director of the Center for Culture-Centered Approach to Research and Evaluation (CARE) at the National University of Singapore.

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