Power and Precision in the Public Health Economy

“(P)ower is at its most effective when least observable” - Steven Lukes

“We need a better understanding of how to influence the least observable forms of power, but not principally through the lens of power.”
- Christopher Williams

By Christopher Williams
Founder, Public Health Liberation

Steven Lukes’ second edition of Power: A Radical View appears to have little import for public health theory and practice. Its academic discussion is well-cited and well-written, but dense and conceptual. lts practice-based reasoning is wanting. Lukes admitted as such, “And yet, among those who have reflected on the matter, there is no agreement about to how to define it, how to conceive it, how to study it and, if it can be measured, how to measure it. There are endless debates about such questions, which show no sign of imminent resolution, and there is not even agreement about whether all this disagreement matters.”1

On the other hand, Public Health Liberation seeks transdisciplinary synthesis to elucidate and affect the Public Health Economy. It is imperative to sift through the concepts and theories in Lukes’ Power to fulfill the mission of our transdiscipline. As such, here are five critiques of this discourse to build upon the disciplinary foundation of Public Health Liberation. This discussion is meant to bridge core tenets of PHL, as discussed in our inaugural manuscript. First, we discuss power in the context of Steven Lukes’ Power: A Radical View, then provide five takeaways for thinking about the Public Health Economy.

Steven Lukes on Power

Steven Lukes presented a three-pronged challenge on power in his first edition (1974) of Power: A Radical View (PRV). He had sought “(1) to search for observable mechanisms of what I call power’s third dimension, (2) to find ways of falsifying it, and (3) to identify relations, characteristics and phenomena of power for which the first and second dimensions cannot account.”1 Lukes was responding to what he viewed as drawbacks with one-dimensional and two-dimensional views of power. The one-dimensional pluralist approach was characterized by 1) observable behaviors in the context of 2) the central study of decision-making, including 3) relative “power” of certain groups within 4) conflict-dependent context. Power is based on “an observable sequence of events,” often seeking to understand causes that lead to victories or defeats in decision-making.1

Pluralist C. Wright Mills challenged his contemporaries who believed that, in Alan Wolfe’s words, the “concentration of power in America ought not to be considered excessive because one group always balanced the power of others”.2 In Mills’ writings, he directed attention to a nexus of the elites that command hierarchies across sectors of society.

“As the means of information and of power are centralized, some men come to occupy positions in American society from which they can look down upon, so to speak, and by their decisions mightily affect, the everyday worlds of ordinary men and women...they are in positions to make decisions having major consequences. Whether they do or do not make such decisions is less important than the fact that they do occupy such pivotal positions: their failure to act, their failure to make decisions, is itself an act that is often of greater consequence than the decisions they do make. For they are in command of the major hierarchies and organizations of modern society.”3

Fellow pluralist echoed and expounded on Mills’ critique of the elite. Writing in 1953, Floyd Hunter’s findings determined,

“The method of handling the relatively powerless understructure is through . . . warnings, intimidations, threats, and in extreme cases, violence. In some cases the method may include isolation from all sources of support, including his job and therefore his income. The principle of ‘divide and rule’ is as applicable in the community as it is in the larger units of political patterning, and it is as effective. . . the top leaders are in substantial agreement most of the time on the big issues related to the basic ideologies of the culture…The individual in the bulk of the population of Regional City has no voice in policy determination. These individuals are the silent group. The voice of the professional understructure may have something to say about policy, but it usually goes unheeded.”1

Though within the pluralist school of thought, Robert Dahl leveled a criticism at Mills and Hunter that neither scholar examined conjectures about the ruling elite through a “behaviorist” lens based on case studies. Dahl argued that any theory of the ruling elite needed to be subjected to scientific testing, to posit a clear definition of this group, and to define cases in which this group regularly prevailed. He believed that a ruling elite theory needed to account for different actors, issue areas, and constituents, “(T)he small group that runs urban redevelopment is not the same as the small group that runs public education.”3 Still, Dahl brought a methodological approach to power defined as, “‘A has power over B to the extent that he can get B to do something that B would not otherwise do’ (Dahl 1957)4. Critics argued that the precision and rigor of Dahl and his followers had limited insight to “addressing wider questions concerning less overt and visible ways of securing the compliance of more or less willing subjects”.1 Max Weber defined domination as ‘the probability that a command with a given specific content will be obeyed by a given group of persons”.5 His influence along contemporary Dahl gained wide influence in the 1960s.

