The premise of this book is that public health policy is locked in a stalemate between the evidence-based and the politics-driven policy-making perspectives. This chapter argues that local public health actors on the ground develop strategies to work around this stalemate and circulate their evidence into the policy process. These strategies are indicative of a politically savvy conception of the policy process. The argument builds on data from an empirical study of active transportation policies in Montréal and Toronto (Canada) using the Advocacy Coalition Framework (ACF). In several instances, public health actors sidestepped political constraints by circulating their data to non-governmental organizations (NGOs) and citizens or by building “coalitions” with stakeholders sharing similar policy values. We argue that these strategies for circulating evidence show how science and politics are intertwined in local practices. Local public health actors sometimes take the moral high ground but are also keenly attentive and attuned to local politics. The following strategies could help sidestep the stalemate: better connecting public health evidence with practical policy solutions; developing sustained interactions with non-public health actors working with or advocating for these policy solutions and getting the help of boundary actors skilled in connecting problems and solutions across policy sectors.
- Active transportation
- Public health actors
- Local policy
- Actor interactions
- Healthy public policy
We have argued elsewhere that public health actors often display a certain naiveté when it comes to the policy process. They tend to believe that presenting evidence to policy-makers should be sufficient to change policies. They also tend to ignore the inherently political nature of public health, the characteristics of the policy process or the competing priorities and factors that guide public policymaking (Bernier & Clavier, 2011; de Leeuw et al., 2014). As de Leeuw succinctly puts it: “The moral high ground that many if not most health professionals and scholars occupy may also stand in the way of a realistic appraisal of the complex and competitive nature of integration efforts. There is significant naiveté when it comes to the politics and power games and the role that the health sector can or should play” (de Leeuw, 2017, p. 344). This is consistent with the premise of this book that public health policymaking is locked in a stalemate between the evidence-based and the politics-driven policy-making perspectives. Public health actors are thought to rely solely or primarily on scientific evidence to guide their influence strategies over the policy-making process, thus setting their efforts apart from and above politics. By contrast, elected officials, their political advisors and senior civil servants take the broader view that party politics, public opinion, interests, past decisions and other political factors influence policymaking, thus resisting the sole influence of scientific evidence. Overcoming the stalemate would require more overlap between the two worlds of scientific evidence and politics.
By contrast, in this chapter, we take a nuanced perspective on the stalemate between evidence and politics by revisiting our earlier claim that public health actors are naive about the policy process. What prompted us to do so are the results from a recent comparative study of active transportation policies in Montréal and Toronto. We have found that local public health actors (professionals and senior officials from local public health agencies) are very involved in official policy processes (e.g. public consultations, committees). They have developed sustained interactions with other local actors interested in active transportation policy (from elected officials to NGOs) with the explicit aim of influencing the emergence and implementation of active transportation policies (Clavier et al., 2019). Evidence is central to the arguments that they put forward, but what public health actors do to circulate evidence suggests that they engage strategically with the policy process. These findings lead us to question the extent of the political naiveté or, to the contrary, political savviness of local public health actors.
The central question we address in this chapter is: what do the strategies that local public health actors used to circulate evidence suggest about their conception of the policy process and about the role of evidence in the policy process?
The next two sections present the active transportation policy study, including the methods used for data collection and analysis, as well as insights from theories on policy coalitions, actor interactions and the reception of policy transfer that will be useful to examine the insertion of evidence into the policy process. The results are organized into two main sections, (1) the strategies that public health actors used to circulate evidence into the policy process and (2) how local public health actors conceive of the policy process.
2 Theory and Methods—Considering Strategies for Evidence Circulation in Local Policy Subsystem
2.1 Evidence and the Policy Process
The debate juxtaposing evidence-based policymaking and politics is an enduring feature of the literature (Newman, 2017; Standring, 2017), as is the quest for methods to produce the “right kind of evidence” for use by policy-makers and understanding how policy-makers use evidence (for instance: Hunter, 2009; Ouimet et al., 2010; Pawson, 2002; Whitehead et al., 2004). Policy studies are also concerned with how theories of the policy process conceptualize evidence and the realities of introducing evidence into the political process of policymaking (Béland & Katapally, 2018; Cairney, 2016; Fafard, 2008; Parkhurst, 2017; Smith, 2013). This latter stream of research has highlighted the competing ideas, social values, interests and issues that characterize the policy process; the challenges to democratic legitimacy posed by evidence and expert knowledge, and the limitations of experts’ understanding of the policy process. Among theories of the policy process, the Advocacy Coalition Framework (ACF) (Sabatier & Weible, 2007) considers that technical information contributes to policy learning, i.e. it contributes to transforming how policy actors view a public problem and its solutions. Policy learning is one way to bring about public policy change. More generally, the ACF maps interactions between actors involved in one policy and seeks to identify coalitions among these actors, based on their sustained interactions and shared beliefs about the policy. It explains policy change through the opposition between policy coalitions, when the dominant coalition may be replaced by a contestant, or through changes in the beliefs of the dominant coalition.
