Introduction: Placing the Public in Health Inequalities Research

Frustration and concern about the persistence of health inequalities in the United Kingdom (Mackenbach, 2011; Bambra et al, 2012) have stimulated efforts by researchers to increase public awareness of, and engagement with, research in this area, efforts that are being facilitated by the UK’s evolving ‘research impact’ agenda (Greenhalgh, 2014). Yet the purpose, and potential consequences, of this kind of public engagement is not always adequately reflected upon. In many cases, it seems, such efforts rest on an elitist model of knowledge production, in which scholars come to know the world in ways that others cannot and then work to translate their findings into more accessible formats for other, less scholarly folk. Innovative examples of efforts to communicate health inequalities and the social determinants of health in accessible ways include, for example, the London tube and Glasgow metro maps of life expectancy (McCartney, 2011; Cheshire, 2012) and Bambra’s (2015) ‘football league table of health inequalities performance’. The aim of such research is to draw public attention to the impact of structural and material inequalities on people’s health, an aim that appears to be underpinned by an assumption that, if decision makers and the public only knew more about the structural and material inequalities underlying health inequalities, they would do more to address them. Such an assumption belies the small number of in-depth, qualitative studies of public understandings of health inequalities, which demonstrate that many of the communities most negatively affected by health inequalities already have a good understanding of the factors and processes that contribute to their communities poor health (for example, Popay et al, 2003; Davidson et al, 2006) To quote George (1976, p. 289), those living in poverty already ‘know what is wrong with their lives’. The issue, then, is what we, collectively, might do about this. With this in mind, we argue here that what health inequalities research requires instead are forms of participatory practice that are oriented around overcoming alienation.

To grasp the potential of participatory practice to empower diverse minorities in health inequalities research, we need to place the practical composition of associational life at the center of concern. That is to say, how do we become collaborative subjects of knowledge, judgment and action while maintaining values of equality and justice? How can health researchers (in a broad sense) engage with each other and with the world in ways that not only enable them to escape the dominating power of elites but also, more positively, to create new formations of power and authority that are more democratic, open and empowering (Blencowe et al, 2013)?

As Marent et al (2012, p. 190) have argued, research on participation and health has been dominated by a focus on methods and models of participation, with little effort to systematically connect these approaches to social theory. Existing research theorizing participatory practice in health promotion has focused on three areas: the function of participation within the societal context in which health promotion takes place; ways of establishing lay actors as stakeholders in health promotion; and the complexities of participatory processes and their initiation and organization (Marent et al, 2012, p. 193). In this essay we draw upon a wider set of debates in post-structuralist social and political theory to explore the relationship between participatory research practice and a broader egalitarian politics of knowledge production in a contemporary context characterized by widespread alienation. In doing so, we extend recent approaches that focus on the constitutive role of materials in participation, thereby distancing ourselves from approaches within deliberative democracy that view publics as being constituted primarily by linguistic, deliberative or abstract communicative processes (cf. Marres and Lezaun, 2011).

The essay draws together: theoretical work on participatory democracy conducted by the three authors through a literature review and collaborative retreat/workshop on theorizing participation, authority, knowledge and performance (Noorani et al, 2013); and empirical knowledge of mental health service user movements gained through a 4-year research project as well as 8 years’ experience of working as a volunteer ‘ally’ of the steering group of a hearing voices self-help network, and other related research projects (Blencowe, 2013a; Noorani, 2013b). We have also developed these ideas through reference to the specific case studies in mental health mutual aid practice in of the Hearing Voices Movement and Stepping Out Theatre Company (Blencowe et al, Forthcoming). Mental health and health inequalities are, of course, intricately woven, with the unequal distribution of the social determinants of health shaping differential experiences of both mental and physical health (each of which informs the other) (Marmot, 2014). Moreover, we suggest reflections on participatory collaborations with mental health practices have a great deal to offer researchers concerned with health inequalities; both involve working alongside people frequently labelled as ‘hard to reach’ or ‘vulnerable’ (but who might otherwise be understood as ‘easy to ignore’).

In the following section, we argue for a form of participatory practice that focuses on positive power and overcoming alienation. Next, via the theory of Rancière, we explore the material spaces, objects and encounters in participation, arguing that the craft of participation is about setting the stage for encounters and not explaining things or directing outcomes (as the current emphasis on ‘research impact’ in UK universities tends to suggest – Rogers et al, 2014). Third, we explore the relationship between objectivity and alienation, arguing that participatory politics, against alienation, can look to reclaim objectivity for participatory, lively, practice. We then seek to show that participatory practice can play a role in creating common knowledge and culture, and in fostering a sense of public ownership over objective knowledge and institutions concerned with health. We conclude by asking what this looks like in practice, drawing some ‘rules of thumb’ for participatory practice in health inequalities research from existing inspiring examples.

