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Difference and health


Under this heading we are considering a range of problems, analyses and strategies which involve different kinds of 'difference': gender, class, race/ethnicity, caste, sexual preference, ability, religion, etc. More specifically, they involve power relations across difference; across gender relations, across race, across class etc.

'Power relations-across-difference' confront activists frequently and in many different forms. They contribute to many of the most familiar barriers to health for all. They contribute to many of the larger dynamics of economic inequality including globalisation.

Building other kinds of relationships across difference (relations of communication, respect and affection) are necessary elements of activist practice. How we think about and deal with relations across gender, class and race are critically important in shaping the effectiveness of our practice as activists; both our relations with our colleagues in the movement and our strategising with respect to movement building and campaigning and advocacy.

Our purpose in this topic is to explore possible frameworks for thinking about the 'relations across difference' in reproducing the barriers to Health for All and for thinking about our own practice in relation to these 'relations across difference'.

Frameworks for thinking about relations across difference

We start this discussion focusing on gender, not because gender is the most important axis of difference (although is many circumstances it is), but because difference across gender points to a framework of analysis and strategy which may be more widely applicable. In particular, we introduce the triad of ideology, structure and practice as an analytic framework which casts light on how gender relations are reproduced (and how they may be changed) but it is a framework can also be very useful in analysing class, caste, race and other axes of difference.


Patriarchy (literally, 'when men rule women'), is a health hazard, to both women and to children and perhaps to men also. The high maternal mortality rates experienced in highly patriarchal societies is one of the starker examples.

Feminist theory provides many different ways of looking at patriarchy. One of the key insights involves the ways in which the ideology of patriarchy interacts with norms of interpersonal behaviour and with established institutional structures and practices. Ideological assumptions about gender relations naturalise unequal and oppressive patterns of interpersonal relations; unequal interpersonal relationships reinforce institutional structures which structure and naturalise inequality.

Feminist theory has also brought forward new insights about how we think about difference more broadly. It warns us that mobilising around a single shared identity (gender) can render invisible cross-cutting axes of difference such as race or sexual preference and can reproduce oppressive relations across these boundaries.

The women's movement has explored many different strategies for confronting patriarchy with various degrees of success. These include electoral and legislative reform (suffragettes, equal opportunity); collective action at the interpersonal level (avoiding sexist language); and challenging the power of the ideology ('consciousness raising'). There is much to learn from the successes and the disappointments.


The health consequences of poverty, exclusion and oppression are well known. The health hazards facing the marginalised rural immigrants in the big cities of the Third World (Mexico, Beijing, Mumbai, Rio) exemplify this.

We have a number of different frames of analysis for thinking about this kind of poverty:

  • small farmers versus the subsidised producers of Europe, Japan and the US;
  • small subsistence farmers versus local landlords and middle persons and local agribusiness exporters;
  • rural interests versus the city based exporters;
  • working class versus the owners and managers of capital; and
  • imperialism and the reserve army of the unemployed at a time of 'over production'.

There are some parallels between some of these analyses and the analysis of patriarchy above; in particular the interactions between ideology, institutional structures and norms of interpersonal behaviour. This is most useful in relation to classical confrontations between labour and capital; sustained by an ideology which naturalises exploitative institutional relationships which are themselves governed by unequal norms of behaviour.

Widening income differentials in the rich world (obscene executive salaries beside union busting) are clearly consistent with this analysis. However, the reproduction of poverty and inequality in the cities of the Third World is not completely explained by the direct antagonisms of labour and capital. As shown in the list of contradictions above there is a range of other dynamics which contribute to marginalisation and poverty in these settings. It is much more complex when the co-existent dynamics of unequal gender relations and race relations cut across these primarily economic analyses.

The health costs of economic inequalities and of social and economic marginalisation are huge. They are measured in hunger and obesity, violence and drug abuse, hypertension and tuberculosis, AIDS and measles. The traditional strategies associated with the labour movement and its struggles against the capitalist class include: organising labour to make the threat of withdrawal more credible and ideological engagement to challenge myths such as 'there is no alternative'.

However, globalisation has complicated this set of strategies with competition between workers from different countries and regions (and pay rates) and a reserve army of unemployed to be drawn on when capital decides to shift its labour-intensive processing.

Historically one of the weaknesses of the labour movement has been a single-minded focus on economic relationships and the oppressions and exploitations which operate across class. This has been accompanied by a certain blindness to the co-existing dynamics of unequal gender relations, race relations and imperial relations.


Race relations, like relations across ethnicity, tribe and caste, can be the source of rich multiculturalism but have commonly been the cause of division, exclusion and violence. In many settings it is hard to disentangle contemporary challenges in race relations from histories of colonisation (and slavery and dispossession)and imperialism (and the forced appropriation of value).