Our primary interest is not how actors in the dominant coalition come to include new evidence (new technical information) into their policy beliefs. It is, rather, how actors from opposing coalitions (or from the fringes of the dominant coalition) circulate new evidence so that it comes to the attention of the dominant coalition. Considering actor interactions on the basis of their shared belief systems brings attention to two issues relevant to the strategies of evidence circulation, namely the processes of actor inclusion and actor exclusion from the policy process and the ideas that bring coalitions together (Clavier & O'Neill, 2017). If some actors are not in a position to cooperate closely with decision makers from the dominant coalition, how else do they circulate their knowledge? Do they seek cooperation with actors sharing similar, or at least compatible, ideas about the policy? Do they try and introduce their evidence into other narratives about active transportation so as to influence policy? Based on these questions, this chapter focuses specifically on our research about what public health actors do for circulating evidence in the policy process and towards the dominant coalition in the case of active transportation policies in Montréal and Toronto (Clavier et al., 2019). Going back to the starting point for this chapter, we will then reflect on what these strategies tell about how public health actors conceive of the policy process.
2.2 The Active Transportation Policy Study
Empirically, this chapter draws on data gathered in a comparative research study on the processes underlying the implementation of active transportation policies in Montréal (Québec, Canada) and Toronto (Ontario, Canada). This was a funded study with human subjects review.Footnote 1 We studied active transportation policies as potential healthy public policies. As such, one of the research objectives was to question the role of public health actors and knowledge in the emergence and implementation of active transportation policies.
To achieve our objectives, we used the ACF as a template to identify the contours of the active transportation policy subsystem. We identified policy actors involved in the emergence and implementation stages of the policy process, while recognizing that these stages do not logically follow one another (DeLeon, 1999), their belief systems as well as their interactions. We collected data through document analysis (official plans and reports) and semi-structured interviews with key policy subsystem actors (20 in Montréal and 20 in Toronto) conducted between 2015 and 2017. In this chapter, we rely on interviews with public health actors in both cities (two in Toronto, three in Montréal). Although the sample is small, interviews with other actors from their respective active transportation policy subsystem confirm their practices for the circulation of evidence. The public health actors under study here are professionals and senior officials in local public health agencies, that is Montréal Public Health and Toronto Public Health. Their job descriptions entail programme and policy development, programme implementation—in conjunction with local partners from different institutions or community organizations—and research. This means that they not only circulate evidence but also produce evidence, either on their own or through collaborations with academics and NGOs. We use the term “evidence” in a broad sense here to refer to conclusions of research projects carried out by local public health actors, reports based on literature reviews and original data, and experiences from active transportation policies in other cities and countries.
We conducted thematic data analysis (Braun & Clarke, 2006) of the verbatim transcripts of interviews using an online data analysis platform (Dedoose). We established a list of themes related to the conceptual categories of the ACF (actors, interactions, belief systems, relatively stable parameters and external events) and added to that list inductively during data analysis. The research yielded data on the role of public health actors and public health knowledge in the processes of active transportation policy emergence and implementation (Clavier et al., 2019). This chapter builds on the data presented in the 2019 article to identify strategies that public health actors used to circulate evidence. However, the arguments we make here about how public health actors conceive of the policy process go beyond the scope of the original comparative research on active transportation policy. Besides, we do not consider how municipal decision makers weigh evidence from public health actors as compared to evidence from other sources (private consultants, industry lobbies and so on): focusing on public health actors only may overstate the coherence and influence of their narrative about active transportation.