Pluralist discourse expanded with Joseph Schumpeter’s critique of classical democracy, finding democratic practice change as "products of the capitalist process" and "outgrowth[s] of the structure and the issues of the bourgeois world".6 Through democratic activities such as voting, the electorate "partake(s) in the business of ruling or influence or control those who actually do the ruling."7 The effect with modern democracy, according to Schumpeter, is that politicians “"simply act to carry out the will of the people”.6

The two-dimensional assumes that 1) “exploitation of some kinds of conflict and the suppression of others” are inherent and 2) power manifests in the scope of decision-making, defined as the influence of “nondecision-making”.1 Lukes elaborated by quoting Bachrach and Baratz, “Thus, nondecision-making is ‘a means by which demands for change in the existing allocation of benefits and privileges in the community can be suffocated before they are even voiced; or kept covert; or killed before they gain access to the relevant decision-making arena; or, failing all these things, maimed or destroyed in the decision-implementing stage of the policy process’.1 Bachrach and Baratz and other so-called neo-elitists revealed the “second face” to power. “All forms of political organization have a bias in favor of the exploitation of some kinds of conflict and the suppression of others because organization is the mobilization of bias. Some issues are organized into politics while others are organized out,” claimed E. E. Schattschneider.8 Antonio Gramsci’s contribution of hegemony to explain capitalist exploitation within democratic apparatuses gained influence within neo-elitism. “Gramsci’s view was that in ‘the contemporary social formations of the West’ it was ‘culture’ or ‘ideology’ that constituted ‘the mode of class rule secured by (explicit or tacit) consent’ (by the social and political order)”.1 Adam Przeworski interpreted Gramsci’s consent as conveying,

“Social relations constitute structures of choices within which people perceive, evaluate, and act. They consent when they choose particular courses of action and when they follow these choices in their practice….More specifically, (wage-earners) consent when they act collectively as if capitalism were a positive-sum game, that is when they cooperate with capitalists as they chose their strategies. Gramsci asserts that consent becomes reproduced on the condition that the hegemonic system, which is based on the private ownership of the means of production, yields outcomes that to some degree satisfy short-term material interests of various groups. Thus, in this view the reproduction of a particular form of social relations is conditional upon the outcomes of conflicts organized within these social relations…Yet this consent cannot be maintained interminably unless it corresponds to the real interests of those consenting….Consent to the existing social relation is thus always tentative….The consent to capitalism is permanently conditional: there exist material limits beyond which it will not be granted, and beyond these limits there be crises.”9

The notion of a consenting populous met a challenge in Charles Tilly who offered a proposition, “if ordinary domination so consistently hurts the well-defined interests of subordinate groups, why do subordinates comply? Why don’t they rebel continuously, or at least resist all along the way?”1 His list of potential explanations included that 1) subordinates are continuously rebelling, 2) subordinates’ pacification (“get something in return”) for subordination, 3) implication in exploitative system, 4) lack of competing ideological alternatives, 5) constrained by force and inertia, and 6) costly and unavailable means of rebellion.

Lukes’ first edition became a definitive read on the concept of power. Arguably, the book’s most famous passage and borrowed central premise “defined the concept of power by saying that A exercises power over B when A affects B in a manner contrary to B’s interests”.10 Thirty years later, Lukes admitted, “It was a mistake to define power” as narrowly as domination and binary relations. In addition, he regretted 1) a unitary conceptualization of interest that 2) eschews the capacity for internal contractions and conflict.

