In a recent paper in the International Journal for Health Equity, Berenson et al. deliver a hopeful vision of a world better able to take advantage of SDH research. Had the article been published in 2015, it would have landed in a world positioned to take full advantage of the prescription. Unfortunately, the very value frame that supports SDH interventions has fractured. They note this in the lightest way possible, citing a paper by Woolf et al. as evidence of “adverse political environments” for SDH. This characterisation completely undersells what Woolf et al. actually observed — a complete ban, a dismantling, of any research on SDH-style categories: equity, race, diversity, and inclusion. Woolf et al. provide what is close to a complete rebuttal of the point Berenson et al. seek to make.
One of the strongest conclusions from the authors is that “SDH researchers must aim to create and cultivate policy windows of opportunity by being active protagonists…” This assumes at least a world with something approaching shared values, not a world in which “social determinants” are not simply contested but openly reviled and its advocates cast as the enemy — where your notion of fairness is an attack on our cultural values, where your racial equality is advocacy for our genetic and cultural replacement. By their own adopted framework (Kingdon), policy windows rely on a conducive political context. That cannot be created by researchers and has not existed for over a decade! The current political context is not simply unconducive, it is actively hostile. If “cultivating policy windows” — something like a horticultural endeavour at the South Pole — were the solution, then climate regulation would have been resolved, and abortion laws would be universal and rights-protecting, but they are in retreat.
Berenson et al. warn against research that risks being too “technocratic and detached from real-world constraints”, that offers “descriptive documentation of inequities” without “confronting the interests and institutions that benefit from the status quo.” They will say, rightly, that they are not naive about politics — that they explicitly concede research alone cannot overcome entrenched power, and devote an entire section to asking whether the problem is politics rather than research conduct. All of that is true. But notice what the concession does in their hands. They file it. Then without any apparent guile or appreciation of irony, they propose a five-point technocratic corrective. What is needed, they say is more methodological pluralism, more multisectoral collaboration, better communication, reformed incentives, stronger “brokering institutions.” These echo the calls made in the health policy and systems research literature for at least the last fifteen years — including in several of the paper’s own citations, e.g., Rasanathan & Diaz 2016.
The paper is at its core an advocacy piece playing to an audience of the like-minded. As with so many pieces from the last twenty months, which have come out of a loose coterie of global health scholars, civil servants, philanthropists, and diplomats, it fundamentally preserves a shared delusion of global order (or its complete irrelevance) and the insights of yesterday’s science conducted under the aegis of that order. They want to preserve the findings as if they are real, but not the shared value system and international human-rights framework on which those findings — and their policy relevance — are contingent. That, finally, is the more interesting question the paper never asks: not why its fifteen-year-old prescriptions haven’t worked, but whether those contingent truths can ever reach beyond the frameworks that made them possible.
Berenson et al. call knowledge and science “a crucial bulwark to combat forces arraigned against solidarity.” But a bulwark is a defensive structure. It only matters if you still hold the ground behind it. And the ground — the shared value system, the international human-rights framework on which every one of their findings depends for its meaning — is precisely what is being overrun, and they do not seek to protect. This is the paper’s absurdity. Until universal values and rights are put back into the intellectual core, prescriptions like this one are not merely ineffective, they are complicit. They sustain the fiction that the problem is technique rather than the loss of the framework that made the technique meaningful. They keep wanting to refill the gas tank after the bandits have stolen the engine.