3 Strategies of Public Health Actors to Circulate Evidence into the Policy Process
The strategies that local public health actors used to circulate evidence address different dimensions of the policy process, namely ideas, the existence of competing interests, the formal instruments of public participation/consultation, the interactions of policy and politics as well as the interactions of actors. As these dimensions are closely related, we have organized the presentation of these strategies into two categories: those that address ideas and framing and those that address actor interactions.
3.1 Framing Active Transportation and Health Through Evidence
In both Montréal and Toronto, local public health actors have become involved in the development of active transportation policies by building evidence about the links between air pollution, transportation and health and about the links between the built environment, physical activity, collisions and health. Toronto Public Health has published a series of reports on the built environment and health titled Healthy Toronto by Design as well as a series on walking, cycling and the built environment (Toronto Public Health, 2011, 2012, 2013, 2014). “Le transport urbain, une question de santé” is a key publication by Montréal Public Health on the links between transportation, health and the built environment, including suggestions for action (Direction de santé publique, 2006). In addition, public health employees with a research role have published reports that local actors promoting active transportation policies often reference. Among these, two reports analyze what makes neighbourhoods walkable (Paquin & Pelletier, 2012) and the numbers of pedestrians and cyclists injured in collisions at intersections in Montréal (Morency et al., 2013).
In building this evidence base, local public health actors reference the influence of public health actors in other jurisdictions as an incentive to address the subject of active transportation, as well as the importance of research and academic publication. Working with other public health institutions in an intervention research partnership broadens the scope of issues that the local public health units work with. Involvement in academic research and publication also lends legitimacy to their involvement in active transportation:
Then by 2011, came this concept of Healthy Toronto by Design, and again broadening our focus. So you get a healthy city because of many spheres, but, of course, transportation is one. Then things like Walkable City. And here, what I want to say is I think a key influencer is Dr. David Mowat from Peel. And he was the one who encouraged a number of health units including Toronto Public Health to be joined on a grant from CPAC (Canadian Partnership Against Cancer). (Public health actor, Toronto)
This is what allowed me to survive, so to speak: producing academic research is a way to gain legitimacy, so that I could give talks for citizens, NGOs, the public. Academia has been an ally. (Public health actor, Montréal)
If building an evidence base was a necessary first step, local public health actors have also sought ways to communicate this evidence effectively. Data visualization is one of them. In Montréal, several local public health actors—including a researcher employed in the provincial public health agency—have mentioned the importance of maps in their efforts at building evidence:
Maps [displaying the number of pedestrians injured at each intersection in the city] raised profile because they were accessible to the public and citizens brought them up at city council or borough council meetings saying, ‘People get injured on my street.’ (Public health actor, Montréal)
Visualizing data about injuries at intersections proved a powerful tool for communicating the data and for promoting its uptake by citizens, NGOs and other actors. In the case of pedestrian injuries at intersections, it also provided another angle to raise awareness about active transportation. As another public health actor put it, transportation safety provided a more compelling agenda for citizens and policy-makers than arguments about the effects of active transportation on the reduction of greenhouse gas emissions. It contributed to the introduction of security measures such as reduced speed limits in residential neighbourhoods in the City’s transportation plan.
In their efforts to frame evidence so that it makes sense for other policy actors, local public health actors have also mentioned the need to consider how others perceive the problem, based on their own professional norms and objectives. For instance, one public health actor in Montréal says that while his professional experience leads him to consider the influence of the built environment on collisions involving pedestrians and cyclists, the police look at the situation from another standpoint as they are responsible for implementing regulations about individual behaviour. Another public health actor recounts efforts to understand the values and opinions of local politicians before presenting them with policies from other jurisdictions. This, he said, was part of the strategy to construct health, transportation and the built environment as a public problem in the late 1990s in Montréal:
Before you start tackling a problem, it is important to understand how people perceive this problem, what they know about it, what are their values, their attitudes. … If you want to change behaviours and paradigms, you have to find out what they think first. (Local public health actor, Montréal)
Local public health actors have used a number of strategies to make the case for the health benefits of promoting active transportation. They have built evidence, presented and framed that evidence so as to create interest in active transportation and changes to the built environment. This denotes an understanding of the processes of framing and the construction of public problems, as well as an understanding that changing policy paradigms will not result from merely framing evidence in a compelling way. It is also necessary to recognize and work with the competing paradigms, values and professional norms of the different actors involved.
3.2 Circulating Evidence Within the Local Policy Subsystem
Complementary to their strategies for building an evidence base and for framing policy problems, local public health actors have developed several strategies to circulate evidence among other actors in the local policy subsystem.