Positive Freedom, Power and Authority in Participatory Practice

Many attempts to build theories of participation have focused on the issue of attaining freedom from authoritarian domination and interfering institutions. This is clearly visible in various highly influential ‘ladders’ of participation that have been proposed to theorize the different levels of participation, from one sided ‘community consultation’ to more empowering forms of participation (Cornwall, 2008). In Arnstein’s (1969) ladder of participation, the highest (that is, best) rung is full ‘citizen control’; in Pretty’s (1995) ladder, similarly, the highest rung is community ‘self-mobilization’. In both cases, authentic participation is equated with full autonomy from external powers, authorities and institutions.

This distrust of authority is also visible within many radical participatory movements. As contemporary versions of a centenary tradition of anarchist praxis, movements such as Occupy have recently conducted highly productive experiments with forms of leaderless ‘leaderfulness’ based on consensus decision making. For this tradition, we suggest the classic feminist pamphlet ‘The Tyranny of Structurelessness’ (Freeman, 1971) remains insightful as to the dangers of letting distrust of hierarchy result in a neglect of the power relations within a participatory movement. Freeman reflects on the experiences of the feminist movement of the 1960s. Identifying power with the ‘Others’ of the feminism, especially with patriarchy, the movement thought of itself as being free from power relations. But this fantasy of organizing without-power (the myth of structurelessness) actually fostered the emergence of pernicious forms of power. In the absence of explicit processes of representation an elite formed – the ‘stars’ of the movement. In the absence of formal structures of delegation and accountability, informal patterns of support emerge that brought with them all the usual (if unintentional) forms of discrimination implicit in any in-group or ‘sorority’. The effort to collaborate without power relations, Freeman argued, creates a situation in which power relations are pushed underground, becoming all the more ‘tyrannical’ because they are not subject to explicit reflection.

Similar problems have been identified in aspects of the mental health service user survivor movement that are run along non-hierarchical principles. Community advocacy groups have turned against those who are perceived as speaking for them once they gain media attention, for the understandable reason that these people do not stand (or speak) for the groups (Lakeman et al, 2007: provide a pyramid model of service user involvement). Problems of representation and legitimacy are deeply embedded within the service user and recovery movements, and for good reason. Individuals taking up ‘representative’ roles within service user and survivor consultation mechanisms have been put forth as evidence of ‘service user involvement’ without there being any formal structure or process through which such claims to representation could be legitimated. Such difficulties can lead those who take on these roles to experience stress and ‘burn out’ (Snow, 2002; Basset et al, 2010, p. 7).

As Pearce (2013b) has shown, many grassroots activists agree that power or authority is not a bad thing in and of itself, and that fostering positive authority through ‘enabling others’ is an essential aspect of working for community empowerment (Pearce, 2013b). Pearce argues that it is essential for participatory democracy that we do not simply reject, or seek freedom from, authority, but rather work to build new forms of authority through participatory practice, constructed around values of integrity, trustworthiness, commitment and critique (Pearce, 2013a, 2013c). With Pearce, we maintain that participation needs authority, and that authority needs to be remade through participatory practice (Brigstocke, 2013a; Blencowe, 2013b).

In theoretical terms, the issue has been stated as the difference between ‘negative’ and ‘positive’ freedom (Berlin, 1961). Participatory democracy cannot only be about the negative freedom ideal of working to free people from elite power (although this is of course important). Participatory democracy must also address the positive freedom of developing capacity: creating ‘freedom to …’. Such an approach assumes that real freedom, self-determination and democracy are rooted in equal collaboration, which takes time, attachment and trust – it is not simply about taking away constraints or opening up choices. Crucially for the rest of our argument, capacity (freedom to) develops through things, momentums, ideas, people coming together and joining forces. Participatory democracy must be critically and constructively engaged in the production of new subjects, which means recognizing and affirming the encounters, material investments, associations, attachments and solidarities (becoming solid) that this involves.

