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Roundtable on Population Health Improvement; Roundtable on the Promotion of Health Equity and the Elimination of Health Disparities; Board on Population Health and Public Health Practice; Institute of Medicine. Supporting a Movement for Health and Health Equity: Lessons from Social Movements: Workshop Summary. Washington (DC): National Academies Press (US); 2014 Dec 3.

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Supporting a Movement for Health and Health Equity: Lessons from Social Movements: Workshop Summary.

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2Lessons from Social Movements

The workshop opened with presentations from two scholars of social movements: Francesca Polletta, professor of sociology at the University of California, Irvine, and Marshall Ganz, senior lecturer at Harvard University. Polletta shared insights from her work and from the sociology literature on the formation and dynamics of social movements, and she described circumstances, structures, and strategies that are associated with effective social movements (Polletta, 2008).

Ganz, who studies and teaches leadership, organization, and strategy in social movements and politics and who has worked as a community organizer, described lessons learned from his long experience in building successful social movements and in training change leaders (Ganz, 2010).


Concerning the need to establish goals for a movement for health improvement and equity, Polletta noted that the history of social movements indicates that movements are well served by pursuing multiple goals. Even “vague and capacious” goals can be advantageous, she said, because they may have broad appeal and therefore widen recruitment of participants and supporters. Also, a group that undertakes several goals is more likely to find success in at least some of them (e.g., litigation and consciousness raising, which have been shown to be mutually reinforcing).

Polletta then reviewed what sociologists have learned about how participants in successful social movements become mobilized to support a cause. “There is debate over every single one of the points I am going to make today,” she said, and welcomed workshop participants to challenge her conclusions. Sociologists define a social movement as “an organized effort to change laws, policies, or practices by people who do not have the power to effect change through conventional channels,” Polletta said. She emphasized that while movements often target the government and seek legislative change, they also challenge institutional policies and practices outside the government, as well as popular beliefs and common behaviors.

“The single most important insight of social movement research over the past 40 years is that movements don't come out of nowhere,” Polletta said. Rosa Parks, for example, was not simply a woman too tired to stand up on the bus one day; rather, she was a longtime civil rights activist and secretary of the Alabama chapter of the National Association for the Advancement of Colored People (NAACP). Since most social movements arise from the efforts of stalwarts for a cause, it is important to understand how such activists are able to gain the necessary leverage to mobilize more broadly. Poletta described three “essential ingredients” that contribute to mobilization: political opportunities, mobilizing structures, and resonant frames (i.e., effective messaging).

Political Opportunities

“Political opportunities are typically defined as changes in the political environment that make the government newly open to challengers' claims,” Polletta explained, adding that it is important to remember that movements target more than the government alone. Political opportunities include electoral instability, cleavages within a ruling elite or regime, new legislation, or even rhetoric (e.g., the president's statement on inequality)—that signal the government's openness to challengers' claims. Similarly, opportunities may be created by the presence of allies within or around the government who can petition for the movement's cause; and the appearance of threats that support the movement's claims (e.g., as the Three Mile Island disaster provided support for the antinuclear power movement).

The recent passage of the Affordable Care Act (ACA) presents several political opportunities for a movement seeking an enlarged notion of public health, Polletta said, despite the fact that the ACA itself has little to say about public health.1 The extraordinary media coverage of the ACA's implementation means that groups promoting public health could make arguments in the press that the act does not sufficiently support cost-effective preventive health care or that other factors than access to health care determine the state of the nation's health. Such efforts would be worthwhile, she said, because mainstream news media continue to set the terms of public debate, and policy makers pay attention to the media, including newspapers.

Bureaucrats implementing the ACA may also further the cause of health improvement and health equity, Polletta said, much as support was garnered for the elderly following the passage of the Social Security Act in 1935. State health insurance exchanges have some flexibility in their interpretation of the act, which could be shaped by officials sympathetic to an enlarged notion of public health, she pointed out. Polletta suggested that a public health movement could also find allies among organizations that supported the passage of the ACA (e.g., the AARP and several unions) and which now potentially could be convinced to adopt the cause of health improvement and equity. These organizations may prove instrumental in leading change beyond the purview of government—an arena that social movement scholars now recognize as important to achieving movement goals overall, she added.