First, we consider how local public health actors share evidence with municipal politicians and civil servants who are in a position to make decisions about active transportation policy. Practices in the two cities differ slightly in this respect given that Montréal Public Health is a local unit of the provincial health and social services administration, whereas Toronto Public Health is part of the municipal administration.
In Montréal, local public health actors take advantage of formal policy mechanisms such as public consultations and membership of municipal committees on active transportation and related issues. They regularly write briefs as part of official consultation processes on a range of issues related to transportation. Past briefs dealt with the revision of the city’s road classification (which has implications for speed limits, the volume of traffic and which administration gets responsibility for pedestrian and cyclist infrastructure), major road works such as the renovation of the Turcot Interchange, pedestrian street designations and so on. Montréal Public Health is also a member of the municipal Cycling committee, although the role of this committee has fluctuated over time, from being rarely convened to holding regular meetings.
In Toronto, some public health actors that we interviewed mentioned that they shared their evidence with other public health professionals within their own organizations and that they worked with service delivery programmes such as diabetes and obesity. Primarily, local public health actors describe how they cooperate with managers and professionals from other municipal services over significant periods of time to bring about changes to the built environment. For instance, the report Air Pollution Burden of Illness from Traffic in Toronto (2007) was prepared in collaboration with Transportation Services and its publication was announced in a joint press conference. Public health actors also mention that municipal services tasked with implementing changes to the built environment used evidence from public health community consultations about how to increase walking, cycling and health in several neighbourhoods of the City:
For instance, they’re [Transportation Services] getting some opposition out in the east end of the city to sidewalks being put in on a particular street, because it’s a higher income street, they don’t want to lose their front lawn. So they’re now going back to the demonstration project that was in that area to say the community identified sidewalks as being very important in this area. So they’re going back and referencing some of the reports that we’ve done. So it’s a good use of how Public Health can have an influence. (Public health actor, Toronto)
Local public health actors also mention other opportunities that they use to establish collaborations with other municipal services, for instance, helping with the cost of buying documentation on active transportation, creating information packages for local transportation coordinators and including their own reports on health, the built environment and transportation in the packages. Overall, they describe long-term efforts to build alliances and frame policy issues. They explained that building trust and collaboration with managers and professionals from other services was an ongoing process, influenced by the formal responsibilities of each policy sector; the hierarchical accountability structure within the organization and the individual managers and professionals perceptions of their own role within the formal municipal organization.
Second, local public health actors in both cities have developed collaborations with NGOs interested in active transportation, urban planning and the environment to promote active transportation. These collaborations are opportunities to circulate evidence among a broader audience. Montréal public health actors, who are not part of the municipal administration, claim this strategy more forcefully than their counterparts in Toronto. Nevertheless, in Toronto, NGOs and local public health actors view their partnerships positively, the latter sharing evidence that the former use in their advocacy efforts.
In Montréal, public health actors have developed long-term collaborations with NGOs advocating for active transportation and for changes to urban planning and the built environment. These collaborations include cultivating relationships with NGO representatives and journalists in all their areas of expertise (notably smog, air quality and the built environment); jointly developing research on shared areas of interest (for instance, the health impact of smog among populations living along urban highways); organizing and participating in meetings with NGO representatives and politicians to advocate for policy changes (for instance, inviting prominent speakers such as architect Jan Gehl to present examples from other countries); sharing evidence. Montréal Public Health also supports specific NGO interventions related to active transportation and related topics through regular funding programmes under its control.
These long-standing collaborations appear to help build the credibility of novel ideas: sustained interactions between local public health actors, NGOs and professionals from municipal services through professional training, conferences and accounts of policies in other cities and countries help frame the agenda around active transportation. In that sense, public health actors embed their production and sharing of evidence in those interactions with other actors concerned with active transportation. This public health actor even considers that his mandate is to build evidence and share it with NGOs so that they can use it into their advocacy efforts:
Our service is to do research and share the results, namely to transfer the results to NGOs. They are the ones that set the policy agenda, much more than I can do. (Public health actor, Montréal)
As mentioned above, local public health actors in Montréal work in a local unit of the provincial health and social services administration. They are civil servants in a different order of government than municipalities. Although Montréal Public Health has historically enjoyed some latitude in sharing public health concerns about municipal and provincial policies, they have no formal status within municipal administrations. Therefore, collaborations with NGOs and municipal services such as described above are a valuable way to circulate evidence among the local policy subsystem to indirectly influence municipal officials. This was what happened with the data displaying the number of injured and deceased pedestrians at each intersection across the city of Montréal. The report also formulated several recommendations to increase safety at intersections, such as building sidewalk bump outs and changing pedestrian and cyclist crossing signs (timers, dedicated lights). Although municipal councillors and employees appeared initially reluctant to acknowledge the data, its distribution among NGOs and citizens provided an alternate way to share and discuss the evidence with municipal actors. It appears to have swayed the discussion on this topic as the city has been redesigning intersections to make them safer for pedestrians (e.g. building bump outs to reduce the width of intersections) for the past few years.
