Advocacy, like the kind PATH pursues, is one means of health activism. Direct action by individuals and groups is another.
As we stand at the intersection of the COVID-19 pandemic, the Black Lives Matter movement, and increasing global urgency to address systemic inequity and racism, history offers important lessons about the necessity of direct action, and its contributions to public health.
1854: John Snow and the water pump
The story of John Snow is legend in the public health sector. A physician working in London, England, Snow investigated a local outbreak of cholera and became convinced that it was not caused by tainted air—the dominant theory of disease transmission at the time.
Instead, he tracked the outbreak back to a single water pump. By having the handle removed from the pump, Snow effectively ended the outbreak. In doing so, he revolutionized how the medical establishment approaches disease outbreaks and he is often considered the father of modern epidemiology.
By mapping the incidence of cholera, John Snow was able to identify the location of the contaminated well in London. Image: University of California, Los Angeles, Department of Epidemiology.
His work, both the map of the outbreak and the removal of the water pump’s handle, directly challenged the contemporary understanding of disease transmission. Snow had long worked to introduce new theories on the origins of infectious disease, but it took many years and this public success to alter how the government responded to cholera.
Eventually, his ideas contributed to the development of London’s sanitation and sewage system and led the government to revise their guidelines on cholera response. His individual direct action was a critical turning point for an entire sector—and changed the way we view diseases and their prevention.
1894: The Milwaukee smallpox riots
When smallpox emerged in Milwaukee in early 1894, the public health system rapidly responded to contain its spread. The city’s population was anxious to see an end to the outbreak, but they reacted against the aggressive approach taken by city officials.
Containment measures often affected Milwaukee’s Polish immigrants more severely than other residents, reinforcing their mistrust of city officials. Patients from immigrant communities were forced to isolate in unsanitary and abusive conditions at the city’s Isolation Hospital, while more affluent patients were allowed to isolate at home. When health officials attempted to move a child to the hospital, more than 3,000 community members surrounded the child’s house and large-scale protests began. These protests eventually changed the city’s approach to the 1894 outbreak and led to the impeachment of the city’s health commissioner, Dr. Walter Kempster.
Residents of Milwaukee, USA, protested the forced isolation of patients in the city’s Isolation Hospital, which had a reputation of poor conditions and abuse. Image: Library of Congress.
The experience of Milwaukee highlights the importance of working with communities, building trust, and providing timely, accurate information to the public, and is often compared to the 1947 smallpox outbreak in New York City, during which public health officials took a more inclusive, measured approach to the response. Lessons from Milwaukee and many outbreaks since continue to shape how governments and health systems plan their responses.
2000: Protests at the International AIDS Conference in Durban
Any summary of health activism is sorely incomplete without recognition of the incredible work of HIV/AIDS activists around the world. Even from the earliest days of the HIV pandemic, members of marginalized communities demanded a role in research, development, and treatment of the disease.
Activist groups around the world—many still going strong today—have pushed the boundaries of how governments and medical institutions work with impacted communities. In South Africa, the Treatment Action Campaign (TAC) used a variety of tactics to demand equitable access to treatment of new antiretroviral drugs.
TAC organized marches, including at the International AIDS Conference; worked directly with health officials; and filed lawsuits against the government to advance the prevention of mother-to-child transmission and reasonable pricing for HIV treatments. The combination of direct action and classic advocacy made TAC’s work incredibly effective and led to significant changes in how the South African government addressed HIV. It is a critical lesson in how activists and advocates can work together toward the same goal, something another HIV group, ACT UP, refers to as their “inside/outside strategy.”
2019: Morocco’s stethoscope revolution
Not all health-related activism is sparked by the outbreak of a disease. Proposed changes to medical education and service requirements for new doctors in Morocco inspired large-scale protests by medical students in 2015. These new requirements were intended to expand access to high-quality health services in rural and underserved communities, but instead reinforced the disparities between the country’s public and private health services. In 2019, protests ensued as doctors, medical students, and others in the health sector called for improved working conditions, better training, and increased pay. In June of that year, not a single student participated in exams.
Just as Milwaukee emphasized the importance of working with communities, Morocco is an example of the importance of working with health care workers. Government reforms, even well intentioned, can have long-lasting and negative repercussions. When the people impacted by these reforms do not have a seat at the table, they often demand one.
First, we listen
In each case, activism introduced something essential: a push against the status quo in favor of science, justice, or both.
Nongovernmental organizations like PATH have a responsibility to elevate the voices of the people and communities who experience the greatest health disparities and injustices. By standing in solidarity with health activists and being open to uncomfortable criticism, we become better advocates and better partners in the pursuit of health equity.