Reforming the practices of the health care industry or of medical schools and other institutions may effectively further the cause of health improvement, Polletta said, and in the current climate of increasingly consumer- or patient-oriented health care this is a real possibility. She noted that the movement for alternative medicine made little headway until insurance companies recognized the value of that approach and that corporations, sensitive to issues that affect their reputations, supported equal treatment of gay and lesbian employees before governments did.

Mobilizing Structures

How does one get people mobilized to participate in a social movement? “People rarely join movements on their own,” Polletta said. “Even if you believe in a cause, it doesn't make rational sense to participate,” she explained. “It makes more sense to be a free rider. If the movement wins, you're still going to enjoy the benefits.” People who join movements generally feel compelled to do so as a result of messages they receive from pre-existing structures (e.g., churches in the southern United States that buoyed the civil rights movement or breast cancer support groups that encourage advocacy) or from friends or others whom they respect.

The Internet makes it easy to support a social movement, Polletta noted. “If participation means signing a petition, and all you have to do is click a button, you have solved the free rider problem,” she said. Thus, it is possible that Web-based organizing may make pre-existing mobilizing structures less important to the growth of new social movements, but this will be true only if Internet-based protest actually foments change. “I think it can,” Polletta said.

Research suggests that many effective social movements combine grassroots participation with support from elites. “Outsiders” who bring time, energy, and commitment to a cause can ally with “insiders,” such as political officials and executives who have political and economic capital and connections. “We need to think much more about ways in which elites and grassroots participation can work together effectively,” Polletta said. Another characteristic of successful social movements is the presence of coalitions, which are strategically beneficial, but are effective only when personal relationships and comfort among people of the separate groups are forged.

Deploying Effective Messages

“To mobilize participants, garner media coverage, enlist support, delegitimize antagonists, and persuade policy makers, movement groups must generate a persuasive message,” Polletta said; that is, they must “frame,” or communicate, their issue in a way that resonates with the general public. Effective framings explain the problem, offer a solution, and motivate participation, and they do so in the context of dominant values, such as equality, cost effectiveness, and personal responsibility, Polletta said. Equality is an especially persuasive theme, she said, and it usually trumps the theme of personal freedom; according to findings by the Pew Research Center. Polletta noted, that according to the Pew findings, 90 percent of Americans believe that “the government should do everything it can to ensure equality of opportunity” (Pew, 2009).

Polletta's work has led her to the observation—one that not all movement researchers agree with—that social movements are most effective when they rely on multiple framings. As an example, she spoke of using possibly contradictory arguments against the death penalty in order to appeal to different audiences: first, that capital punishment violates the sanctity of life, and, second, that it is not an effective deterrent to murder and therefore not a cost-effective means of crime control. How important is “staying on message” in mobilizing support for a social cause? Although some pundits may disagree, Polletta said, “in fact you maintain more in the way of support and coverage by having multiple messages that speak to different groups.”

Research also suggests that effective framing demands an antagonist, Polletta said. “It is hard to mobilize without an enemy,” she explained, although she noted that some successful social movements, such as Mothers Against Drunk Driving and anti-littering campaigns have done that. Movements without antagonists, sometimes called “consensus movements” can be effective, but are often limited in scope and momentum. She offered as an example the movement to address climate change, which has been compromised, according to environmental activist Bill McKibben, because it has become a “lifestyle” movement of individual recyclers and Prius drivers rather than a broadly driven campaign to compel developed nations to decrease their greenhouse gas emissions.2

Those who wish to mobilize a movement to promote health equity and raise awareness of the social determinants of health face a similar dilemma, Polletta said. “[I]f you don't have an antagonist, then does the movement risk being styled a lifestyle movement?” she asked. Although convincing individuals to take responsibility for their health through such means as weight control and exercise is undeniably important to the health of individuals, “you don't want that to be the sum total of the movement,” Polletta said, and she challenged those who are seeking to create such a movement to define without alienating potential allies who or what they are fighting against as they strive for health improvement.


Ganz began his presentation by emphasizing the importance of social movements over the course of U.S. history. That social movements have served as the main engine of political change in this country is not an accident, he said; rather, it is a direct result of the “particularly sclerotic set of electoral and formal political institutions” established by the founding fathers, who intentionally created a system with multiple barriers to innovation, including “many veto points, [at the] legislative, judicial, state level, and such deep principles of unequal representation, whether the Three-Fifths rule3 as applied to voting or institutions like the Senate that allocated representation regardless of the electorate.” Models for change instead emerged from the religious movements known as the Great Awakenings, which were followed by the temperance movement, the abolition movement, the suffrage movement, the populist movement, the early labor movement, the civil rights movement, the women's movement, the environmental movement, and the conservative movement, among others. When the United States is not under the influence of war or depression, political change happens primarily through the influence of social movements on electoral politics, Ganz concluded.

