Hegemonic Arrangements in the Public Health Economy: Gaining Insight into Motivations and Behaviors
Suggested Citation: Williams, C. (Ed.). (2023, January 29). https://www.publichealthliberation.com/hub/hegemonic-arrangements. PublicHealthLiberation.com. Retrieved from https://www.publichealthliberation.com/hub/hegemonic-arrangements
Introduction
The theory of hegemony is a “grand theory” that helps to explain how and why societies are organized the way they are, including maldistribution of resources and mistreatment of certain populations. This essay builds on Antonio Gramsci’s concept of hegemony to examine the performance of the macro- and micro-Public Health Economy. It first provides a brief summary of hegemony, relying heavily on George Hoare and Nathan Sperber’s An introduction to Antonio Gramsci: His Life, Thought and Legacy. It extends this framework to contemporary issues using extensive community knowledge and experience. It answers questions on why opposing the status quo can be difficult.
On Hegemony
Hegemony dates back to the Ancient Greek word “eghestai,” meaning to direct or to lead.[1] It was used to denote a leading power within a political or miliary alliance and remains part of mainstream international relations theory.[1] During the Russian revolutionary period from the 1880s through the early 20th century, hegemony changed meaning toward a class alliance of the working class and peasantry to exert “hegemony” over the bourgeoisie.[1] Antonio Gramsci (1891-1937), an Italian Marxist philosopher, widened the Marxist view of hegemony to “any form of directing political action on the part of one social group” to include the “cultural, moral and cognitive aspects of that leadership” toward political reform.[1] “For Gramsci, hegemony is thus constructed through the power of attraction of the leading group and also through compromises and concessions aimed at the conscious rallying of auxiliary forces.”[1] While some ambiguity has been noted in Gramsci’s concept of hegemony, consent and coercion are characteristic features.
According to George Hoare and Nathan Sperber’s interpretation of Gramsci, “The coercive apparatuses of the State are, then, the means to implement public policies that have been sanctioned by elections, while the electoral mechanism itself contributes to ensuring the durability and stability of the violence of the State by making that violence, in another of Weber’s terms, ‘legitimate’.”[1] Brute or mortal force is less visible or essential because of the ubiquity of consensual institutional practices and policies.
Hegemony operates as a “superstructure” in society beyond a singular discipline. The hegemonic apparatus relies on influence within political society (political leaders, city agencies, courts and so on) and civil society (school systems, media, nonprofits/businesses) for ideological and moral legitimacy. Hegemony is viewed as a dynamic system of reproduction through the everyday decision-making and actions to include struggles with rival hegemonic tendencies.
‘this form of relationship exists throughout society as a whole and for every individual relative to other individuals. It exists between intellectual and non-intellectual sections of the population, between the rulers and the ruled, elites and their followers, leaders [dirigenti] and led, the vanguard and the body of the army. Every relationship of “hegemony” is necessarily an educational relationship’. (Gramsci)
Gramsci sought an ethical or cultural State “to raise the great mass of the population to a particular cultural and moral level” to supplant the bourgeois State. He sought a mass psychological transformation or paradigmatic shift in class consciousness imbued with intellectual awakening followed by political action to challenge the hegemonic order. This is understood to be a catharsis “whereby the popular classes seize on and take possession of the knowledge that is created by the philosophy of praxis” to reconcile social contradictions.[1]
On Contemporary Interpretations of Hegemony in the Public Health Economy
Hegemonic theory helps to better explain deep and chronic health inequity within the Public Health Economy - both at the micro- (states, cities, neighborhoods) and macro-levels (national). Classic frameworks or theories involving racism or classicism alone are inadequate because there exists a more complicated view of social and political alliances. Populations that would seem to be naturally allied because of shared health burdens, race, or class can differ significantly in how they respond to the hegemonic arrangement, defined as a system of beliefs and practices within political and civil life that maintain the maldistribution of resources and allow for the mistreatment of certain populations. Some groups from marginalized, burdened populations determine that it is better to accept the social condition and to extract some benefits from the current system, however unequal and injurious to their broad interest group. Their desire for expediency to achieve some material improvement over risking social and political exclusion (in calling for radical change) forms a barrier for the intellectual and moral reform needed to improve the performance of the Public Health Economy.