In sum, public health actors in Montréal and Toronto focus their work around evidence of the links between health, transportation, the built environment and the environment (air quality, climate change). They have developed a series of strategies to facilitate the uptake of evidence by local actors and to change how they frame policy issues. Joining health and urban planning, for instance, provides a different way of considering the effects of transportation on health and the possibilities for public action. Collaborations with other actors, whether municipal services or NGOs, provide ways of circulating evidence but also of strengthening advocacy efforts. These strategies suggest that, although evidence is the core of their work, public health actors conceive of municipal policymaking as a political process that requires changing how policy issues are framed and requires building alliances with like-minded actors. In the next section, we question this perception of the policy process in greater detail.
4 How Local Public Health Actors Conceive of the Policy Process
The conception of the policy process that emerges from interviews with local public health actors as part of the active transportation policy study is ambiguous. It certainly contains traces of the “moral high ground” (de Leeuw, 2017, p. 344) but it also denotes an awareness of how politics and policymaking affect their work and should shape their strategies for circulating evidence. This ambiguity is noticeable in how politicians perceive the role of public health actors.
4.1 Traces of the Moral High Ground in How They Engage with Other Policy Sectors
Taking the moral high ground translates into claims about the superior value of health and health-related evidence. Public health research and public health actors are then legitimate to make suggestions about other sector policies, so that they become healthier. In our exploration of the strategies that public health actors use to share evidence with other actors, we have noted their awareness of the different paradigms and interests of other policy sectors. This awareness, however, appears a little ambiguous as a conception of health as a superior value may come in the way of engaging those other sectors:
[Our data] is always perceived as a criticism of their practices. But no [it is not a criticism], it is a problem. People get hit, they get injured, that’s how it is in large cities. […] But the initial reaction is always defensive: ‘Is that true? We do our job, we do what’s best, we conform to the guidelines.’ (Local public health actor, Montréal)
Our MOH [medical officer of health] met relatively recently, I don’t know, a few months ago, with the chair, the councillor chair of the Public Works and Infrastructure Committee […] And she kind of felt that the MOH was encroaching on other people’s mandates and was working well beyond the health mandate. So not understanding and not accepting the health mandate, our health mandate comes from the WHO, where health is not just absence of disease, it’s wellness, mental health, you know, physical health, the whole thing. So we got a little bit more work to do to bring people into that understanding. (Public health actors, Toronto)
This last excerpt does not mean that local public health actors are unaware that the formal mandate of public health units in the province of Ontario is legislated. Rather, it speaks to their conception of health as encompassing all areas of life and, therefore, government activity.
Considering health as a superior value has consequences for how local public health actors engage with other sector actors. Is the benefit to public health an argument compelling enough that other sector actors should accept policy recommendations that come in conflict with their own norms and practices? Despite these traces of the moral high ground, local public health actors recognize that understanding the legitimacy of other policy ideas is a necessary first step to changing them through training and education:
“But I also learned to be very respectful of, they’re all trying to protect people, they’re trying to build good safe roads and to challenge their beliefs is not something that we’re trying to do; what we were trying to do is to say that we also have our mandate, so how can we work together and still build safe transportation structures, but do it in a way that helps people to be more active? […] [‘Somebody that teaches road design “] did not know what a Complete Street was. So yeah. And if these are the people that are teaching the new students that are actually doing the road design, the surveyors, the engineers, then we’re going to have to make sure that we sort of go down that stream” (Local public health actors, Toronto).