According to Ganz, “social movements emerge from the efforts of purposeful actors, individuals or organizations, to respond to changes, to conditions experienced as unjust—not just inconvenient, but unjust—so as to assert new public values, form new relationships, and mobilize political, economic, and cultural power to translate those values into action.” He also defined social movements by what they are not: fashions, styles, or fads, none of which are collective, strategic, or organized. However, he added, to say that a social movement is organized “doesn't always mean that everybody is getting along,” because social movements often incorporate competing groups. The aim of such movements is not simply to reallocate goods, or “win the game,” but instead to change the game's rules. Furthermore, he said, social movements are not the same as marketing, which is transactional in nature (e.g., “Buy my idea, give me your vote”), leaves people unchanged, and does not attempt to build capacity. At best, marketing can mobilize people to support a movement over the short term, but it cannot sustain participants' commitment.

Relationships Build Movements

Movement building is about building relationships among people that change the people involved and that also build capacity, Ganz stated. It involves both mobilizing people and organizing people, which are two distinct processes. To understand the distinction, he said, consider what happened in the aftermath of the Sandy Hook Elementary School shooting, which was followed by “enormous mobilization around gun violence, [that] came up, and went away. What [the groups reacting to the Sandy Hook shooting were] confronted with was 13,000 local gun clubs of the NRA [National Rifle Association]. That is organization, which is very different than momentary mobilization,” Ganz said.

Successful social movements go beyond mobilizing to actually organizing, Ganz said, which enables them to create the capacity to support ongoing and sustained change. Such efforts must be structured strategically so as to combine local action with regional and national purpose and also to benefit from timing, e.g., by taking advantage of events that shift public opinion in favor of a cause. “E. E. Schattschneider, the political scientist, pointed out that elites always try to localize conflict because they are likely to have an advantage in that setting,” Ganz said; by contrast, “insurgents are always trying to create turfs that are translocal, because it creates more opportunity to create a playing field in which you can find leverage” (Schattschneider, 1960). For example, Ganz added, the battle for civil rights was carried out by linking cities across the South and mobilizing support in the North.

“Since participation rests on moral suasion more than economic or political coercion,” Ganz said, “the outputs of movements depend on voluntary, motivated, and sustained effort” as well as on leaders who can motivate that commitment rather than merely assert control, which might work in a conventional organization, but does not in a movement. The less authoritative structure of movements tends to produce campaigns that incrementally alter the status quo. “Rarely do you start a campaign with all of the resources you need to win it,” Ganz said. “You are developing the capacity and the resources you need to win it in the course of doing it.”

Leadership resides at the heart of social movement activity, Ganz continued (Ganz, 2010). Leaders are those “who step up, who accept responsibility, who care deeply enough to commit, who begin to do the work of enabling others to join them to achieve purpose under highly uncertain conditions.” Rather than focus on the question of “What is my issue?” successful leaders first ask “Who are my people?” because movements are built by the people whose cause is being undertaken—a cause that they themselves must define, Ganz asserted. The leader's purpose is to determine what it will take for the (powerless) people to create the power they need to solve their problem, not how the resources of the powerful can be mobilized to solve it.

Because movements are about giving voice to underrepresented people and groups, they are inherently insurgent undertakings, Ganz said. In order to do that, they must tap new sources of power, new sources of capacity, and often new leadership—something that requires not only great commitment, but also immense creativity.

Marshall Ganz's Core Practices of Movement Building

According to Ganz, five “core practices” are required to build and organize successful social movements. They are:

1. Relationship Building

“Movements are built by the formation of new relationships among people,” Ganz said. People move people, and people are moved by examples of people moving people. The “skilled, intentional, purposeful forming of relationships” on which social networks can be built is essential to the success of social movements—especially insurgent ones, Ganz said. He described how in the course of his life's work, house meetings provided a way to accomplish these relationship-building goals when institutional conduits were inaccessible, both in the context of community organizing with the United Farm Workers, and later, when advising the first Obama presidential campaign. Through such house meetings, he said, movement participants established common ground for a commitment to work together, thereby creating a solid foundation for ongoing efforts.

