Post-paternalist public health: Examples in community-based obesity prevention

As Iris Marion Young argued, equality refers not just to distribution of goods but “primarily to the full participation and inclusion of everyone in a society's major institutions and the socially supported substantive opportunity for all to develop and exercise their capacities and realize their choices.” By this measure, social justice is at least as much process as outcome, and embodies other core American values, such as liberty and democracy. The inclusion it demands requires particular investment in communities our society disadvantages or oppresses, including supporting self-organization of group members for developing their own analyses and policy positions and creating institutional mechanisms for hearing and incorporating these groups' perspectives in policy making. This is the antithesis of public health paternalism, which typifies what democracy theorist Harry Boyte calls a “liberal professional culture” that is “eroding the civic life of everyday settings and the authority and standing of ordinary citizens.” This paper argues for a radically democratic, post-paternalist public health, building on an expansive and process-centered notion of social justice entailed in Young's politics of difference and Boyte's public work politics. It illustrates this argument using examples from community-based obesity prevention initiatives in the US. These examples draw from reviews of grey and academic literatures, dozens of interviews, and participation in and observation of such initiatives. It proposes cultivating citizens who are able to participate in creating and distributing community health as a core public health strategy for achieving social justice and outlines implications of this for US public health practice.