4.2 Attention to Politics
Alongside this moral position, local public health actors—especially senior civil servants—are also attentive to the politics of active transportation policymaking. Interviews with local public health actors indicate that they understand the confrontation of interests and the varied political benefits of different types of policy instruments. For instance, in the early days of raising awareness for a policy that would reduce air pollution in Montréal, one interviewee mentioned that it was easier for local decision makers to limit emissions from wood-burning stoves than from motor vehicles. Although the logic of the argument was not fully explicit in the interview, interests were stronger and better organized in the transportation sector than in the domestic heating subsector. Besides, municipalities may regulate the maximum amount of emissions allowed from wood-burning stoves in their constituency (wood-burning stoves are static, identified in building and renovation permits, subject to inspection) whereas a similar measure concerning cars or trucks would be outside the remit of their constitutional responsibilities and political influence.
Senior local public health actors in Montréal are also aware of the implications of the current governance of transportation and planning at the local level. The governance of transportation spreads across the province, the metropolitan area of Montréal, the city of Montréal and the adjacent municipalities. Responsibilities are also segmented by modes of transportation, which is detrimental to a general policy of sustainable transportation that plans for how best to move people around, rather than how to develop separate transit, roads and bicycle lane networks:
What we would like is an integrated governance for planning and for transportation systems, road transportation as well as transit and bicycle lanes, with actual political and spending powers. (Local public health actor, Montréal)
Similarly, another actor reflects upon the applicability of different strategies to increase active transportation, showing an understanding of the limits of certain types of policy instruments, of the multi-level governance of planning and how certain instruments may be more amenable to municipal intervention than others.
Local public health actors are also aware of electoral cycles and of sectoral politics—in the sense that politicians and senior administrative officials are keen to protect, even extend, the contours of their policy sectors, just like the public health sector does. Some describe pragmatic attitudes towards electoral cycles and government changes. For instance, if a mayor and municipal council dropped policy changes that public health actors and NGOs advocated for, the latter would take up their advocacy efforts again with the new administration. In Toronto, city politics has had a strong influence on active transportation policy under the populist mayorship of Rob Ford, known, among other things, for his vocal criticisms of the “war on cars.” As a consequence, professionals in Transportation Services had limited abilities to invest major time and resources in active transportation because of the tense political climate around this issue. According to local public health actors, this led to postponing an update of the city’s cycling plan.
Local public health actors are also mindful of the political capital of senior public health officials, that is of the potential political consequences of the evidence and proposals to change active transportation policy that they put forward:
P1: I think really the most important role for both [P2] and myself is to be able to provide good evidence and good information and good strategic advice to the MOH. He really cares about these issues. He is our spokesperson and does it very well. And so the rest of us work to create a good package, and sometimes we have to bring him along because he’s dealing with… I don’t know, about 200 different health issues. And we all have to be careful with reputation management. Like how much political capital did he lose on the speed limit, you know, fiasco. He got a lot of very positive emails, he became like a local hero for getting beat up by the mayor at the time, but then again on some level, everyone’s a bit careful. Like we don’t want repeats of that. That’s not a winning strategy. (Local public health actor, Toronto)
The very public controversy that followed a proposal to impose a 30 km/h speed limit in residential neighbourhoods sheds light on how local politicians view public health’s proposals about active transportation policy and ambition to introduce more health into non-health policies. Following Toronto Public Health’s work on the Road to Health report, the City’s Chief Medical Officer put forward one of the report’s proposals to limit maximum speed limits in residential neighbourhoods to 30 km/h. Although the proposal received positive support from City Planning, it caused a controversy with Transportation Services and, primarily, with the Chair of Public Works Committee and with the Mayor. Consistent with his earlier positions, Mayor Ford called the proposal, “nuts, nuts, nuts.” He went so far as to ask, “why does he [the Chief Medical Officer of Health] still have a job?”, before he had to apologize a few months later (Dale, 2012). The politician who chaired the city’s Public Works committee took a similar stance, claiming that the Chief Medical Officer of Health had no legitimacy to make transport-related recommendations: “If he wants to lower speed limits, maybe he should apply for the general manager’s job in the transportation department” (Dale, 2012). The Chief Medical Officer of Health stood behind the maximum speed limit proposal citing that scientific evidence proved its effectiveness in reducing the number and seriousness of injuries to pedestrians and cyclists resulting from collisions with cars. He further stated the limits of his role by saying that politicians then had to weigh the different interests and make decisions (Rider, 2012). This whole episode was widely reported in the media both as a fiasco for public health and as a heroic stance against the Mayor. More to the point, it establishes a distinction between political decision-making and expert advice, with public health actors in the role of experts that politicians may trust and value (or not) but may also ignore. This local politician expects public health actors—who are city staff—to provide the City with the best possible evidence-based advice, regardless of local politics:
That’s why you pay these guys [public health staff] the big bucks, speaking truth to power. And so another sub-issue in this, and this thing here is the integrity and autonomy of the public service. They don’t work for the politicians individually, they work for council, they don’t work with the grassroots community organizations … they don’t work for them, they’re not their mouthpieces, they have an integrity and autonomy and professionalism and that’s what we want them to do. […] I go back to that line that I said to [the Chief Medical Officer of Health] all the time is, ‘I’m grateful to you because you have the temerity to tell me what I need to hear, not what I want to hear.’ And that doesn’t mean that on the political side, that I’m going to vote the way you recommend. That’s my prerogative. In this world of ours, democracy gives the generalists, i.e. the politicians, the final say on public policy. And I might for totally different reasons vote another way. That’s my right. But it’s not my right to tell you what advice you should be giving me. (City Councillor, Toronto)
Local public health actors concerned with active transportation in Montréal similarly consider that their responsibility is to build and share evidence about the public health impacts of policies that relate to transportation and the built environment. As we have mentioned above, they have also sustained long-term interactions with NGOs sharing similar objectives to influence public policies. Just as in Toronto, this perceived mandate of public health has spurred criticisms from some politicians. In the period leading to public consultations on the refection of the largest highway interchange in Montréal, public health actors organized a conference and a bus tour of the area with journalists and politicians, including the deputy minister of Transportation, to share evidence about transportation and health and discuss policy options. Widely covered in the media, the event caused angry exchanges between the provincial Ministry of Transportation, the provincial Ministry of Health and Social Services and the local public health unit. Just like Toronto’s Chief Medical Officer of Health was “invited” to apply for a job in Transportation services, public health actors in Montréal were “invited” to become candidates in the next election since they wanted to meddle with politics:
The Transportation minister told the Health minister that ‘if the Montréal Public Health gang wants to do politics, they should stick their faces on telephone poles and become candidates.’ […] He said we were doing politics. No, we don’t do politics: we share evidence. (Local public health actor, Montréal)
We could interpret this last sentence as yet another trace of the moral high ground. We could also read it as an acknowledgement that public health actors should frame health-related evidence and share it with other actors in the policy subsystem so that it becomes part of the decision-making process. Whether such practices overstep the administrative duties of public health actors employed in public administrations is not a topic that can be settled here (Fafard & Forest, 2016).
We started this chapter with the following question: what do the strategies that local public health actors used to circulate evidence reveal about their conception of the policy process and about the standing of evidence in the policy process? The short answer is that local public health actors place evidence at the core of their practice, but that they handle evidence in the local policy subsystem based on their expertise and political knowledge. They frame evidence in ways that showcase how health is intertwined with other areas of municipal responsibility, in that case especially with transportation and the built environment. They work together with municipal civil servants from other policy sectors, advocacy groups and NGOs to make sure evidence is part of policy discussions. Interviews indicate that local public health actors have a certain expectation of being right about the importance of health, but a pragmatic view of how to convince others. This pragmatic view draws on their understanding of competing policy objectives, framing policy issues, influence of electoral cycles and politics on policymaking, governance arrangements and their implications for policy.
The worlds of politics and evidence appear to overlap at local level. In that sense, we could say that local public health actors sidestep the stalemate between evidence and politics by developing politically savvy ways of circulating evidence among other actors in the local policy subsystem.
How does this relate to the challenges of improving collaboration between public health and political science? To a certain extent, it stands in contrast to Fafard and Cassola’s (2020) claim that the lack of a common language between political science and public health, especially as regards the conception of evidence, impedes collaboration. Indeed, political interests are not only obstacles to the strategies of public health actors to influence policy: some become opportunities to share evidence with other actors and to build narratives to increase the legitimacy of their preferred policy. However, the conclusions from this chapter agree with these authors’ second challenge, embracing complexity, which calls for political scientists and public health researchers to consider several ways of knowing about public health policy, including “public health actors’ frontline knowledge of policy implementation from both a clinical and community perspective” (Fafard & Cassola, 2020, p. 108).