2. Developing a Narrative

Ganz, as did Polletta, emphasized that successful social movements tell a story. The purpose of the story, he said, is to “articulate the challenge that is to be faced and bring alive the values to be drawn upon in order to find the moral or emotional resources to confront that challenge.” Such a narrative prepares movement participants—whether as individuals, communities, or movements as a whole—to face daunting challenges by countering fear with hope, empathy, and a sense of self-worth. People gain a sense of agency through identifying with the story's protagonist as well as with a set of values, which should be understood not as abstractions, but as reflecting emotional relationships to experiences, objects, and people. Thus, he concluded, the narratives of successful movements inspire urgency and protect participants from fear, isolation, and self-doubt.

“When we work with people on this,” Ganz said, “we construct it as a three-part narrative: a story of self, which is an articulation through narrative of why you have been called to what you have been called to; a story of us, which is a way of bringing alive the values shared by the community being mobilized; and, a story of now, which is a way of making real the challenge to those values that demands urgent action.” A complete narrative, he said, answers the questions, “Why are we doing this?” “What is at stake?” and “Why do we care?” but the narrative does not explain how the problem should be addressed. To do that requires the next practice: strategizing.

3. Strategizing

Although narrative does the emotional work of movement building, strategizing is its cognitive partner, Ganz said. At its most basic level, strategizing is figuring out how to turn what people have—that is, resources—into what they need—power—in order to get what they want, he explained. “Effective movements strategize at multiple levels and equip people with the resources and the capacity to be strategists.”

People are hard-wired for both storytelling and strategy, Ganz said. “We go through life telling stories and strategizing, but often we do so implicitly.” In his own work, Ganz attempts to bring intentionality and purpose to these actions and direct it toward the community's goal. And because social movements are, in his words, “always David, never Goliath,” they must compensate in resourcefulness what they lack in conventional resources. “People become the fundamental source of power of a social movement,” Ganz concluded, whether they choose to walk to work instead of taking a bus in Montgomery, Alabama, to defy British rule by making their own salt in India, or to boycott California grapes. How to aggregate resources that are broadly distributed into a purposeful focused effort—and, thereby, transform the important into the urgent—is the key strategic challenge in most social movements, he concluded.

4. Action

“Unless strategy and story and the relational foundation turn into effective, clear, measurable, recognizable action, nothing much is happening,” Ganz said, adding that action is occurring only if there is something to count: votes, for example, or people coming to rallies and showing up at meetings and signing petitions. “I was trained in organizing and in movement building that if you couldn't count it, it didn't happen, because you then have no way of measuring your effort—and that means you have no way of learning,” he said.

5. Structures

Many participants in movements have operated under the belief that structure meant one person telling everybody else what to do, Ganz said; in reaction, his own generation came to believe that structure was evil. In the early 1970s Jo Freeman, a feminist sociologist, wrote an influential article called “The Tyranny of Structurelessness,” in which she pointed out that groups naturally create some sort of structure for themselves (Freeman, 1972). If that structure is informal, she argued, decision making tends to be opaque, personalistic, and factionalized rather than explicit, accountable, and transparent. Thus, appropriate structures allow movements to coordinate, make decisions, and strategize effectively. Ganz's recent work—including for the first Obama presidential campaign—has focused on the development of such structures in the form of interdependent leadership teams and cascaded leadership teams.

Ultimately, building effective movements requires both the identification and recruitment of leaders and also their development, either with formal or informal training, Ganz said. Effective social movements carry out this identification, recruitment, and development at multiple organizational levels throughout the movement, he added. As an example of such an effective social movement, he described the Grange, a 19th-century movement supporting agricultural communities, which had 450,000 members in 450 chapters—a structure whose operation required 77,775 volunteer leaders, of which 99 percent were local. Today, the NRA is organized along similar lines, he said. It is investment in local and intermediate levels of leadership that allows these movements to be able to build and sustain constituencies over time, Ganz said. The people in these movements are organized, not merely mobilized, as is the case with the millions of people who “click and forget” their support of a cause.