“Moreover, it was inadequate in confining the discussion to binary relations between actors assumed to have unitary interests, failing to consider the ways in which everyone’s interests are multiple, conflicting and of different kinds. The defence (sic) consists in making the case for the existence of power as the imposition of internal constraints. Those subject to it are led to acquire beliefs and form desires that result in their consenting or adapting to being dominated, in coercive and non-coercive settings.”

Lukes, however, does not fully concede (“still, power as domination”). Power as domination (asymmetric power) is only subsumed under the broad concept of “power,” which is “to have another or others in your power, by constraining their choices, thereby securing their compliance.” A longtime Lukes’ critic, Peter Morriss opined, “(W)e do not normally expect Chapter 2 of a book to tell us that much of chapter 1 was just wrong. Yet that is what occurs here. Lukes reprints PRV, and then, with remarkable honesty, admits that the work contained major mistakes”.10 Morriss argues that power is best understood as power to affect outcomes rather than to dominate others.

Third Dimension of Power
Lukes’ third dimension of power was captured in Tilly’s writing, “the power ‘to prevent people, to whatever degree, from having grievances by shaping their perceptions, cognitions and preferences in such a way that they accept their role in the existing order of things.”1 Lukes felt that two-dimensional views of bias and control required deeper analysis and needed to offer insight into groups and issues within a sociological context. He raised critical questions:

• Opportunities to Escape - “examining how people react to opportunities - or, more precisely, perceived opportunities - when these occur, to escape from subordinate positions in hierarchical systems,” and “how people behave in ‘abnormal times’ - when (ex hypothesi) ‘submission and intellectual subordination’ are absent or diminished, when the apparatus of power is removed or relaxed”

• The Counterfactual - How to “find out what it is that people would have done otherwise” - the counterfactual

• Observation - how to observe and “interpret nondecision-making behaviourally”

• Value Judgment - how to define the value judgment or position of an actor or set of actors (affected population, community institution or corporation, politician, etc.)

• Preventing from - What the exercise of power prevents people from doing, and sometimes even thinking.

• Internalization - Extent of internalization of subordinate status

• Unconscious Power - How to determine forms of unconscious power and awareness of consequences, “How can power be exercised without the exerciser being aware of what he (it) is doing?” Further, “one may be unaware of how others interpret one’s action. Or, third, one may be unaware of the consequences of one’s action.”

• Power vs Structure - “The problem is: when can social causation be characterized as an exercise of power, or, more precisely, how and where is the line to be drawn between structural determination, on the one hand, and an exercise of power, on the other?

• Attributing Responsibility - As opposed to actors, do we attribute “power to those in strategic positions who are able to initiate changes that are in the interests of broad segments of society but do not, claiming it to be ‘now sociologically realistic, morally fair, and politically imperative to make demands upon men of power and to hold them responsible for specific courses of events?”

• What is Power? - Power discourse is characterized by wide disagreement of its conceptual definition and its relevance (“there is not even agreement about whether all this disagreement matters.")

• How to know when power at play? - This is a question over which there is no consensus and much debate. Lukes argues straightforwardly, “We should search behind appearances for the hidden, least visible forms of power.”

According to Lukes, the study of power is important for several reasons. First, understanding power in needed to “know our own powers and those of others in order to and our way around a world”.1 To wield influence upon other human actors within this world to one’s interest, it is important to know their relative power. Second, power is intimately tied to responsibility. Holding powerful people accountable relies on a moral judgment. A structural problem in the economy or housing, for example, may find fault in “strategic positions,” such as elected officials, for failing to act. Third, assuming powerlessness due to the powerful or structural domination is too narrowly conceived because of its dynamism, changeability, and indeterminacy, “an interplay of power and structure, a web of possibilities for agents, whose nature is both active and structured, to make choices and pursue strategies within given limits, which in consequence expand and contract over time.”1

The assessment of power for any given agent falls under two judgments: their scope in defining power (“how wide the lens”) and agents’ capacity to affect outcomes.1 Issue-power is the range of issues that agents can determine the outcomes. The contextual range of power concerns the circumstances in which power will be operationalized. Active power is an observable action equated with exercising power while inactive power is abstention or non-intervention. Both can have significant consequences.