They may seek small gains from the political class that appear to be a meaningful improvement but only harden the grip of the hegemonic arrangement and its concomitant excesses and harm. The costs that they pay will be to hinder social progress on health equity and create intellectual limitations that can call attention to determinants of health within the Public Health Economy. Gramsci believed that the role of organic intellectuals to “persuade through their ideological activism” was essential to building bridges with affected populations and to support their cause. [1]
Across all racial and class strata of the Public Health Economy, individuals will be susceptible to deference to the hegemonic arrangement. We consider the acceptance of this to constitute illiberation. Their rational choice is not illogical. If the hegemonic arrangement to strengthen inequity is so strong and thorough, then efficient pathways can be considered the most rational choice given limitations and competing demands on time and resources. Perceived or actual mortal or retaliatory threats are another consideration. Examining the underlying policies to explain health inequity reproduction in one’s neighborhood is itself a highly demanding cognitive exercise - that this organization knows all too well.
These decisions to acquiesce are based on a complex decision-making tree of which the intimidation and denseness of policy analysis is one. If allying with vocal opposition to the hegemonic arrangement leads to social stigma, diminished social capital, or puts one’s economic livelihood in jeopardy, then groups may perceive that the decision is made for them - a fait accompli. Some groups’ choices of alliances are colored by historical and contemporary accounts of people like them, including their leaders. They may determine that an assassination, imprisonment, or ostracizing of individuals or groups proved the lengths that hegemonic powers will go to secure the power balance. Still today, the assassinations of several prominent political and civil rights leaders during the 1960’s and afterwards are considered a cautionary tale for many. We know this because it comes up in our community conversations. Broadly, this discussion can be understood as part of rational choice theory - an explanatory framework for understanding motivations and decisions of agents in the Public Health Economy.
To understand why some groups defer to hegemonic arrangement though they stand to benefit most from transformative change in the Public Health Economy, it is important to understand the “reward” (consent) and “punishment” (coercion) system. Hegemonies in the Public Health Economy rely on consent and coercion as Gramsci’s hegemonic theory posits. Those consenting agents willing to “play the game” receive rewards in various forms that could include but not limited to social elevation, access to power circles and social networks, direct economic benefits, employment/career opportunities, political patronage, steering of contracts, rule-making powers, authoritative legitimacy, and so on. Such rewards are not readily available to more critical voices. Consent involves reward for “good behavior” and willingness on the part of consenting parties to engage in self-regulation. For example, parties that consent to the hegemonic tendencies of racial inequality may engage in speech and practices that de-emphasize race, employ stereotypes of marginalized groups, shift blame to other factors, and engage in “covering” to minimize their association or identity with certain groups. Taken to extremes, they may even denounce their cultural heritage to demonstrate their loyalty to the perceived hegemonic socio-cultural and socio-political order. Properly understood, consent takes various forms well beyond race. A common, albeit uncritical, hegemonic practice is to exclude certain groups from coalitions, membership bodies, or conferences who would likely seek a greater pace of change in accelerating the Public Health Economy toward health equity.
Hegemonies have highly sophisticated tailored tools and approaches to ensure that there are sufficient “auxiliary” groups to maintain their entrenchment and dominance. Gramsci directs our attention to political and social institutions, but our understanding of hegemonic influence is grossly incomplete and underexplored. In part, this is the result of the lack of transdisciplinary synthesis and training. Another root cause is the exchange and interdependency of hegemonic industries across the Public Health Economy in law, politics, civil society, education, health systems, housing, regulators, etc. To concretize with an example, gentrification is associated with displacement and economic marginalization of minority residents. Neighborhood change is often the result of consensus-building among developers, elected officials, and at least some neighborhood representatives. Local television and newspaper media can also contribute to hegemonic discourse through storytelling - regular (exaggerated) reports on crime to stigmatize the neighborhood as crime-ridden and run-down and to prime public attitudes in favor of gentrification. The attitudes of propertied minorities in a gentrifying economy who favor neighborhood change are less well-understood. They may, in fact, provide insight into the emergence of gentrifying forces if they exert greater influence within the hegemonic micro-Public Health Economy (standing as “community representatives”) than impacted or vulnerable populations. Increasing property value may be a “reward” for hegemonic allyship, but it also means displacement and hardening of racial inequity.
Hegemonic practices not only protect the Public Health Economy from radical change but ensure that they produce rewards and punishment. Inefficiencies are built into systems to allow for material benefits - access to public funding, transfer of government functions from public to private management, increased services and programs - that do not fundamentally alter maldistribution and mistreatment in the Public Health Economy. Such inefficiencies are often discussed related to US health care spending. Agents are drawn into the hegemonic nexus out of narrowly defined self-interests. They are often disincentivized to engage in meaningful change to the PH economy. Even if social calls for reform grow, the hegemonic order ensures that at least some auxiliary groups stand ready to defend it against change, though their self-interests must align in a meaningful way with this order to explain their conduct.
