Advancing the Study of Power: Opportunities and Priorities for Understanding Population Health Inequities

Abstract

In this essay, we provide an overview of how power has been conceptualized in public health and allied fields and describe recent advances connecting power to the topic of health inequities.

To aid researchers in capitalizing on these historical and contemporary insights, we offer 6 concrete suggestions for empirical work.

Systematic analyses involving these recommendations can help return public health scholars to foundational principles of the field and test the limits of power as an explanatory factor in population health inequities. (Am J Public Health. 2025;115(6):883–889. https://doi.org/10.2105/AJPH.2025.308015)

Recent years have seen innovation in our thinking and in empirical work about the role that power plays in shaping the health of populations.^1–9 Although this emergent work is new, the insights motivating such efforts are not. To mention 2 seminal thinkers in the area, Rudolf Virchow, the father of modern pathology, conducted a study of Prussian typhus in the mid-1800s and concluded that improved employment opportunities, higher taxation, and better wages were the most effective remedies to the typhus epidemic. According to Virchow:

If we get free and well-educated people then we shall undoubtedly have healthy ones as well. I do want to stress that such measures, combined with a just and direct system of taxation and the abolition of all privileges and feudal duties, would enable the poorer classes to make good use of their wages and, at the same time, to get pleasure out of their work.^10(p208)

Here Virchow emphasized not only the importance of education and economic redistribution but the abolition of feudalism. As a system in which landed aristocracy held power over peasants who worked the land in exchange for protection, feudalism prohibited the translation of socioeconomic resources into a better life. The importance of empowering the working classes with education ran throughout Virchow’s subsequent work and helped contribute to the emergence of the field of social medicine, a discipline that heavily informed the social determinants of health literature.

At the end of the 1930s, as a young physician and minister of health, Salvador Allende wrote La Realidad Médico-Social Chilena (Chile’s Medical-Social Reality).¹¹ In this text, he outlined how mortality, communicable diseases, emotional disturbances, and occupational illness were byproducts of the poor living conditions of Chile’s working class. Central to Allende’s agenda was the expansion of government and the empowerment of workers. Allende believed that shifting economic power from domestic elites and foreign corporations to the state and the working class would be more effective than medical interventions in ameliorating the problem of poor population health.

CONCEPTUALIZING POWER

In its simplest terms, power is the ability to act or to make others act in a particular way. More sophisticated definitions of power have been offered by scholars across the ages. Among the most influential have been those of Emile Durkheim, Max Weber, and Karl Marx. Durkheim originated power as emanating from the ability of society to create a “collective consciousness” that binds people together through shared norms, values, and beliefs. Weber defined power as the probability that one actor within a social relationship will be able to carry out his or her own will despite resistance, regardless of the basis on which this probability rests. According to Marx, power is a resource that the ruling class employs to dominate the working class in the economic sphere to amass wealth.

Theories on power have centered on the various forms that power takes. Notions of “power over,” the predominant view of power, center on dynamics of domination and cast power in a repressive (i.e., negative) light. They presume an asymmetrical relationship in which one party (the dominant party) exercises control over a subordinate party. Typically, the dominant party occupies a higher position in some institutional hierarchy. In power-over scenarios, the controlling party’s gain is the subordinate party’s loss. Notions of “power to” center on dynamics of empowerment and cast power in an emancipatory (i.e., positive) light. They presume an asymmetrical relationship in which one party resists being controlled by another party. Typically, the subordinate party occupies a lower position in an organizational hierarchy. In power-to scenarios, the subordinate party’s gain is the controlling party’s loss.

Although these 2 notions differ in their normative assumptions about power, they are not mutually exclusive. As noted by McCartney et al.,

Campaigns for social justice can be seen as mobilising “power to” and “power with” in order to exert “power over” dominant interests. Conversely, “power over” in a context of domination entails “power to” and “power with” for those actors in control.^3(p24)

Moreover, both notions assume antagonistic relationships between groups competing for social and economic resources. Unlike notions of power over and power to that focus on domination of one group over another, power with emphasizes collaboration and shared power among groups. Here power need not be a zero-sum game in which one party’s gain is necessarily the other party’s loss.