The Prophetic Imagination

In closing, Ganz shared an idea he credited to Protestant theologian Walter Brueggemann. In his book The Prophetic Imagination (1978), Ganz argued that transformational vision occurs at the intersection of two factors: criticality, which is perception of the world's pain, and hope, a sense of the world's possibilities and of its promise. “One without the other doesn't yield the energy for change,” Ganz concluded.


Pros and Cons of Antagonism

The concept of antagonism as a tool for mobilization—when it can be used, its possible drawbacks, and its applicability to a public health movement—led to an extended discussion. It was initiated by a question from Terry Allan, president of the National Association of County and City Health Officials, and health commissioner of the Cuyahoga (Ohio) County Board of Health, who asked how a movement for population health improvement and health equity might define its opposition and avoid alienating key allies. Polletta replied, “We don't want to antagonize anyone, but we know that having an antagonist is mobilizing. We know that the media covers stories of conflict. If you present your story, then they are going to want to have the opposing side.”

It is more important to be clear about what you are fighting for than what you are fighting against, Ganz said. Demonization is not very effective and can be turned against those who use it—which is not to say that healthy conflict is not good for a movement. “I wouldn't get too hung up on the enemy,” he said; if the goal is clear, anyone who gets in the way is by definition an antagonist.

Mary Pittman, president and chief executive officer of the Public Health Institute, noted that demonizing an antagonist was an effective tool for the anti-tobacco movement, but that such obvious, single targets are not always available. When they are, she said, she worries about scenarios in which antagonists learn to use the language of the movement to disguise their own intent and thereby steal power.

“That has been a criticism often leveled at groups like BP [British Petroleum] and other oil companies that have now glossy advertisements where they talk about local movement building,” Polletta observed. She noted that both she and Ganz had defined social movements as representing people who are relatively powerless, so the danger of the movements being co-opted by the powerful is always there. That is why it is important for movements to be organized rather than being run by “a bunch of entrepreneurs,” she added. Organizers will understand such strategic trade-offs and eschew marketing (e.g., of the sort conducted by BP) in lieu of real commitment to change. Moreover, Polletta added, “if a company is attempting to co-opt, then that provides an opportunity for a movement to say, ‘These are your so-called values, but your actual practices diverge wildly.’” Revealing such co-optation as hypocritical gives the movement power, she noted. Ganz agreed and noted that Saul Alinksy, a famous community organizer, once said that organizers have to be “well-integrated schizoids” who can “polarize to mobilize and depolarize to settle” (Alinsky, 1971). Alinksy (1971) also advised that if enough pressure is applied to the opposition, it will make mistakes of which a movement can take advantage.

Nevertheless, Ganz added that he objects to the use of demonization because it gives opponents too much power. Instead, he offered the example from Shakespeare of Henry V's speech to his men before the Battle of Agincourt, in which they were vastly outnumbered by the French. Henry, Ganz noted, never mentions the enemy, but instead he focuses solely on enhancing his men's sense of worth and value. “The opposition has to be named, has to be called out, has to be recognized as opposition,” he acknowledged, “but I also think we need to avoid giving it too much power.”

Catherine Baase, chief health officer for The Dow Chemical Company, asked the speakers if they felt that the antagonist needs to be identified as an individual entity, such as an industry, or whether it could be something as broad as the status quo. Although it is certainly easier to stand in opposition to a clear adversary, such as the tobacco industry, it is also possible to mobilize against something more abstract, Polletta said. “We can't always put faces and names to the antagonists,” she said. “We have to think about ways in which you can make the challenge to overcome structures, beliefs, practices, institutions.”

By way of answering Baase's question, Ganz distinguished between “power over” problems, such as those posed by a polluting industry, and “power with” problems, which stem from a lack of cooperation or collaboration. An example of the latter was the need for cheap credit, which was solved by the organization of credit unions. But even in these circumstances, adversaries can emerge, he observed—in this case, predatory lenders, who lost business to credit unions. “Even when we think we are just being collaborative, power dynamics being what they are, we often wind up in a situation in which conflict comes our way,” he said. “We want to change things. That is going to cost somebody something.”

Therefore, Ganz continued, “the question is, under what conditions will they accept that cost?” Answering that question is a key point of strategic focus for a movement, he said. In the civil rights movement, for example, the decision was made to take on the bus company in Montgomery, Alabama—before schools, housing, or another deserving target—in order to build capacity, and then move on to other goals.