Racism is a necessary concept with close parallels to patriarchy as described above. Racism incorporates the mutually reinforcing triad of ideology, institutional structures and norms of interpersonal behaviour. The ideology (of racial superiority) supports and is supported by the institutional structures; the ideology is reproduced in the established patterns of interpersonal relations; the structures and the norms of behaviour reproduce each other.

Racism is a powerful health hazard which operates in various different ways. In many countries racial inequality is closely aligned with economic inequality; an inequality which is sustained by racism. In this degree the health hazards of racism are the health hazards of poverty and exploitation. However, racism also operates in less obvious ways through a continuing stream of subtle accusations of inadequacy and internalised shame.

While the economic consequences may be manifest in poverty and hunger, the psychological consequences contribute to hypertension, obesity, violence and drug abuse. Theorists of racism (and 'post-colonialism') have added depth to the triad of ideology, structures and behaviours. They point to the significance of stereotypes in reproducing the behaviours and the ideologies (and the structures) and to the importance of communication practices in working past such stereotypes.

These insights point powerfully to practical ways in which the political can be personal. Just as the women's movement introduced 'consciousness raising groups' to assist women (and some men) to challenge the ideologies of patriarchy, so the post-colonial theorists have highlighted the challenges of listening past stereotypes. The strategic significance of 'listening past stereotypes' extends well beyond race relations. It is relevant also to the marginalisation of disabled people and discrimination against people who are not heterosexual. It is relevant also to the struggles against patriarchy and against economic exploitation.


Finally we consider briefly religion. Religion provides answers, for many people, to deep questions about what it means to be human in this world. Nevertheless tensions across religious boundaries have been associated with economic exclusion, communal violence and national aggression. Religion often features prominently in the content of the ideologies which naturalise such violence and the institutions of religion play a powerful role in promoting such ideologies. Nevertheless, the people who are the adherents to these different religious traditions hold tightly because of the guidance and direction which religious teachings provide for them. Religion looms large in the shaping of how people understand themselves in the world but also invites stereotyping where it serves as a flag which is taken to reveal all about the person.

Learning objectives

Participants will have:

  • a broadened range of conceptual frameworks for thinking about identity and difference in social relations and in particular in relation to the determination of people's health chances and the directions of social change and norms of organisational practice;
  • a clear understanding of the mutually reinforcing links between ideology, institutional structures and interpersonal practice in maintaining inequality across various axes of difference (gender, race, class, caste, etc) and the implications of this conceptual framework for developing strategy and practice;
  • a heightened reflexivity regarding their own assumptions, attitudes and practices in relation to 'others' who are 'different'; likewise a heightened reflexivity regarding the culture and norms of the organisations of which they are part;
  • a broadened range of strategic options for organising at the local, national and global level to address the health consequences of unequal relations across gender, class, race, caste etc.

Discussion questions about activist practice

What is the role of theory in developing our practice?

  • developing the languages we can draw upon in thinking through the health challenges and political challenges we face;
  • analysing the role of gender relations, class relations and race or caste relations in the case of a particular issue; (identifying the triad of ideology, structures and practice); going beyond singular analytic frameworks - gender or class or caste or race - and thinking through the ways they interact in relation to any particular issue or campaign;
  • identifying and delineating the role of sexism, racism, ableism, etc as determinants of health;
  • developing a language to reflect upon our own practice; developing a language to reflect upon on our own assumptions and our own ways of relating to people who are different (including within the PHM).

What are the implications of gender, class and caste relations for an understanding of maternal mortality in South Asia and Africa? What are the implications for political strategy of such an analysis?

How to reach out to 'other' publics, other communities who are not 'natural allies' of PHM in the sense that they might disagree with many of our assumptions and might perhaps support some of the policies we are critical of?

Can we build 'consciousness-raising' into our regular practice? How can we develop our own reflexivity about the ways in which stereotypes shape our own thinking, how can we develop our own skills at listening past stereotypes?

What is the role of practice in developing our theory? Participatory action research provides a framework for systematically reflecting on the implications of our experience for our theory.

Is there a 'reality' beyond 'ideology'? Or is ideology just another way of speaking about different ways of seeing the world? Are there 'non-ideological' ways of seeing the world which are not influenced by the power relations of the institutional structures and of interpersonal relations?


Working across difference (Laura Turiano at Savar Nov 2007)

Other Topics within this Module

Gender and Health

This topic developed with input from Leticia Artiles, Debora Tajer, David Legge, Laura Turiano and Dorothy Broom.