By Martha Roberts

This article is based on my experiences over the past 9 years of working with the Alliance for People’s Health (APH) as a founding member. I have permission of current APH collective members to post this article and am very grateful for their thoughtful comments and contributions. This is my attempt to sum up the process the organization went through in the development of our political positions, practices, and of nearly a decade of struggle in which over a dozen collective members participated.

The APH is an organization of health workers, grassroots organizers and people committed to the struggle for health for all led by a small collective of grassroots organizers in East Vancouver. The APH remains active to this day, advocating for health for, all exposing and opposing the structural determinants of health and connecting health care workers and providers to democratic and people-powered struggles against imperialism, colonialism, and hetero-patriarchy, and struggling for total for social transformation.

In my experience, at times the APH core group consciously applied principles of mass line, and at other times our practices evolved more organically out of our roots in working class communities, primarily communities of colour, and our people-to-people relationships within revolutionary movements.

Looking back over the past 9 years I am impressed and deeply appreciative of our work and of our strong collective analysis. In this short article I am attempting to analyze how the APH conducted mass line practice through cycles of experience, analysis, action toward health for all.

Step One: Identify the Principle Contradiction

“Contradictions in post-revolutionary China after 1949 were the material base of the mass movement,

which in turn is a socialist strategy to resolve these contradictions.” (Ching, p. 61)

When the original APH core group members started meeting in 2006, our first challenge was to identify the main struggle that we wanted to collectively take up. We drew a lot of inspiration from a mass organization in the Philippines called the Health Alliance for Democracy which connects health workers to popular campaigns for social and economic justice. We also drew inspiration from the Council for Health and Development, an institution of People Power that supports the establishment and ongoing development of Community Based Health Programs to provide community-controlled health programs led by Community Health Workers in urban poor and rural communities. Which path were we going to follow? A mass organization of progressive health workers, or an organization leading health programs in working class and marginalized communities? Or both? What was our mass character going to be?

We started by surmising, based on our own personal and organizing experiences, that the “basic requirements for health cannot be achieved for all under a system that oppresses and exploits working class people, women, people of color and Aboriginal people.” If, as our basis of collective unity states, we seek to achieve “a just, liberated and healthy world” for all, what is the main impediment that stands in our way? And how can we organize communities to defend their right to health?

What we needed to do was identify and substantiate the principle contradiction in the social structure which undercuts our experiences of ill-health and prevents communities and individuals from achieving optimal health and well-being. Identifying the principle contradiction forms the basis of our struggle, both as health workers, and as community members, and becomes the overarching ‘call’ of the organization. It is this position that allows us to define the sides of the struggle and digs right into the class dynamic of the issue. This is necessary to identify who’s with us, who’s waffling and can be moved, and who’s against us. It guides us to identify the revolutionary aspect of how to resolve that contradiction.

This process of identifying the principle contradiction and the overarching mass line of the organization necessitates active participation with the masses, for the masses are the drivers of change.

Capitalism is a Disease: the Structural Determinants of Health

The People’s Health Series started in 2008 when APH organizers set about to investigate and struggle to overcome health concerns in our community. We started by selecting what we assessed to be the major health issues in working class communities based on our collective decades of grassroots organizing through the Bus Riders Union, Grassroots Women, the Poverty Action Network, and other mass organizations. These issues included: worker safety, back and neck pain, nutrition, dental care, and access to public health services. We designed popular education workshops that flowed to move people from experiences of ill-health, to analysis of the roots of the health issue, to practical things we could do as individuals, as a group, and as an organization to work towards improvements in our health and the health of our communities.

Over time and through learning from people in our communities, we added mental health, heart health, diabetes and chronic disease prevention, healthy sexuality, migration and health, knowing your health history, patients’ rights, and more. The People’s Health Series expanded to include the Women’s Health Series and the Immigrant and Refugee Health Series. Hundreds of community members participated in these popular education workshops and contributed to our collective understanding of the impacts of capitalism, colonialism, patriarchy, and structural racism on people’s health.

We heard time and time again that the overarching problem people were facing in their health, the thread that connected all of our health problems, was exploitation and oppression under capitalism. What we learned through this constant connection with working class people in our communities was that, while we could implement coping measures or cover up symptoms, the roots of the problem lay in our economic exploitation as workers, in our experiences of institutionalized racism and sexism, and in the limited health and social services within the neoliberal state.

Our mass line became Capitalism is a Disease expressed through our ever-sharpening analysis of the structural determinants of health that we witnessed through every single interaction we had in the programmatic work of the People’s Health Series.

When a worker gets injured due to unsafe workplaces and the boss’s refusal to provide adequate training and safety equipment…

It is connected to the mother who can’t afford dental care for her children…

It is connected to the farm worker who suffers malnutrition due to poverty.

The principle contradiction was clearly capitalism. Capitalism is the social diagnosis and structural change is our common and collective cure.

The lived experience of working class people and communities demonstrated the correctness of this contradiction, and the development of our initial line on the structural determinants of health allowed us to identify who is with us, who can be moved, and who our enemies are.