An over-emphasis on negative freedom in many attempts to theorize participation might help to explain the apparent agreement, or ‘perverse confluence’ (Dagnino, 2011), between participatory democracy and neo-liberal marketization agendas that has been observed by some health researchers (Ramella and De La Cruz, 2000). This ‘agreement’ is felt to be an acute problem by leftist proponents of participatory democracy. One example of this is proponents of ‘participatory development’ working in majority-world contexts who are committed to radical pro-poor agendas but who see their ideas and terminology adopted and promoted in strategies of marketization and the ‘roll back’ of public services (Cooke and Kothari, 2001; Dagnino, 2011).

The common ground between dominant western approaches to participatory democracy and the neo-liberal marketization agenda is a strong commitment to liberal individualism. If we want to think about participatory practice from an egalitarian perspective, that is clearly distinct from and critical of the neo-liberal marketising of governmental forms of participation, it is crucial to conceptualize participation as a form of positive power that does not just seek freedom from external power, but creates new instances of collaboration. This requires taking up collaborativist–materialist approaches to agency and constructing alternative forms and bases of authority – practicing the craft, or art, of common life. In the next section, therefore, we turn to theoretical approaches to participation that emphasize these themes, placing the issue of alienation (and its overcoming) at the center of concern.

Egalitarian Participatory Practice as a Work to Overcome Alienation

A broad review of political theory and critical pedagogy literature points to a way of conceptualizing the value of participatory practice in terms of overcoming alienation. In this section we recall the concept of alienation and introduce some important theory for thinking about participatory practices in relation to this.

Alienation names the experiences of isolation, powerlessness and disconnection from creative forces and vitality that is associated with economies that are orientated towards the accumulation of capital – economies in which ‘all that is solid melts into air’ (Marx and Engels, 2002). Marx (1977) argued that alienation, or ‘estrangement’, is generated through industrial capital-oriented labour processes, which abstract away the experience and value of people’s creative capacities as they exploit labour for profit, at the same time as separating individuals from each other in the great factory machines of mass production. He points to a fourfold alienation of people: from other people; from the process of production as a meaningful process; from the outputs of one’s labour; and from the ‘species being’ – which is to say the human capacity for creativity. Arendt (1998) less enamoured of the capacities of labour processes to connect us in creative and meaningful ways, instead places emphasis on the transformation of property into wealth that is required by a capital- and biology-orientated economy – most particularly the transformation of land and homes into capitalisable assets and the mass expropriation and displacement of people that goes with this. Simmel (1978), who we draw upon further below, focuses on processes of abstraction and processulisation that provoke a generalized ‘crisis of culture’ in the modern metropolitan money society. However one views the causes of alienation, participatory practice can be understood as an attempt at its overcoming.

Thinking about participatory practice and its value in terms of the aspiration to overcome alienation is particularly associated with the critical pedagogy tradition, which informs participatory action research and an array of democratizing movements and associations, particularly throughout Latin America. The work of Freire (1971), whose ‘pedagogy of the oppressed’ is seminal for this tradition, is centrally concerned with taking ownership of education and action. As noted earlier, there is a widespread assumption within health research that if policymakers and the public simply knew more about the structural forces behind health inequalities, they would do more to address them – leading to a one-directional conception of health knowledge transmission where experts educate and inform the rest of us. By contrast, the Freirean tradition is all about recognizing, affirming and developing the knowledge capacities of ‘the masses’ or ordinary folk. Critical pedagogy is not about experts telling people things, but is rather a participatory process in which all are engaged as active subjects of expertise and knowledge. The process unfolds as a becoming actively conscious of one’s situation. Publics must become active participants in the learning process. Knowing is a social process that involves the whole self: reason, feelings, emotions, memory and affects (Freire, 1971, p. 92). The task of radical pedagogy is to counter alienation and dehumanization: ‘The ability of humans to plan and shape the world for their future needs is what separates man from animals. The oppressed majority must be taught to imagine a better way so that they can shape their future and thereby become more human’ (Freire, 1971, p. 94). These principles remain at the heart of participatory action research (Fals Borda and Rahman, 1991; Whyte, 1991; McIntyre, 2008; Chevalier and Buckles, 2013); participatory art (Boal, 2000); and ‘farmer-to-farmer’ (campesino a campesino) empowerment movements (Millner, forthcoming).