Theories of power concern themselves not only with forms of power but the processes through which they function, especially in the case of power over. Steven Lukes¹² provides what is arguably the most widely used framework for understanding these processes. Lukes’s “three faces of power” framework examines how power manifests as the ability to resolve, address, and define societal priorities. The first face, commonly referred to as “overt power,” is the power to influence whether issues are resolved (i.e., decision-making power). Decision-making power typically operates within formal political institutions (e.g., government, law) through the implementation of rules and regulations that determine the behavior of others. It responds contemporaneously to readily observable issues to settle conflicts.

The second face is the power to influence the issues that are addressed (i.e., agenda-setting power). This has been described elsewhere as “covert power.” Agenda-setting power operates within and outside of formal political institutions by promoting norms and values that determine the considerations of others. It responds early to less observable issues to suppress conflict.

The third face (invisible power) is the power to influence how issues are defined. Invisible power primarily operates outside of formal political institutions by shaping perceptions that determine the wishes of others. Unlike the first 2 faces of power, invisible power does not presume a conflict of interest; rather, it responds preemptively to anticipated issues to avoid conflict. Integrating this third face into previous understandings of both overt and covert power provides a holistic view of how power permeates all aspects of how society is structured.

POWER AS A SOCIAL DETERMINANT OF HEALTH

The role of power in shaping health has been brought back to the fore as part of a growing global focus on the social determinants of health. The World Health Organization’s 2008 report titled Closing the Gap in a Generation¹³ spurred a paradigm shift that encouraged health scientists to think about health inequities not as the result of individual risk factors but as the result of “circumstances in which people grow, live, work, and age, and the systems put in place to deal with illness…. These circumstances are shaped by the distribution of money, power, and resources at global, national, and local levels.”

The report’s discussion of power did not, by some standards, go far enough. Some critiqued the final version as not providing sufficiently strong foundational policy recommendations to ameliorate well-documented health inequities.¹⁴ Others issued more full-throated commentaries on areas of improvement:

The Commission’s studious avoidance of the category of power (class power, as well as gender, race, and national power) and how power is produced and reproduced in political institutions is the greatest weakness of the report.^15(p440)

In the years that followed, the “Barcelona group” (as it came to be known by some) and a small group of American scholars⁷ advanced efforts to emphasize how power and power relations shaped health inequities within and across nations.⁹ They argued that cross-national health inequities observed in the welfare state literature were reflective of inequities in the distribution of power.⁵ This was even more true of the stark and often-overlooked health inequities between the Global North and Global South¹⁴ in which dominant classes of developed and developing countries united to consolidate their power and shape neoliberalism in directions that benefited them.¹⁵ Scholars of public and population health echoed these sentiments in major reports¹⁶ and integrative frameworks that placed power squarely at the center of research on global health inequities.¹⁷

Around the same time, the shrinking health advantage of the United States relative to peer nations became an object of interest. In 2013, the National Research Council and the Institute of Medicine¹⁸ released US Health in International Perspective: Shorter Lives, Poorer Health, which documented in stark terms health disparities between the United States and other rich countries. The report generated a body of work in which scholars imported comparative emphases of welfare state effects on health to the domestic sphere,⁸ producing a wealth of empirical research on social policy as health policy.¹⁹ A parallel body of literature reinforced the notion of US states as entities that “vary in policies, resources, and opportunity structures in ways that affect population health.”^20(p624) This research on the political economy of health presented institutions as the context in which risk factors for health are engendered,²¹ underpinned by a definition of institutions as a combination of schemas and resources that organize power.