Strategic Alliances

Returning to the concern that creating an enemy might alienate potential supporters of a movement, Polletta emphasized that movements need to be open to alliances with novel and unlikely partners—for example, corporations that instituted benefits for partners of gay and lesbian employees before legislation required them to be provided.

Michelle Larkin of the Robert Wood Johnson Foundation asked both speakers to expand on this point with a specific focus on its implications for public health. “Business, for example, can at one time be an ally and in the next breath be an antagonist for us,” she observed. “How do you maintain those relationships and keep those networks well connected and trusting so you can come together [and] work on the common areas . . . [but] when you have to, separate and be comfortable in . . . critiquing each other and really pushing each other to change and move forward for a better outcome?”

Longtime combatants can develop a relationship of respect, Ganz said, and such a relationship should be possible between business and public health community and its partners. The challenge in such relationships stems from power imbalances, he explained; thus, the public health community needs to organize itself to achieve the status of equal partner to industry so that it can exercise agency and truly collaborate. Otherwise, power gets in the way.

To illustrate this point, Ganz described a project in which he is involved that involves a collaboration between public health officials in New Zealand and the Pacific Islander youth community. Diabetes rates are especially high among these youth, Ganz explained, and the public health group wished to engage that community rather than try to impose its own agenda. Thus, the members of the public health group took an organizing approach, which allowed them to learn that the young people were much more concerned about suicide among their peers than about diabetes and that they had been organizing themselves around that issue. Public health is now supporting that suicide-prevention effort, Ganz reported, and he and colleagues have collected data that show that the young people involved in leadership teams are functioning well and that positive health outcomes are resulting from this collaboration—confirming not only the importance of true collaboration but also the notion that “agency is good for you,” he concluded.

Ganz also reported that in the past 3 years he has noticed a sharp increase in interest in organizing among medical and public health students at Harvard University, where he teaches in the Kennedy School of Government. Until 3 years ago it was extremely rare for him to have such a student in one of his classes, whereas in the past year, he said, he had 20 students from the School of Public Health, half of them doctors. “I think there is something starting to happen out there that you probably sense better than I do,” he said.

Polletta said that public health is an issue that crosses many institutional boundaries and disciplinary boundaries and, as such, lends itself to broad alliances. For example, she said, urban planners could take up the issue of population health improvement and health equity, developing their own movement to create cities that can be more responsive to public health concerns.

“I think there are all kinds of alliances that could be made,” Polletta said. “I don't want to imagine a kind of central group directing these efforts. I think what is important is that these different groups, like medical students or urban planners, come to feel that this is their issue, that they own it, and that they want to mobilize around it.”

Lessons from Occupy Wall Street

Replying to Anthony Iton of The California Endowment, who asked both speakers to “diagnose Occupy Wall Street,” Ganz described this phenomenon as “a tactic in search of a strategy.” It was a great tactic, he added, because it succeeded in shifting the discourse and made taxes an issue in the 2012 campaign, but it did not build the power that was needed because it was not embedded in a structure capable of strategizing. “It is as if there was one sit-in, and that was the only tactic the civil rights movement ever used,” he observed. “There has to be an organizational venue in which the strategizing goes on. If it doesn't exist, then it is not happening.”

Polletta largely agreed. “A lot of people say the problem with Occupy was that they couldn't agree on a goal,” she observed. “I don't think there was any possibility of that.” On the contrary, she argued, Occupy would have had greater impact if its participants had been free to organize around a broader range of issues. “If there were people within Occupy who wanted to work with progressive congressional candidates, they should have gone off and done that. If there were people who wanted to go off and squat in foreclosed homes, they should have gone and done that.” She observed that the tremendous media coverage, interest, and support from surprising allies could have been utilized to push for change in many directions.

Measuring the Impacts of Organizing

Martha Argüello of Physicians for Social Responsibility–Los Angeles noted that the difference between mobilizing and organizing often confuses funders and sometimes even movement practitioners, who associate large numbers of people at rallies or demonstrations with success.

Polletta agreed. “That is the problem: How do you measure the impacts of organizing?” Because the relationships that are built by organizing are not readily quantifiable, the benefits of organizing can be difficult to ascertain. On the other hand, she said, creativity in tactics can help produce a movement that has been built without actual organizing. To illustrate this point, she told the story of Harvard University School of Public Health professor Jay Winsten, who in 1988 worked with Hollywood writers and producers to embed the concept of the “designated driver” in prime-time television shows—an apparent factor in a subsequent substantial decline in alcohol-related traffic fatalities.4 Although Winsten's actions did not substitute for organizing in the anti-drunk-driving movement, Polletta observed, Winsten was able to take advantage of an opportunity and benefit the movement.