Critiques of Power Discourse

1. Efficiency - Public Health Liberation offers an inherent critique of academic discourse on power. We posit that theories are themselves deficient without alignment with core pillars of PHL theory - philosophy (meaning values, worldviews, and goal orientation), practice (meaning situatedness in application or clinical work), research, and training. Whether power discussions are intended as actual theories of cause-and-effect, that is not clear. Our conclusion is that this study of power forms an inefficient school of thought because theorists do not assume responsibility or desire for verifiability, public consumption, or practical applications. Lukes offers little insight into the underlying drivers that inform various theorists’ conclusions and whether their construction of power is intended to promulgate the interests of a group or class; namely, their own.

Clear statements on theorists’ values and worldviews, aside from power construction, are wanting. We cannot assume non-neutrality in theory-making on power. On whose behalf is Lukes defending his construction of power? Within the scope of our readings on the history of power discourse, theorists provide no generalizable tool (PHL research), training (PHL training), or cogent, accessible theory (PHL theory) to elucidate and affect challenges within the Public Health Economy. They rely on others to take their writings, even assuming one can wade through erudite scholarship, for effective teaching and use. There is little use in such scholarship if it is only to be consumed and understood by few. This criticism is consistent with our values on democratized knowledge, practice-based learning, and facility for teaching and training.

The power discourse has left the public and public health scholars with so few tools and too much discursive theory. It has lacked focus. Although Max Weber’s and other scholars’ dictum on encouraging empirical analysis (Weber on “the messy realm of practices and relations and the compromised, corrupted, partial ways in which these entities inhabit the real world”; Lukes on “In PRV I suggested that there can be an “empirical basis for identifying real interests”), robust tools and empirical approaches are infrequent and generally insufficient to understand and affect power within real-world challenges. Alignment with the five areas of PHL theory would have fixed this.

2. Exposure through Horizontal and Vertical Integration - The first problem, described above, leads to a second problem - information bias. Lukes provides little discussion into his own or other scholars’ real-world experiences. This is important because theories on power, especially given their context-independent generalizations, would require high degrees of exposure across different contexts, populations, and decision-making to be well-informed and generalizable. In Public Health Liberation, we particularly look at the degree of horizontal and vertical integration, meaning the diversity of coalition members and available pathways to health equity. Theories on power are inherently bounded by value judgment, evaluative perceptions, social context, and experiences. The rightness or wrongness of any position on power is not as important as whether the theory and theorists share our values and common experiences. The race and gender bias due to the white male-dominated discourse on power does not reflect PHL values. The commonness of the alienated scholar, including those who selectively participate in narrow areas of the Public Health Economy (e.g., one-time community research), is a contributing factor to health inequity reproduction. These experiences, in turn, shape research questions and strengthen fragmentation in the Public Health Economy. We argued in our manuscript that, “PHL eschews estranged public health, which can occur through alienation of the “objective” researcher from a community of practice rather than engaging non-instrumentally in promotion of an inclusive public health agenda.” Lukes’ PRV II suggests deep alienation among discussants from the populations of interest to PHL - those most disadvantaged in the Public Health Economy.

3. Power as Collective Liberation - Lukes’ PRV II is a valuable source to understand the history and movements in power discourse. While Lukes himself settles on a definition of power, it matters little if we do not know his personal philosophy, set of values, and orientation. We know ours, as described in our inaugural manuscript. Thus, we are left to glean where we can and to be consistent with our worldview and praxis for accelerating the pace of change to achieve health equity. We start with liberation.