THEORIES OF POWER IN HEALTH RESEARCH

More recently, there have been unified theoretical frameworks articulated that attempt to explain how power might operate across institutions to influence health.¹ McCartney et al.³ provided a wealth of information on the forms, sources, and positions of power as well as where power resides. Heller et al. discussed the relationship between structural determinants of health and power, describing power as representing “a continual struggle and negotiation in which actors draw on social, political, and economic resources to maintain or alter social constraints (i.e., structures).”^2(p6) In their framework, structures take shape, maintain, and change because of the power that distinct groups have to shape decision making, agendas, and worldviews.

Health power resources (HPR) theory⁶ provides a framework for understanding how power dynamics within society, particularly rich modern democracies, affect the distribution of health across populations. Unlike prevailing approaches that depict empowerment as an individual trait arising from social conditions, HPR theory underscores how the consolidation of power in major societal domains (e.g., health care, labor markets) acts as a collective resource harnessed in ways that influence social conditions and, therefore, health disparities across major social axes such as race, class, and gender.

The theory suggests that although many social determinants of health imply power imbalances between groups, the effects of these imbalances have seldom been explicitly theorized or tested. HPR theory contends that regardless of the quantity of socioeconomic and health-relevant resources one has, their impact on health is determined by how necessary, valuable, and useful they are. Therefore, whereas many theories focus chiefly on the distribution of resources, HPR theory delineates 3 power-related processes (commodification, discrimination, and devitalization) that shape the meaning of resources in ways that matter for health.

HPR theory offers several advantages to public health researchers interested in social determinants of health. First, by focusing on power distributions across groups, one shifts from individual traits to the underlying social factors that make these traits significant. As reflected in the burgeoning research on structural determinants of health, health advantages and disadvantages associated with these traits reflect complex dynamics originating “upstream” rather than arising because of “downstream” risk factors.

Second, HPR theory can help understand why differences in traditional social determinants do not always correlate as expected with differences in health. For example, research has shown that despite their higher income and education, supervisors often exhibit worse mental health than their supervisees. Because it contradicts established patterns, this association might be regarded as a health paradox of sorts. It is less paradoxical, however, when we account for the contradictory class location²² of supervisors who are in conflict with workers as well as upper management.²³ As such, supervisors may possess the lowest levels of workplace power as they are simultaneously responsible to leadership and excluded from many workplace protections.

Third, HPR theory extends research on institutions and health by explaining how an institution’s effects on health are influenced by the power dynamics within the institution. For example, power resources determine the benefits or costs that an institution aims to deliver to specific groups.

Fourth, HPR theory provides a new interpretation of individuals’ adoption of unhealthy behaviors even when healthier options are readily available. According to its concept of devitalization, lifestyle choices are a logical response to chronic deprivation and repeated opportunity blockages.

PRIORITIES TO ADVANCE UNDERSTANDING OF HEALTH INEQUITIES

Empirical public health work on macro-level sources of health inequity has yet to fully capitalize on the conceptual and theoretical advances that have unfolded over the past couple of decades. Two groups of literature have proven to be exceptions. The rapidly growing literature on structural determinants of health examines hierarchical power wielded by the few and affecting many. Although the role of power in this literature is varied and sometimes murky, it is assumed to be both a cause and an effect of the “rules of the game” that determine who gets what.²⁴

A separate but related group of literature focuses not on axes of inequity (e.g., race, sex, nativity) but on institutional sources of inequity. Two of the institutions that have gained increased attention in recent years are government²⁵ and commerce.²⁶ Research suggests that population health tends to fare better when democracies and good governance thrive.²⁷ Given the links between government and business, especially in an era of multinationalism (or supranationalism), the literature on the “corporate” and “commercial” determinants of health has grown over the past decade.²⁸ This research suggests that the distribution of power between corporations and governments is at the heart of the distribution of health between people and places.²⁹

To guide efforts toward translating conceptual and theoretical advances into empirical ones, we provide 6 concrete suggestions as to what a capacious version of this research might include. We offer these specific suggestions because we believe that they constitute significant departures from current approaches, are well suited to the strengths of public health scholars, and would most substantially advance research on upstream drivers of health and health inequities. These suggestions also each treat power not only as something that an individual or even a group has but in terms of relations between at least 2 groups with opposing goals. As Muntaner et al.⁴ point out, inequity is an inherently relational phenomenon and, as such, relational approaches should be used to understand it. We concur and prioritize suggestions that reflect this sentiment.