Step Two: Identify the Process of Change

“Without the opposite or when the opposite is not well focused,

energy created in a mass movement is often diverted to different directions and eventually dissipated” (p.65).

Once we know who’s with us, we need to know where we’re headed, for the mass line not only allows us to understand and analyze society, but it is also the process by which the collectivity of the oppressed and exploited organize in mass democratic formations and then move with unity in the struggle to transform society. We can have an ‘anti’ movement: anti-imperialist, anti-colonial, anti-capitalist, anti-patriarchal. But this is not enough for transformation to occur. If the masses are to be the drivers of change in society there needs to be a clear direction for where that struggle is headed or the struggle will dissipate.

This requires the next step of what Mao called “setting up the opposite” in the contradiction. This requires us to understand the contradiction very deeply and from the perspective of the oppressed and exploited masses. By doing so, we begin to grasp the main impediments to working class power and control. For ultimately, to tackle capitalism as a disease, we need a socialist cure. This is going to require highly organized communities.

As Mao explains, “the other does not exist in the objective world but the material conditions to set it up exist. For example, the waterfall exists in the natural world. Without setting up an opposite, one cannot create something from the waterfall. Building a dam is setting up an opposite to the waterfall. Then energy can be created to generate electricity.”

To set up the opposite is to find the key to building people power, to shift the balance of power so the subordinated becomes the dominant; to generate great energy from the people. This requires a long-term strategy to challenge bourgeois power and harness working class power toward a social system that not only eliminates bourgeois power, but is based in the power of the people.

Contesting Neutrality: What’s a Radical Health Worker to Do?

Our need for healing and medicine exists objectively in the world. But for the masses to really be in the driver’s seat, we can’t just fight for more profit-driven health care based on profit-driven research and profit-driven pharmaceuticals and directed by bourgeoisie capitalist interests and carried out by petty-bourgeois health care professionals. Capitalist medicine reflects bourgeois power.

What we need to do, what our strategy needs to be, is to subordinate that bourgeois power to the power of the people. We needed to set up our opposite, not as amorphous capitalism, but as bourgeois medicine. As working class communities we should no longer buy the ideology that bourgeois medicine is neutral medicine. From there we can start to build health institutions of people power. Even as we begin to analyze how bourgeois medicine dominates and controls as it heals, we begin to collectively resist by asserting Our Patient Rights within the oppressive institution.

Our line becomes contesting neutrality. Medicine is a major institution of bourgeois and colonial hegemony; there is no such thing as neutral medical research and practice under capitalism. This means that not only as health care providers can we not be neutral and we must decide who we stand with, but even further, the tools we employ in the course of our work are not neutral tools to be used the way we intend. There is bourgeois hegemony embedded in professional institutions, practice structures, and protocols[i].

A neutral care provider is one who lacks a critical questioning of their elite petty-bourgeois role in the system, and through their active participation, actually serves to perpetuate bourgeois ideology and practices. A neutral care provider doesn’t ask ‘does the care I provide perpetuate a class-driven and racist ideology of blaming the individual for their illnesses?’ Instead a neutral care provider unquestioningly adopts a reductionist bio-medical framework which fails to strike at the root of the problem, that ultimately capitalism is our main social disease today. This neutrality is what perpetuates a sick system driven by profit and greed.

But even if we do ask those critical questions above, there are no personal solutions to political problems. While some of our skills and knowledge may be useful for healing, much of what we carry in our heads and also potentially much of what we do with our hands might contribute more to harm and the perpetuation of bourgeois hegemony than actually heal. It is not just up to us to decide what harms and what heals. It is impossible to transform ourselves as health care providers until we subordinate ourselves to a movement for economic and social justice led by the oppressed and exploited.

For example, North American health care statistics indicate that somewhere in the range of 26% of women are taking psychiatric medications, and this fact was reflected in the lived experiences of the many women who participated in the Women’s Health Series. We’re pathologized for our experiences of gender oppression, our personality traits, our sexuality, our menstrual cycles and hormonal balances, how we express emotions such as anger or frustration, how we cope with grief, trauma, and abuse, how much food we eat or don’t eat, our experiences of alienation or isolation as mothers, and the list goes on. And when we reach out for help, the attentive health care provider’s first line of treatment usually involves practices such as Cognitive Behavioral Therapies (including mindfulness, etc.). While this may be helpful for some, as an intervention overall it entrenches women’s social experiences in personal failings and ‘wrongful ideas’. The attentive care provider’s second line of defense usually rests in either a) referral to psychiatry for medications, or b) direct prescription of medications, which might address bio-chemical imbalance (or might be harmful), but does not get at the social roots which undercut much of women’s experiences of poor mental health.

What isn’t talked about are things we can collectively do, together, to support positive mental health for our communities. Like fighting for our collective rights against exploitation and for collaborating, building social networks of resistance against alienation and for unity, and celebrating our beautiful diversity against structural racism and heterosexism.