As Holloway (1996) argues in his discussion of the Zapatista movement in Mexico, participation can be viewed as a way of combating alienation, and in doing so, gaining dignity. He describes an innovative conception of power where the rejection of the state motivates a form of participatory organization based on the principle of ‘mandar obedeciendo’ (lead by obeying). This is the idea that the leaders of the movement must obey the members, and that all major decisions should be taken through a process of collective decision making. The language used here implies that the aim is not an elimination of all forms of obedience and authority, but a new way of practicing ‘bottom-up’, collaborative authority. At the heart of this is a concept of truth as dignity, wholeness and positive freedom:

Dignity is to assert one’s humanity in a society which treats us inhumanly. Dignity is to assert our wholeness in a society which fragments us. Dignity is to assert control over one’s life in a society which denies such control. Dignity is to live in the present the Not Yet for which we struggle. (Holloway, 1996)

This leads to a second key point in this section. While we are committed to the politics of traditions of combating alienation through participation, we take issue with the ways in which alienation is theorized within these traditions as a form of distance and separation (see Evans, 1978; Yuill, 2005). Alienation, in Hegelian and Marxist thought, is associated with a critique of separation – whether a separation of people from God, people from Life, people from each other or people from the objects and processes of labour (Brigstocke, 2014). Such separation functions to dehumanize and objectify people, because it separates active makers from passive recipients of knowledge and power. Freirean participatory practice, similarly, sees radical pedagogy as a counter to alienation and a path towards ‘fully human’, undivided subjectivity (Dale and Hyslop-Margison, 2010).

Some of the assumptions of the Freirean tradition of critical pedagogy have been questioned recently through reference to the ideas of Rancière (1991, 2011; see Millner, 2015). Rancière points to the ways that well intentioned pro-poor agendas of participation and empowerment seem to wind up inscribing their own forms of domination or denigration. Attempts on the part of critical pedagogues to ‘educate the masses’ and overcome students’ alienation from knowledge always wind up somehow affirming and inscribing inequality, and dependency between students and teachers (and, we might add, researchers and the communities they are working alongside). In fact, Rancière maintains, people have the creative capacity to learn without the need for teachers giving explanations and acting as bridges to comprehension.

Rancière supports his argument through the story of Pierre Jacotot. Jacotot was a revolutionary who was forced to flee France after the restoration of the monarchy following the 1789 revolution. He settled in Flanders and took a job as a school teacher. However, he spoke no Flemish and had to teach students who spoke no French. Working from a dual-language edition of The Adventures of Telemachus, in French and Flemish, he assigned the students an essay on Telemachus, to be written in French (a language the students did not know), using the only resource that bridged teacher and student: the dual-language book. Through an interpreter, Jacotot asked students to read half the book with the aid of the translation, constantly to repeat what they had learned, to read the other half quickly and finally to write in French about their opinions on it. To his shock, Jacotot found that the students wrote excellent papers. From this, he derived four conclusions about emancipatory pedagogy: everyone has equal intelligence; everyone can instruct themselves; we can teach what we do not know; and everything is in everything. The act of the teacher who obliges another intelligence to exercise itself is independent of the teacher’s possession of knowledge.

According to Rancière, the creative capacity and contribution of students to learning is masked and actually suppressed in traditional forms of pedagogy, because efforts simply to transmit information from teacher to student undermines the student’s capacity to learn autonomously and spontaneously. The more genuinely emancipatory and participatory approach is to start with the assumption of intellectual equality between teacher and student (and hence, by extension, researcher and public or community), and thus of the infinite capacity of all to learn. A crucial point to take from this is that learning and creative intellectual development are not simply passed on as memory or accomplished explanation from human subject to human subject. Instead, they are constituted in direct encounters between subjects, drives and materials – be that texts, calculations, facts, matter, physical processes, poetry or stories. The craftwork of facilitating participation is about setting the stage for such encounters (creating spaces, providing materials, building confidence), and not explaining things or directing outcomes (Noorani, 2013a, 2013b; Wakeford and Pimbert, 2013). It is about holding things open rather than prescribing possible pathways of understanding or action (Blencowe, 2013b; Millner, 2013; Pearce, 2013a; Wakeford and Pimbert, 2013). The relationships through which we emerge as collective (and individual) agents include relationships with material forces, objects, bodies and things: relationships that are often constituted in apparently ‘passive’, quiet, observing modes of co-presence.