The interplay of hegemony differs depending on the level of analysis and specialty focus. In terms of political theory, the macro-Public Health Economy must contend with the limitations of federalism and the widening gaps of the two major political parties. The political risks of attempting to fix the Public Health Economy through legislative or regulatory action can be great and unpredictable in shifting public attitudes. If any reconfiguration of the Public Health Economy does not provide existing material benefits, here meaning those defined as inefficiencies, then that could alienate auxiliary groups and upset the hegemonic arrangement. Political paralysis on the issue of the poor performance of the Public Health Economy benefits the hegemonic arrangement.
In terms of economic theory, the stock markets may respond negatively to sudden shifts in the Public Health Economy - whether good or bad - because the markets are sensitive to uncertainty. New laws aimed at health equity could produce unintended market behavior that becomes a political liability because the public misattributes the correlation of the stock market and economy. (“The Stock Market is Not the Economy,” Nasdaq.com) Thus, in some respect, we can understand inaction to address the Public Health Economy as politically and economically constrained.
On a state-level, the micro-Public Health Economy may be more apt to hegemonic strength due to a lack of political diversity - one-party rule. It may more strongly incent even marginalized communities to accept self-defeat and self-diminution, bargaining only for marginal reform. Some communities may withdraw from political and civic life, of which chronically low voter turnout might be evidence. The role of community leaders, whether public officials or local representative, is altogether another issue. They may feel powerless to identify any other pathway for equity in the Public Health Economy except by following the lead of predecessors or contemporary colleagues who may feel that they can only negotiate for small gains.
Punishment or coercion is also a major tool of hegemonies. As with rewards, they employ sophisticated tools and approaches varying by setting and circumstance. At the interpersonal level, enforcers of the hegemonic arrangement may engage in denialism in response to others’ arguments, meaning that adherents deny that there exists unfairness or inequality in the Public Health Economy. They might rely on an Alger-ian notion of dogged determination, as in Horatio Alger. The hegemonic socio-political and socio-cultural paradigm may be so deeply internalized and uncritically reflected upon that adherents may not recognize the source of their perceptions. If asymmetry exists in power or social standing, then that denialism can be construed as a powerful form of punishment and portend deep division or separation in a personal or professional relationship. The mentee benefits of a mentor relationship may be withdrawn or curtailed.
In a highly hegemonized environment, the social costs for anti-hegemonic resistance may mean intense social alienation and may require a residential move outside of a neighborhood, city, or state. Like many aspects to hegemonic governance, little appears in the literature on these social phenomena and their health effects. Depending on the strength of hegemonic rule, individuals may suffer embodiment due to their activities (“praxis”) aimed at reforming the Public Health Economy. The physical and mental health impacts of praxis are underexplored. It can be expected that the hegemonic order is intentionally constructed and internally resistant to change, meaning that communities will need to be engaged in a persistent Douglassian or Herculean struggle. An autopsy revealed that Dr. King’s heart is said that of a 60-year-old than a 39-year-old, his age at the time of his death. Embodiment happens. Punishment also exists at a social level wherein groups face stigma, labels of “radical” otherness, and economic costs.
Liberation
In our inaugural manuscript, Public Health Liberation posited liberation as:
“Liberation is a philosophized mindset and way of life that allow individuals and collectives to pursue emancipation from all manner of constraints on thought, expression, and collectivism. The gestalt of liberation is to circumvent barriers that impede idealized health. For every barrier, there is a liberation response, if not solution. Liberation reflects self-worth and higher cognitive demand that is valued in-and-of itself and regarded as the lifeblood of Public Health Liberation theory and practice.”
This is consistent with Gramsci’s process of catharsis - self-consciousness and self-knowledge that translate historicized theory into praxis. Liberation philosophy leads communities of practice to engage in intellectual regeneration for informed transformative practice and change in the Public Health Economy. The hegemonic order is only as resilient insofar as it is uncritically examined and re-constructed only from within. Health equity achievement in the Public Health Economy requires an intellectual movement along with “critical-practical activity”.
Proponents have to be willing to deconstruct theories and practices by relying on their experiences and observations happening in their communities of practice to gain insight into the performance of the Public Health Economy and its innerworkings. That is an important first step. Because determinants of health cut across various specialties and include both historical and contemporary sources, it is appropriate to elevate public health discourse to view and measure the Public Health Economy as a singular and complex body of knowledge and unit of analysis.
This series on hegemonic theory will continue in subsequent publications in The Hub.
1 - Hoare, G., & Sperber, N. (2015). An introduction to Antonio Gramsci: His life, thought and legacy. Bloomsbury Publishing.
