Targeted change making for a healthy recovery

An unprecedented global mobilisation of health workers has called upon G20 leaders to focus on a healthy recovery from COVID-19 that centres on equity, climate change, biodiversity, and other planetary health considerations necessary to prevent the next crisis. Having been disrupted, global societies are being reimagined and generationally significant funds are being spent to bring new systems to life.

International response to the pandemic has proven once again that politics is a determinant of health. Although many in the global health community remain deeply occupied with direct management of COVID-19, now is the critical time for evidence-based, ethics-driven voices to influence change.

Achieving optimal outcomes requires consideration of not only the what of change making, but also the how. The planetary health community must move beyond an information-deficit theory of change to support policy work, advocacy training, and political engagement. We describe a tool outlining elements of change making—team, strategy, target, tactics, story, and win—that can help practitioners rapidly upskill to meet the challenge (figure ). We then showcase examples of successful health-sector engagement on coal power phase-out.

Figure.

A picture of change

Evidence-informed policy goals are most resonant when contextualised as an opportunity for a given actor at a specific time. Marshall Ganz¹ states that, “narrative is the discursive means we use to access values that equip us with the courage to make choices under conditions of uncertainty, to exercise agency.”¹ Both data and stories can generate emotion, with individual and group-based emotions influencing actions taken. In Ganz' model, action inhibitors can be overcome by activators: inertia by urgency, apathy by anger, fear by hope, isolation by solidarity, and self-doubt by a feeling that “you can make a difference.”¹ Where collective action is concerned, hope, anger at injustice, anticipated pride at proenvironmental behaviours, and positive emotions associated with group-based work all have shown relevance.² Pictures and videos can help with story-telling, and in communicating a planetary health frame and key data points to new audiences (appendix p 1).

Trust in leadership is key to instilling the confidence needed to make change in a situation of uncertainty. A compelling personal story of motivation can enhance trust between a leader and their audience.³ Message testing in target audiences is paramount, with engagement enhanced by narratives based on shared values and respect for diverse perspectives, illustrated beautifully by the Alberta Narratives Project.

A strategic target is the evidence-aligned change with the most potential to improve planetary health achievable by a given team with available resources in a specific context. Targets might be envisioned at multiple scales. Health-focused work in social accountability has been described as occurring at various levels: micro (individual or patient), meso (hospital or community), and macro (sub-national or national) levels.⁴ Global networks inclusive of a diversity of voices from high-income, middle-income, and low-income countries also make possible a meta level where international goals are developed collaboratively, and mentorship, toolkits, and other supports are offered, as appropriate, to community-centered initiatives with the goal of creating an international wave of change that influences norms and markets (appendix p 2).

Once a target is chosen, a variety of tactics, such as sign-on letters, op-ed pieces, relationship-building with decision makers and political involvement are employed.

It can be helpful to envision a ladder of engagement with targets at various levels and the possibility of iterative progress as power grows. Often, micro level change can be more quickly accomplished, with successes (or meaningful failures) helping to build skill, hope, and momentum that attract team members, thereby providing the possibility for ever-bigger targets. In the crisis context, rapid macro level change might be more possible, and ambitious targets should be considered. Instruction on target selection, pitch making, power mapping, and interaction with media and policy makers help maximise impact, reduce frustrating trial-and-error, and build competence-related confidence.

Increased resource must be dedicated to supporting change-making teams. Ganz describes isolation as an action inhibitor, and solidarity as an action motivator.¹ Shared identities such as health professional, medical student, parent, and others can generate group-based efficacy beliefs and enhance participation.² Adequately resourcing public health and ensuring their political independence is critical, as is the involvement of clinicians, given their frontline perspective and numbers.

As teams convene, ground rules emphasising cultural safety, simple language, avoidance of acronyms, and generosity in terms of attributing good intent to others can help avoid harm as different knowledge bases and cultures intersect.

Push-back is to be anticipated from powerful interests asked to change in the name of improved planetary health. Mutually supportive team structures that enable each member to contribute from the place on the risk spectrum most available to them based on their position and privilege are key.