Rancière’s work offers some key insights into the craftwork of creating egalitarian and emancipatory spaces of knowledge production. Although this is easily misinterpreted as a celebration of something like ‘structurelessness’ (an ideal of freedom from power critiqued above), Rancière in fact offers insight into the practical construction of forms, structures or (in his vocabulary) ‘aesthetics’ that enable egalitarian encounters and emancipatory knowledge-production. Crucially, a practitioner of ‘emancipatory pedagogy’ such as Jacotot is clearly still in a position of authority over the students, commanding the student to go and learn. The command to learn enables students to fulfil their autonomous intellectual capacities. Somewhat counter-intuitively, therefore, command and an authority structure are central to the emancipatory process as described by Rancière. Leadership and/or authority and the unequal relationships it implies can be a crucial tool in making spaces where a more fundamental equality and emancipation are possible. Furthermore, the whole event of learning/emancipation as described by Rancière is only made possible through the presence of a ‘third thing’, which is neither student nor teacher, but the material with which the student engages (see Millner, 2013). In Jacotot’s case, this was the dual-language book. Students’ capacity to learn a new language without a teacher giving explanations constituted the radical emancipatory moment. Such moments are made possible through the existence of material – objects or issues – with which students or participants can engage.

Although Rancière’s theory of participation is an implicit critique of the Freireian approach to combating alienation, we suggest that it would be a mistake to take this as a rejection of the whole Freirean project of overcoming alienation as democratizing and participatory practice. The point, rather, is to recognize the emancipatory potential of encounters in which subjectivities participate with materials in external realities and relationships. Whereas communitarian politics is about overcoming distance between people (and tends towards a normalizing solidarity found in being the same) an egalitarian materialist politics of participatory democracy is about subjects moving outside of themselves to join forces with others, entering into relationships with the world and becoming renewed through such encounters. This includes encounters with matter and active forces that are not always human and certainly not always the same. Things, objects, books, articles, ‘materialised’ relations of authority, established distance, technologies – these material components of world are rightfully the tools, not enemies, of subjective development and empowerment (Blencowe, 2013a; Brigstocke, 2013b; Noorani, 2013a).

Understanding the Relationship Between Alienation and Objectivity

Through Rancière’s arguments we come to a conception of overcoming alienation that is less humanistic or human centred. Another way of putting this is to say that it places less emphasis on subjectivity, and more emphasis upon the objective, material, world in relation to which subjects become. We will now extend this approach through Simmel’s conception of the crisis of culture, to argue (against the grain of humanistic approaches to participation) that it is through objective culture and knowledge that alienation is overcome. We offer Simmel’s account of the over-objectification of culture as a way of conceptualizing alienation that is highly relevant to contemporary health research, and as a way of opening up understanding of multifaceted ways in which research – or objective knowledge production – can contribute to overcoming alienation.

Simmel distinguishes between objective and subjective culture. Objective culture is the forms through which we share experiences, and in which we often become trapped and constrained, including objects (such as texts, works of art, buildings and tools) as well as standards, established practices and styles (Frisby and Featherstone, 1997). Subjective culture, in contrast, is the individual experience of cultural life: the desire, dissatisfaction, striving and enjoyment that creates endless restlessness and reinvention – seeking meaning, breaking forms, working towards new ones. Culture is the process by which human subjectivity (or ‘the soul’) reaches beyond itself to become something else – entering into objective forms. Collective, cultural, development takes place in the movement back and forth between the objective and the subjective; life becoming more than life (see also Williams, 1998). Objective culture constitutes the grounds of collective life. It is enables the pooling of resources and the collectivization of experiences, empowering people to become more than individual and more than opinion. It is a means of aggregation – media for the connection of capacities. Simmel insists that objective culture is plural, that different domains of objective culture involve different, sometimes contradictory, values and truths (for example, the drive to efficiency in the objective culture of engineering, or the drive to differentiation in the objective culture of modernist art).

This approach casts light on the relationship between objectivity and alienation. As Read (2010, p. 124) has argued (against the grain of humanistic assumptions), alienation is not about the loss of subjectivity for individuals but is rather about ‘the loss of objectivity for the subject’: ‘[A]lienation is a separation from the condition of the production of subjectivity; it is not a loss of what is most unique and personal but a loss of connection to what is most generic and shared’. In Simmel’s terms we can say that alienation is what happens when the subjective and the objective are separated – when the flux of development is interrupted. This can occur in two ways. When an individual is stuck within their own subjectivity, unable to reach beyond themselves, we have a situation of solipsism. When a project of objective culture has become too complex, vast or rigid to be understood, appropriated and transformed by subjective life, we have the problem of ‘over-objectification’ – when an objective form can no longer be appropriated into the understandings and creative actions of subjects. This situation describes our general relationship to the highly specialised, vast and heavily invested (that is, rigid) objective cultures of biomedical science. Simmel suggests that such over-objectification is something that happens to all cultural practices and fields at some point. However, the conditions of metropolitan, capitalist society intensifies this, generating a widespread crisis of culture in which so many facets of culture become over-objectified at once that we come to feel estranged from form itself (Frisby and Featherstone, 1997, pp. 55–101, 174–186).