We lean toward any line of thinking that supports liberation and collective striving. Talcott Parsons regarded power as a mechanism to bring about changes through pursuit of collective goals and collective action in advance of “the performance of function in and on behalf of the society as a system”.1 Parsons centrally situates “value consensus” derived from “obligations (that) are legitimized with reference to their bearing on collective goals”.

The conceptualisation of power which Parsons offers allows him to shift the entire weight of his analysis away from power as expressing a relation between individuals or groups, toward seeing power as a ‘system property’. That collective ‘goals’, or even the values which lie behind them, may be the outcome of a ‘negotiated order’ built on conflicts between parties holding differential power is ignored, since for Parsons ‘power’ assumes the prior existence of collective goals.1,11

Parsons attempted a grand theory “to integrate all the social sciences into a science of human action,” although functionalism slowly faded in the last quarter of the 20th century. 12

“Actions consist of the structures and processes from which humans are motivated to form meaningful intentions (through available goal-attaining means) that are put into practice within the social system (Parsons 1966). Parsonian “action” is considered from all of the following perspectives: culture (values), society (norms), personality (source of motivation), and organism (source of energy). For Parsons, people cannot choose goals and means without society in the background, and they cannot make sense of agency or action without enforced or expected social norms. This means people must have an intention and awareness of society’s norms, and they cannot escape these norms. Parsons is sometimes criticized for this position because he cannot account for social change.”12

Although Parsons and functionalism, in general, have been criticized as “conservative, restrictive, or even demonstrably false,” insight into social systems and their underpinning values and norms can be affected to advance health equity.13 The Parsonsian goal to “define and maintain a set of norms and values, which in turn legitimates action within the system itself” informs then oppositional positioning for critical agents.13 Here, two-dimensional views of power are helpful because social systems are not unitary. Norms within any given social systems are apt to self-contradiction and internal inconsistency and to change. Whether in historical, political, legal, or social sources, advocates and practitioners can cull from these sources to advance arguments for accelerated health equity.

4. Pluralism Has Advantages - The one-dimensional view of power of which Lukes and others are critical has major advantages precisely because of its more limited scope. In other words, health equity practice must seek efficient theories for effective, time-delimited design and implementation within real-world constraints whether in research, political engagement, or liberation space-making. Three-dimensional power, though likely more reflective of the complexity within the Public Health Economy, is too resource-intensive and beyond the reach of practical research and advocacy. The context-dependent sociopolitical lens, which Lukes sought, is infinitesimal given different actors in varying contexts and decision-making. Decisions impacting community health occur throughout the course of economic, legislative, regulatory, and social activities. It is not reasonable, as opposed to what Lukes proposes, to examine each decision in light of layered causal determinism and nuanced understandings of power.

Mill’s simplicity is attractive, “Whether they do or do not make such decisions is less important than the fact that they do occupy such pivotal positions: their failure to act, their failure to make decisions, is itself an act that is often of greater consequence than the decisions they do make.”1 We find that accepting suffering is a consequence of inattention and inaction of a concentration of powerful ruling elite. That paradigm can be used to frame compelling narratives for liberation space-making and collective action. In other words, it can focus on a common source or set of agents engaged in conduct against affected populations. That does not mean, however, the three-dimensional power is not relevant. Lukes’ second reason to study power (moral judgment) is germane. “Strategic positions” in the Public Health Economy should and must be confronted and held accountable when they fail to act.

5. The Least Observable - Lukes argues that, “power is at its most effective when least observable”.1 Here, he sought to challenge power that emphasizes behavioral observation. He argues that views of power can be limiting when they do not account for the sort of questions that we discussed above. However, we question whether a framing of power is all that important in public health.