A movement can measure its progress in various ways, Ganz said, by counting its members, by counting its leaders, or by measuring the extent to which it has developed infrastructure. He noted that before the 2008 election, the Obama campaign measured its progress by counting votes based on voter identification—until organizers argued that a better indicator of progress would be the level of capacity that was being built, such as the number of volunteers recruited or the number of leadership teams formed. Funders, he observed, “want razzle dazzle, quick action.” To maintain their freedom from such demands, movements must operate without a lot of funding, or else receive funds from several competing sources. Grant-driven organizing “is not going to produce a whole lot of change,” he contended.

Making What's Important Urgent

Marthe Gold of the City University of New York initiated a conversation about how movements develop a sense of urgency among different constituencies. Associating population health with cost-effectiveness and equal opportunity would seem to appeal to two broad strands of American values, but neither message seems to have “caught fire,” she observed. What could be done to change that?

“I am struck by how much media attention there is right now to the inefficiencies of health care provision,” Polletta replied. “There seems to be real interest in the kind of arbitrariness as well as wastefulness of health care spending.” That provides an opportunity to publicize the cost-effectiveness message, she said.

The equality message is more difficult to sell because to some people it means equality of opportunity, while to others it means equality of result, Polletta continued. Health tends to be viewed as a personal, individual problem that requires self-care. If a baby born into poverty has a shorter life expectancy than one born into the middle class, she asked, “how do you get people to see it as equality of opportunity rather than equality of result?”

“Urgency is created through action,” Ganz said. To illustrate this point, he described the planning behind an act of civil disobedience at Harvard to support higher pay for its janitors. “Nothing was happening until one day 28 students went in to visit the president and just decided to stay in his office until something was done,” he recalled. This was a strategic action, he explained. The students had spent several years building a base of support in the university and city. “They were very smart about how they chose to do their civil disobedience,” he said, because it took a general concern and “ratcheted it up to the top of the urgent list.” The occupation lasted 20 days and was eventually successful. Although not all actions are so successful, they do raise urgency, Ganz concluded. One does not win all the time when one summons the moral courage to take the risks that action requires, he added; good timing helps.

One of the risks one takes in acting is offending, which might undermine one's cause, Gold observed. For example, she imagined that, to make a point about health care inequality, people might hold a protest at the funeral of a very elderly affluent person with the message that the average poor person's life is many years shorter. “That would give you a lot of publicity, but that would perhaps not be seen as sensitive,” she said. But how can you both be sensitive and grab attention?

“That is where the creativity comes in,” Ganz said. Ghandi used the issue of salt regulation to mobilize his countrymen to confront the British colonizers, much as American revolutionaries had done with tea, he noted. Non-violent tactics such as sit-ins and fasting are elegantly simple—and effective. “I think you are right about the cemetery. I don't think that would be too cool,” he advised. Instead, it would be better to pursue “a rhetoric of action that is consistent with what you are seeking.” “There is no easy answer to this,” Ganz said. However, he added, the moral authority of the public health field is “enormous” in the United States, and that authority can be leveraged to effect change. “I really do think that there is something stirring in this whole world of healing,” he said. “The dissonance between being called to healing and the commodification and bureaucratization that is faced in trying to do it is growing not just because the system is becoming more problematic, but because I think the expectations of the people who are called to this calling are raised,” he said. “I think that is a good thing. I am hoping that can be a source of change for us.”



Polletta used “public health” to refer to “the public's health” or population health and not to the governmental public health agencies.


Speaker Martha Arguello of Physicians for Social Responsibility–Los Angeles later challenged Polletta's characterization of McKibben as “the father of the climate change movement.” The environmental justice movement has had a long interest in climate change, Arguello said, and it is crucial to recognize their broad, committed leadership on this issue, particularly as that recognition influences funding decisions.


Refers to the so-called Three-Fifths Compromise of 1787, which determined how slaves would be counted for electoral purposes.

Copyright 2014 by the National Academy of Sciences. All rights reserved.
Bookshelf ID: NBK268722


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