Within public health, there appears to be a fault line between public health researchers—whose conception of evidence presumably ignores the complexities of the policy process—and public health practitioners, whom we have shown to have a more pragmatic understanding of politics, interests and how to influence policy through the circulation of evidence. Our results suggest that the stalemate is less at the frontlines of public health practice and more among (academic) analysts of healthy public policymaking, who come from different academic departments and intellectual traditions. However, this chapter builds upon a small sample of interviews with public health actors, all of them involved in the same policy area, given that this was not the original focus of the research. It also describes the situation in two of Canada’s larger cities, each with long histories of healthy public policy advocacy. To what extent might these findings hold in smaller centres without such a history of accumulated experience and expertise? Further research could help build a more complex portrait of how public health actors conceive of the policy process. Does it, as we assume based on our interviews, vary according to their position in the hierarchy of their institutions, with senior public health actors (managers) having a more politically informed view of the policy process than professional or junior public health actors? Do their views of the policy process vary depending on their policy area or public health problem of expertise? To what extent do public health researchers and senior public health practitioners have different conceptions of the policy process? In turn, this knowledge would provide a stronger basis for collaborations between public health and political science that make better use of the diversity of expert and experiential knowledge while recognizing their respective scope and aim (Gagnon et al., 2017).
Our results also echo findings from other studies that consider “strategic public health advocacy” (Smith & Weishaar, 2018) crucial for networks to influence policymaking. According to Smith, network theories, such as the ACF, tend to overestimate the influence of values in the formation and success of policy coalitions. Communication between network members, collectively engaging in political trade-offs, leadership by policy brokers and a supportive context are crucial to networks developing a coherent, cohesive and timely strategy to influence policy (Smith & Weishaar, 2018). ACF scholarship also points to the importance of social interactions among coalition members, of the support that coalitions derive from related networks to explain coalition behaviour and of the influence and of their ability to rely on political institutions (Kübler, 2001).
What are the implications for resolving the stalemate between science and policy in public health policymaking? Taking inspiration from our earlier proposals for research collaborations between political science and public health and from Cairney’s “theory-led academic-practitioner discussions” (Cairney, 2014), we suggest that part of the way forward to overcome the stalemate between public health and political science is to go beyond the circulation of evidence from researchers to practitioners, or from public health practitioners to other sector practitioners. It is important to consider also how institutions and governance practices across levels of government and across policy sectors frame and influence the ability to make policies for health (Clavier & Gagnon, 2013). Political science researchers, public health researchers and practitioners, practitioners from other policy sectors who work within and outside public administration each have different understandings of politics and policymaking, and of the role of evidence in the policy process. Collaborations between all these actors could be a starting point for conversations about how to build policies for health using theoretical and practical knowledge of the complexities of the policy process.
For these actors to more fully engage with each other, we suggest three related tips: (1) better connecting public health evidence with practical policy solutions, in their social, political and institutional context; (2) developing sustained interactions with non-public health actors working with or advocating for these policy solutions and (3) to accomplish this, getting the help of boundary actors skilled in connecting problems and solutions across policy sectors. Indeed, public health policy problems—in particular those concerned with influencing the more distal determinants of health—relate to several policy areas (see how health, transportation and urban planning are closely intertwined in our active transportation policy study). Actors working as boundary spanners or policy brokers (Nay & Smith, 2002; Stern & Green, 2005; Williams, 2002) have the resources and skills to create links between a variety of policy actors and problems, within a coalition and between coalitions. De Leeuw et al. (2018) suggest overlaying the analysis of networks with the analysis of policy frames defended by actors in the network to identify boundary actors that could bring together actors and their conception of the policy problem.
The research project was funded by the Heart and Stroke Foundation as part of the CIHR competition for Population Health Intervention Research (2014–2018). It was approved by the Ethics Committees of the Université du Québec à Montréal (# S-703818–66), of the University of Toronto (# 31,140) and of Toronto Public Health (# 2015–06).
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Clavier, C., Gagnon, F., Poland, B. (2022). Sidestepping the Stalemate: The Strategies of Public Health Actors for Circulating Evidence into the Policy Process. In: Fafard, P., Cassola, A., de Leeuw, E. (eds) Integrating Science and Politics for Public Health. Palgrave Studies in Public Health Policy Research. Palgrave Macmillan, Cham. https://doi.org/10.1007/978-3-030-98985-9_6
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