Simmel’s account certainly speaks to the current experience. In the context of advanced industrialization mastery of knowledge about some of the most basic and important aspects of our collective existence (such as the provision of energy or food) is restricted to a tiny elite, as processes of production become more and more technical and specialised. Nowhere is this more evident than in economics, where complex financial products, expensive super-fast computation and massive-speculation, render the vast majority of citizens either clueless or powerless to engage in basic economic interaction and planning. This contributes to a general sense that ‘we the people’ are out of control – subject to the whim of impersonal and incomprehensible forces. Simmel was writing a century ago and these processes have not slowed, so perhaps we are now experiencing a kind of hyper-over-objectification.

A generalized condition of alienation is constituted in metropolitan capitalist life because of the widespread over-objectification of so many facets of culture. But overcoming alienation can only be about appropriating or reclaiming – not rejecting – the objective. To flee the objective and embrace only the subjective realms of individual experience, movement and flow is to remain alienated – stuck in the solipsistic condition. Research practices that enable people to participate in the generation of objectivity offer the potential to counter the alienating conditions of over-objectification. Participatory practices can bring us into touch with and ‘humanise’ the powerful forces that dictate our lives, our variable health experiences and our understandings of all this. Participation appeals as so many methods for bringing hyper-objectified-forces or forms into the graspable flux of subjective life and discussion. We might say that ‘participation’ (participatory research, participatory politics) is precisely the moment and movement of flux between objective and subjective.

Objects and Objective Knowledge as and in Participatory Practice

A key difficulty with the usual understandings of participatory science practices is that conventional dichotomies about what is and is not ‘science’ or ‘objectivity’ remain unchallenged, such that participatory practices and user perspectives are always assumed to be the other of both science and objectivity (Blencowe et al, Forthcoming). In particular, the biomedical model (Engel, 1977; Deacon, 2013) is often assumed to have a monopoly on scientific objectivity, particularly in public health (with its strong links to medicine), while participatory practices are characterized (even by advocates of participation) as ways of expressing subjective perspectives (Mattingly, 2005; Moynihan and Cassels, 2005). The retention of the conventional dichotomy is problematic because it radically underplays the importance of committed ethos, knowledge sharing, collectivization of experience and engaging with material reality – which are facets of objectivity – to participatory practices themselves. We focus on these objectivity-orientated aspects of successful participatory practice, and we do so in order to emphasize the role of collaboration in that success (see also Armstrong and Murphy, 2012). Participatory organizations should not be seen as the subjective ‘other’ to the objectivity of science, but rather as organizations acting as ‘engines of alternative objectivity’ (Blencowe, 2013b; Blencowe et al, Forthcoming).

If we are to reclaim objectivity and objective knowledge production for a participatory politics of knowledge then it is essential that we recognize and affirm that objective knowledge is always plural and cannot be the exclusive property of any single subject or perspective (Harding, 1991; Latour, 1999). Objective knowledge is generated through controlled encounters with the world that is beyond us. Any single knowledge or knower cannot capture an objective reality in its totality – the very fact that it is an objective reality means that it is beyond our total grasp. It will always be possible to approach the matter in different ways, generating additional knowledges – sometimes complementing, sometimes overturning, sometimes quite irrelevant to the existing alternatives. Moreover we are increasingly aware that material reality itself is in significant part constituted through practices of paying attention, observation and measurement (Barad, 2007). As feminist philosophy of science has long since demonstrated, discourses that deny the plural nature of objectivity and suggest that there is such a thing as the singular objective or scientific perspective, are ideological (not scientific), ignoring the self-evidently diverse and open nature of scientific enquiry and undermining the quality of such enquiry (Haraway, 1988; Harding, 1991). Stengers (2000) argues for a conception of genuine scientific practice as the adoption of an experimental attitude or ethos, in which all manner of practices and types of subject can participate – against an inegalitarian (and unscientific) notion of scientific-objectivity as norm.