Part of our work at the APH has become engaging health care providers in discussing the implications of the line that there can be no neutrality in medicine and health care. How do health care researchers, students, workers, and providers themselves experience the contradictions that we study and treat the biological origins of what is ultimately social disease stemming from gross exploitation and oppression? How can we support each other to take a stand for social justice in a conservative environment?

As Audrey Lorde once said, the “master’s tools will never dismantle the master’s house”, so it goes that bourgeois medicine is an inherently oppressive tool which serves to perpetuate bourgeois domination and hegemony. This is not to say that that all knowledge and practice contained within bourgeois medicine has no potential value within working class health care, but the point is, it’s not up to bourgeois and petty-bourgeois health care professionals to make the decision about what practices serve to control and which ones have potential to heal.

Step Three: Designing a Long-Term Strategy for Structural Transformation

“Setting up the opposite in a mass movement requires a thorough understanding of the principle contradiction

as well as the skill of translating such an understanding into practice at an operational level.

It is an extremely difficult task.”

Once we have identified the contradiction, and identified where we need to head to build working class hegemony, then we need to outline our strategy to build the actual mass organization of people power necessary for revolutionary transformation.

What does a strategy for change look like?

Community Ownership and Control: New Knowledge and Practice through Democratic People’s Institutions

In order to build “public health care centered on the needs and visions of working-class communities in particular Aboriginal communities and communities of color” we needed to “turn it upside down” and argue that working class people could decide the future of health care for the people. This is the greatest challenge and our most difficult task!

We are not operating in a revolutionary context. My experience in the APH and as a health care provider who dreams of working within an institution of working class power has clarified for me that until we have successfully organized working class and historically-marginalized communities to claim power and control, it will be impossible to subordinate bourgeois knowledge and practices.

Even in advanced movements such as in the Philippines, it is only through the ongoing process of active struggle can bourgeois hegemony in medicine by challenged!

The people must first be organized before power can effectively be exerted. The building blocks of power are mass democratic organizations of the working class.

Developing and then being persistent with a strategy is the only way we’re going to move forward with mass organized resistance. Being persistent means that we learn, we adapt, and we make changes where we need to based on our practical experience, but that we don’t give up on the long-term vision.

The Ongoing Role of the Alliance for People’s Health

The role that the APH plays in building a movement is expressed in our four-point strategy as explained in our APH Primer Spring 2013.

Persistently raising the structural determinants of health and challenging the petty-bourgeois social determinants or bourgeois biomedical frameworks. The leadership the APH demonstrates in advancing an analysis of the structural determinants has been recognized internationally. Demanding the state provide access to adequate health care, through campaigns such as our dental campaign, and through our ongoing support of the call for Sanctuary Health! Advocating for community ownership and control of health services, and the development of community roles in health care such as Community Health Workers – reclaiming health knowledge and expertise! Training health care workers in popular education and people-centred techniques, as well as advocating for community members to reclaim control of preventative and curative health services is a major component of our strategy. We share our skills with communities locally and internationally. Providing concrete support to Liberation Movements across Turtle Island and the world. Supporting mass revolutionary movements for social transformation is in many ways one of our greatest contributions in this moment in the early stages of revolutionary movement building in Canada. Promoting and connecting health care students, workers, providers, and community members to revolutionary movements and struggles, and the comradeship the APH has built in people-to-people solidarity continues to be a beautiful and inspiring practice.

For after all, “only through our united efforts can we make a significant contribution towards a just, liberated and healthy world.”

Recommended readings:

The APH featured on Talking Radical Radio.

Ching, Pao Yu & Hsu, D. (1992). Mass Movement: Mao’s Socialist Strategy for Change. Available in: Revolution and Counterrevolution: China’s Continuing Class Struggle since Liberation.

Anne-Emanuelle Birn, Philanthrocapitalism, past and present: The Rockefeller Foundation, the Gates Foundation, and the setting(s) of the international/ global health agenda. Hypothesis 2014, 12(1)

Feo, O. (2008). Neoliberal Policies and their Impact on Public Health Education: Observation on the Venezuelan Experience. From Social Medicine.

Jardim, C. (2005). Prevention and Solidarity: Democratizing Health in Venezuela. From Monthly Review, January 2005.

De Ceukelaire, W., De Vos, P, & Criel, B. (2011). Political Will for Better Health: a bottom-up process. From Tropical Medicine and International Health.

Krieger, N. & Basset, M. (1986). The Health of Black Folk: Disease, Class, and Ideology in Science. From Monthly Review, July-August 1986.

Mullan, F. (2007). Seize the Hospital to Serve the People. From Social Medicine.

[i] Diabetes diagnosis and treatment in Indigenous and migrant communities is a sharp example of bio-medical reductionism that serves medical profiteering off of the impacts of colonization and forced migration on human biology. The primary problem is the destruction of traditional food systems in the transition to capitalism and forced migration for cheap labour. A de-colonizing approach (or geniune agrarian reform depending on the context) is the only approach that’s going to get at the root of the problem. I’m not arguing that individuals should not treat their diabetes, or that community-based responses don’t exist. Rather I’m saying that diabetes is a disease of capitalism and colonialism and requires a deeper liberatory response for a true cure.