First, we encourage this body of research to explore power as a force that emerges from the coalescence of individuals into groups. Collective action enables groups to wield power that is more potent than that possessed by the sum of their members. Embarking on a wider and more intensive exploration of such group-level power will enable researchers to address a dissonance in the literature wherein potential remedies to inequities are prioritized over investigation into their cause. In much of the literature on power and health, this dissonance manifests as a preoccupation with individual empowerment in which people (or patients) are encouraged to believe that they are capable of autonomous decision making and action.³⁰ Such personal empowerment is highly relevant to improving individual health but has limited ability to address far-reaching inequities.³¹

We suggest that there is a need for research acknowledging that the circumstances from which individual health status emerges are shaped by powerful entities and therefore cannot be addressed without paying attention to how those entities function. For example, “empowerment-type therapies” in which (predominantly low-income) patients acquire knowledge to encourage healthier choices offer the potential for enhanced decision making among those with diabetes; the public health benefit of such therapies, however, will necessarily be circumscribed in the context of the limited power held by consumers (relative to industry) to influence the food environments in which metabolic disorders arise. As Hannah Arendt famously stated,

Power corresponds to the human ability not just to act but to act in concert. Power is never the property of an individual; it belongs to a group and remains in existence only so long as the group keeps together.^32(p24)

Second, we posit an important role for Lukes’s power framework described earlier. Researchers interested in investigating the impact of power on population health inequities are faced with a broad array of definitions of power from which to choose. Many of these definitions are motivated by a desire to understand political dynamics, particularly in relation to how power shapes democracy and democratic processes. But these definitions often lack the necessary insight to fully understand the complex machinations of how power affects health. Lukes described power as the ability to set and resolve societal objectives, to influence the way people feel and think about those objectives, and to help or hinder the accumulation and deployment of resources in the pursuit of those objectives. By emphasizing control across the goal-setting life cycle, Lukes’s formulation lends itself nicely to the study of health inequities. Later in the article we interpret public health scholarship on incarceration and health through the lens of Luke’s framework.

Third, there is a critical need for studies of power in broad-based institutions. There has been some work investigating how power is distributed between certain groups within specific organizations or environments and how that is associated with health inequities between groups. This scholarship is a vital first step toward understanding how group-based power can ameliorate health inequities. We contend that this focus should be extended to major societal institutions (e.g., government, labor markets, law) that transcend the boundaries of a single organization or environment. Unlike organizations—which are defined by specific purposes, people, places, and times (e.g., churches)—institutions are defined by broad purposes, constant population replacement, diffuse geographical reach, and reproduction over time. Therefore, the effects of institutions on people’s lives and health can be more far-reaching than those of organizations.

By way of illustration, we point to the work of Michener,³³ who examined the potential for tenant organizations to force policy changes that improve the housing circumstances of low-income Black Americans. Expanding this analysis to examine the distribution of power in real estate markets offers the opportunity to advance our understanding of racial health inequities that are linked to housing conditions, such as why Black Americans are at significantly greater risk of asthma and other respiratory diseases.