When objectivity is conceptulized in this way, and recognized as being always plural and provisional, then it is not about forcing a universality on health experiences, as is often the case with biomedical reductionism. Rather than accept a view of the ‘biomedical model’ of knowledge as an objective norm, in relation to which ‘participatory practices’ are ‘other’, we should instead envisage the field of participation as populated by a range of practices and ideals of assembly in which collective – objective – knowledges, relationships and realities are materialised.

As Smith (2013) shows, the efficacy of science in the determination of governance is not the same as the force of evidence; rather, its efficacy lies in the force of ideas. Scientific credibility, then, is often a performance of objectivity. The fetishization of big data as a source of scientific objectivity, evident in many areas of research at the moment, including health inequalities research (Schrecker, 2013; Stevens, 2015), is immensely un-democratic, because the production of such data is expensive and the control of such data requires lengthy and expensive training, while the choices made in the acquisition and analysis of the data set suggests important contingencies that get obscured from the public. Meanwhile, experimentation and openness are much deeper elements of the scientific attitude and they are accessible to anyone. So celebrating the ‘experimental attitude’ as an idea of objectivity is a generally democratizing impulse that participatory research practice can make.

Thus, one aspect of a materialist egalitarian participatory research practice aimed against alienation and towards the generation of dignity, involves embracing ways in which ordinary people can participate in the active generation and shaping of objective knowledge and culture (Blencowe, 2013b; Blencowe et al, Forthcoming). In a similar intervention, Honig (2013) has recently argued for the importance of ‘public things’ in the formation of political subjects, and thus of ‘things’ and ‘thingification’ in democratic life. She takes up the object relations theory of psychologist D.W. Winnicott and particularly his well-known concept of the ‘transition object’ (the child’s first possession – often a blanket or soft toy – which is understood to be crucial in the development of autonomy). Infants depend upon such objects to ‘transition’ from absolute dependence on the mother-figure to developing more independent capacities to play and survive when the mother-figure is absent. Honig suggests that specifically ‘public things’ – publically owned, publically used, commonly known things – play a similar role in the development of political subjects, collective consciousness and action. Honig discusses a recent debate in the United States over the privatization of the Public Broadcast Company (PBC). It was clear that people felt a deep affection for this ‘public thing’. The level of affection had an air of childishness, symbolized in the love for the symbol of PBC – children’s TV character Big Bird. This is because, Honig suggests, the ‘public thing’ – the public broadcast company – is not only the thing in itself, it is also the ‘transition object’ that enables the (always emerging) formation of a subject – in this case, the ‘people’ of democratic political life in the United States. In the UK context ‘our NHS’ is surely the most poignant and affective of ‘public things’, a transition object, that enables the British public to exist as and come to life as a collective political subject (Blencowe, 2015).

For Honig then, ‘things’ are essential to the development of political subjectivity. The constitution and destruction of public things becomes a key battleground of democracy. She writes:

In neoliberal economies we are pointed to the finitude and zero-summness of things and to their instrumentality. Do they get the job done? Are they worth owning? Do they insulate us from ‘undesirable’ others? But in democratic theory, especially when conjoined with Winnicott’s object relations, attention is called to the generative power of things and their magical properties to enchant, alter, interpellate, join, equalise, or mobilize us. (Honig, 2013, pp. 68–69)

If Honig’s analysis is right, then the destruction of ‘public things’ is, at once, the destruction of conditions for the emergence of collective consciousness and action – common-life. The struggle to defend the NHS is the very struggle for survival of the democratic people of the United Kingdom.

In the intensively privatized worlds of advanced liberal industrialism the creation of public – common – things is an urgent task. A pro-minority, leftist, materialist politics of participation can embrace this task, working to generate common knowledge and culture, and to foster a sense of public ownership over objective knowledge and institutions concerning health. In the concluding section we consider what this looks like in practice.

Participatory Democracy in Practice

What might this look like in the context of health inequalities research? We are wary of claims to escape power and hegemonies through a retreat into forms of individualism and relativism. Instead, we suggest focusing on those aspects or qualities of practices that lend themselves to combatting alienation through the production of alternative shared worlds that promise objectivity, or orient us to plural collective, material capacitations manifest in distinct knowledges and values.

In line with our analysis and drawing on Simmel’s account of the objective, we have found many inspiring examples of participatory practices, particularly in the field of mental health, where increasingly organized recovery and survivor movements, and traditions of peer support and mutual aid, have provided grass-roots alternatives to mainstream biomedical discourses and claims-making. A reorientation around such collective and collectivizing forms is undoubtedly highly resonant with, and even suggests turning greater attention to, peer support practices: ‘… it is most often a collective sense of being in the same boat with accompanying solidarity and empowerment that forms the basis of peer support and is very important in enhancing individual support and benefits’ (Borkman, 1999; see also Basset et al, 2010, p. 11).