Power is less appropriate as the central pivot for analysis because it is too confining to the central question for Public Health Liberation, which is to elucidate and affect the Public Health Economy. Power discourse is positioned as agnostic about disciplinary application, which is a major drawback. The sources for health inequity reproduction may be found in the political economy, economics, government administration and regulation, legislative oversight, illiberation (socially conditioned, internally maintained oppression or self-diminution), political theory, social systems, race or class politics, lack of horizontal or vertical integration, or other causal factors for a given micro- (neighborhood, city, state), or macro-Public Health Economy. To be sure, power matters, but there are concerns about its resource intensiveness and lack of conceptual clarity. We agree with Lukes that power is polysemic, meaning to have highly diverse meanings as with social or power. Power is also highly gendered in our view because it is associated with typical masculine perceptions and character. In addition to its polysemic and gendered meaning, its lack of a disciplinary home, lack of goal orientation, and lack of a shared group to which it is accountable or responsible are major weaknesses. Unlike power, public health has a clear value-laden mission.

Two elements are needed most to accelerate health equity - knowledge and precision. Public Health Liberation believes that a radical reconceptualization of public health toward the Public Health Economy offers a broader base of knowledge to understand how health inequity is reproduced. It requires attendance and participation across the PH economy well beyond the traditional scope of public health. Practitioners experience inequity reproduction in real-time and are intimately familiar with policies, structures, systems, and barriers. It reduces alienation of the researcher and shifts away from interest-driven engagement in the Public Health Economy. More public health practice is needed to synthesize information within a given Public Health Economy that can more accurately capture how and why health inequity persists through cogent, well-informed data collection in different contexts. PH economic analysis is a data-informed impression of structural synthesis. Public Health economists can navigate different spaces on different issues and pursue a Parsonsian collective goal for health equity.

Rather than power, we find that it is more important to focus on precision. Through knowledge-building, we hope to gain an understanding of precision - what works to change the material conditions of affected populations efficiently at an accelerated pace. We have gained little insight from power discourse into what works and how for the issues that we face in our communities of practice - environmental racism, slum-lording, employment- and community-induced mental health stress, mistreatment, financial stress, food insecurity, gun violence, strengthening social determinants of health, and government mismanagement. Precision leverages vertical and horizontal integration to arrive most efficiently to a change in material condition that health conditions are idealized and physical and mental health are optimized.

Improving public health is largely shouldered by two disciplines - clinical medicine and public health. A refocus within public health through the Public Health Economy has many strengths, as discussed here on an essay entitled, “Securing the Future of Public Health through Advocacy of the Public Health Economy”. [Read More]

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3 Mills, C. W. (1981). The power elite [1956]. New York.

4 Dahl, R. A. (1958). A critique of the ruling elite model. American Political Science Review, 52(2), 463-469.

5 Weber, M. (2016). The types of legitimate domination. In Social Theory Re-Wired (pp. 270-286). Routledge.

6 Schumpeter, J. A. (1962[1950]) Capitalism, Socialism and Democracy, 3rd edn. Harper Torchbooks edition: New York: Harper and Row.

7 Elliott, J. E. (1994). Joseph A. Schumpeter and the theory of democracy. Review of Social Economy, 52(4), 280-300.

8 Schattschneider, E. E. (1957). Intensity, visibility, direction and scope. American political science review, 51(4), 933-942.

9 Przeworski, A. (2017). The Scandal of Consent. The Priority of Injustice: Locating Democracy in Critical Theory, 36, 110.

10 Morriss, P. (2006). Steven Lukes on the concept of power. Political Studies Review, 4(2), 124-135.

11 Giddens, A. (1968) ‘ ‘‘Power’’ in the Recent Writings of Talcott Parsons’, Sociology, 2: 257^72.

12 https://www.encyclopedia.com/people/social-sciences-and-law/sociology-biographies/talcott-parsons

13 Jarvie, I. C., & Jarvie, I. C. (1986). Limits to functionalism and alternatives to it in anthropology (pp. 127-143). Springer Netherlands.