Fourth, although it is important to also understand the potential of informal social institutions (e.g., grassroots or community-based social movements, including those related specifically to health), we submit that adding an examination within formal institutions such as legislatures, industries, and science systems is crucial. Because these institutions are structured according to binding rules and regulations, they offer opportunities to

solve the coordination problems of groups, multiply the power of otherwise disconnected individuals, have the necessary resources to make a difference, and carry greater legitimacy in the national political arena where welfare policy gets decided.^34(p11)

Research on corrections and health serves as an example of what this work might look like. Well before the proliferation of research on structural oppression and health, public health scholars were examining the relationship between incarceration and racial health disparities such as higher rates of infectious diseases (e.g., tuberculosis and HIV) among Black men.³⁵ Much of this research framed hyper-incarceration among Black Americans as a result of a largely White federal administration exerting overt power (Lukes’s first face of power) through a war on drugs that was ostensibly about crime but, in truth, was a backlash against the gains made in the civil rights movement.³⁶

In the institution of science, there have been campaigns to include incarceration in public health systems and training.³⁷ This highlights how public health stakeholders (e.g., federal health agencies, state and local health departments, professional associations) hold unique agenda-setting power (Lukes’s second face of power) to define the province of public health and invisible power (Lukes’s third face of power) to reify the existence of factors such as institutional racism that fall within it. Complementary scholarship on both social movements and formal institutions can offer a richer understanding of how the study of all faces of power can be leveraged and unified in the future.

Fifth, research would benefit from studying groups that occupy similar social locations. We propose that there is even greater potential for theoretical and public health advancement in studying the consolidation of power among groups defined by status-related (e.g., race, class, gender) rather than health-related (e.g., tobacco control) goals. Such groups are larger in size than those with a singular health-related focus and are therefore able to concentrate higher degrees of power.

Moreover, focusing on social status groups complicates the notion of “interests” in a way that can bring nuance to our understanding of power dynamics. Social science research on power often invokes the concept of interests because it helps to explain why individuals desire a specific outcome. Individuals attempt to unite with others who share a common interest because they believe that it will more effectively convey their desires and pressure decision makers to satisfy them. In the case of social status groups, the more diverse mix of desires presents unique challenges and opportunities for research. For instance, the increasing power of working women (relative to men) has the potential to influence workplace customs and laws, such as flexible scheduling and paid family leave, that do not aim to address the comparatively high maternal mortality rates in the United States but nonetheless have significant potential to do so.

Sixth, we suggest that public health research expand its scope beyond those who are the worst off in terms of health status. We recognize that public health research is driven in large part by the desire to improve health among those who are least healthy, and accordingly voluminous research has been dedicated to investigation and intervention among these populations. Remedying the starkest health disparities allows public health to alleviate the deepest suffering in the United States. However, we urge that scholarly attention be widened to social groups that constitute a larger—even if slightly healthier—percentage of the populace.

For example, many of the two thirds of Americans who constitute the working class have lower rates of cardiovascular disease than those classified as poor but still have significantly higher rates than those with high incomes. By expanding the focus of research from the deeply affected but smaller group to the moderately affected but larger group, we may be able to identify factors that can be modified to reduce diseases with high mortality and prevalence rates among large segments of the US population.

CONCLUSION

We suggest that the kind of work described here will bring us back to an often-overlooked foundation of the social determinants of health, one that underpinned public health’s early incarnation as “social medicine.” The conditions in which people live may be important social determinants of health, but those conditions are distributed nonrandomly on the basis of who has power. In a now 20-year-old publication, Hilary Graham^38(p104) argued for the importance of distinguishing between social determinants of health and social determinants of health inequity:

Using a single term to refer to both the social factors influencing health and the social processes shaping their social distribution would not be problematic if the main determinants of health—like living standards, environmental influences, and health behaviors—were equally distributed between socioeconomic groups. But the evidence points to marked socioeconomic differences in access to health-promoting resources.

She pointed even further back to the Diderichsen et al. model,³⁹ one of the first to visualize the social determinants of health; this model distinguished between the conditions in which we live (the social determinants of health) and the factors that shaped those conditions (the social determinants of health inequity) by generating and distributing “power, wealth, and risks.” We suggest, along with others in the annals of AJPH,⁴⁰ that a systematic approach to the study of power is within the ken of population health scholars and stands to be a critical part of advancing social determinants of health research in coming decades.