Elsewhere we have argued that successful participatory organizations produce and strive for objectivity by focusing on the examples of the Hearing Voices Movement and the Bristol-based Stepping Out Theatre Company (Blencowe et al, Forthcoming). Other examples include radical collectives such as the Icarus Project and Mad Pride, which are open to anyone with experiences a biomedical approach would label ‘mentally ill’, peer-run respites and safe-houses where peers over time shape new norms and rules, and online story-sharing repositories such as Erowid and RxISK that aggregate and hold a great number of narratives of experiences for the purposes of sharing and deepening understandings.

As sites of experimentation, we see it as neither possible nor desirable to lift up any one of these practices (or any other) as offering a model for how participation ‘should’ be done. Nevertheless we are drawn towards extracting ‘rules of thumb’ from these examples when inventing new possibilities for collaboration. For one, modes of collectivization and objectification are involved. In Erowid and RxISK, many first-person accounts of the effects of a wide range of psychoactive drugs are submitted and re-presented for Website visitors looking for shared knowledge. These sites remind us of the importance of attending to processes of collecting, recording and systematizing experiences, as part of building knowledge bases over time. Could similar story-sharing repositories exist for an issue as cross-cutting as health inequalities, perhaps for those living in circumstances that are negatively impacting on their health, or for those experiencing interventions intended to reduce health inequalities by improving their health?

Inspired by Stepping Out and the Hearing Voices movement (Harpin, 2010; Noorani, 2013b; Blencowe et al, Forthcoming) and Honig’s understanding of Winnicot, another rule of thumb is to attend to participatory projects that use materials in open ways that enable experimentation and knowledge. This could entail any artistic medium where the potential for a shared work or craft is infinite and where the art practice itself comes to be a crucible for the building of common lives. In some cases, as with Stepping Out or in groups that create music, what is being produced is a shared output that is then submitted to evaluation against objective yardsticks such as theatre or music reviewers. In other cases, individuals experiment in each other’s presences, and the space itself can become precious and its protection, a matter of common life. For health inequalities researchers this would mean something quite different from the imaginative means of promoting awareness of the social determinants of health that are beginning to emerge (such as Bambra’s, 2015 ‘football league tables’); it would entail working collaboratively with communities negatively affected by health inequalities to conceive of, and then develop, desirable shared outputs.

A third rule of thumb is to document how it is that collectives are able to produce an equality among participants, who can then engage with material and the capacities of the whole. This cultivation of some sort of equality might be especially important, but perhaps also particularly difficult, when working within problematics defined in terms of ‘health inequalities’. It would almost certainly require researchers to challenge a (potentially widely held) perspective/belief that they are the ‘experts’ when it comes to health inequalities; this might, for example, be achieved by recognizing experience of poor health as an important form of expertise (Noorani, 2013b).

As a fourth and final rule of thumb, it is always possible that there are nascent collectivizing practices with the capacity to generate forms of objectivity that are far from being recognized as such. Indeed, this may be the usual state of things – wherever two or more people engage, the potential for generating objective forms resides also. It might be wise, then, to refrain from demanding community involvement mechanisms to address a lack of participatory practice in health inequalities in favour of seeking out the subtle potentials and terrain of lives lived in common.

These rules of thumb relate to research practices, and can only go so far without the involvement of government structures. Indeed, a call to reorient participation around the problem of alienation risks being applied only in certain participatory practices at the ‘edges’, while mainstream power structures remain untouched. The full involvement of the local government in Porto Alegre’s participatory budgeting experiments (Pateman, 2012, p. 11) inspires a search for participatory structures centred upon overcoming alienation that are government-backed and meaningfully funded. We note the take-up of upstreaming and co-designing with user expertise in participatory research funded by UK research councils. However, the incorporation of subjective ‘voices’ into predetermined objective forms and processes is fundamentally limiting. As such, we are not calling for ‘more of the same’, or ‘going further’. To be clear, such calls are important but they are not our concern here. Instead, we highlight the need for a wholly different (and historically neglected) orientation, which shifts the participatory gaze from the subject and subjectivity to the object and objectivity. We suggest it is important to ask, how can we move away from the arts of inclusion to the arts of making new collective (egalitarian) spaces and to creating more ‘public things’?