In addition to bringing about substantive policy shifts, solutions-focused work with like-minded colleagues can provide emotional support at a distressing moment in human history by decreasing loneliness and improving wellbeing.² Action feels better than anxiety.

Achieving a targeted change (a win) can produce feelings of empowerment,² leading to increased hope for future success.¹ Ganz posits that, “of all the emotions that help us find courage, perhaps most important is hope.”¹ This can be enhanced by both reports of others' successes and direct experience of small victories.² One such story is coal phase-out in Canada.

Phasing out unabated coal power is among the most critical macro-level targets for practitioners seeking to improve planetary health.⁵ An opportunity arose in the early 1990s in the Canadian province of Ontario due to a confluence of factors. First, health and environmental concerns related to smog, acid rain, climate change, and mercury poisoning were shared by a range of champions. Second, coal-fired power plants were state-owned and relatively old. Third, there was little employment associated with coal extraction—most coal was imported. Last, the Canada–USA Air Quality Agreement had just been signed, committing both countries to cut sulphur dioxide and nitrogen oxide emissions.⁶

The team formed in 1997 when the Ontario Clean Air Alliance began mobilising support for collective action around coal phase-out via discussions with multiple health groups, municipalities, environmental groups, economists, energy planners, politicians, and community groups.⁶

The team's tactic was to communicate the expected public health outcomes of coal power phase-out, including reduced respiratory disease, avoided greenhouse gas emissions, energy costs, employment results, and the technological feasibility of the reform.⁶ The Clean Air Alliance approached municipalities one-by-one to sign on.⁶

The story was centred around health benefits, with images of young children and puffers, and doctors acting as trusted messengers.⁶ Narratives created a vision of a world with clearer air, safer children, and healthier lakes and communities.

The success of this approach was clear by the lead-up to the 2003 provincial election. There was broad-based public and municipal support, and all three major political parties were pro-coal phase-out, indicating consistent, long-term support for systems change— crucial for private-sector support.⁶ The election was held, and the coal power phase-out began. In 2014, the last coal-fired power plant in Ontario was decommissioned—the single largest greenhouse-gas reduction measure in North American history.⁶

Once Ontario demonstrated the possibility of coal power phase-out in a highly industrialised economy, a similar campaign ensued in the traditionally conservative province of Alberta with physicians and health advocates again assuming a public role as trusted spokespeople. The narrative was established with the help of a 2013 report from an environmental, energy, and health coalition showing that coal power was associated with 700 emergency department visits and 100 deaths annually in Alberta.⁷ Multiparty ambition to phase out coal in the name of health was achieved pre-election, and a coal phase-out commitment was made by the winning party.⁷ New elements to the story included discussions around the idea of a just transition for coal workers,⁷ with policies woven in to support retraining, career counselling, tuition, relocation, and pension bridging to facilitate early retirement.⁷

Just months after winning a commitment from the Alberta Government to phase out Alberta's coal plants by 2030,⁸ health and energy workers from the remaining coal-burning provinces joined forces, targeting a change to national regulations. An accelerated national phase-out of unabated coal power was announced in 2018 and is expected to result in cumulative emissions reductions of approximately 100 Mt, with CA$3·6 billion in avoided climate-related damage, and $1·3 billion in health and environmental benefits from air quality improvement.⁹

With health groups in the UK having similarly contributed to a national commitment to coal phase-out in that country, the Canadian and UK Environment ministers joined forces to leverage these commitments to generate international momentum. In collaboration with national governments, businesses, and other organisations, they cofounded the Powering Past Coal Alliance at COP23.

To conclude, global instability combined with historic public expenditures have created a generational opportunity for transformation and a global call for a healthy recovery that the planetary health community is well positioned to inform. Maximum impact will be achieved if resources are allocated to policy and advocacy, wins are communicated to facilitate hope and momentum, and a deliberate sense of solidarity is created within the planetary health community to support courageous work at the intersections of influence and power.