Advocacy for Leaders: Crafting Richer Stories for Public Health

Matthews, Gene JD; Burris, Scott JD; Ledford, Sue Lynn DrPH, MPA, BSN, RN; Baker, Edward L. MD, MPH

Section Editor(s): Baker, Edward L. MD, MPH; Column Editor

Journal of Public Health Management & Practice: May/June 2016 - Volume 22 - Issue 3 - p 311–315
doi: 10.1097/PHH.0000000000000413
The Management Moment

This article describes fresh approaches for providing better insight into the US social landscape and gives useful perspectives to create better messaging for new coalitions to improve public health.

NC Institute for Public Health (Dr Matthews) and Health Policy and Management (Dr Baker), The University of North Carolina at Chapel Hill; Beasley School of Law, Temple University, Philadelphia, Pennsylvania (Dr Burris); and Public Health Division, Wake County, North Carolina (Dr Ledford).

Correspondence: Gene Matthews, JD, UNC Gillings School of Global Public Health, 207 Overlake Drive, Chapel Hill, NC 27516 (gwmatthe@email.unc.edu).

The authors declare no conflicts of interest.

Article Outline

In his groundbreaking book, The Righteous Mind: Why Good People Are Divided By Politics and Religion, Jonathan Haidt1 provides fresh insights into politics and public policy, leading to an examination of the intuitive, mostly subconscious individual decision making that takes place when humans are asked to accept or resist new social concepts or political policies. This research discovers significant differences in moral intuitions between political liberals and conservatives.

We feel that moral foundations theory researchers such as Haidt and others provide new tools for better understanding how people's moral values shape their reactions to public health initiatives. In this article, we consider emergent ways for public health leaders to construct richer stories that also resonate with the fundamental intuitive social values of Loyalty, Authority, and Sanctity. We believe that this is an opportune moment to initiate some new conversations regarding how public health may use these new tools to improve our messaging. Since public health has tended to frame its policy arguments through the lens of liberal values for the last few decades, opportunities are missed because public health hesitates in recognizing how to frame our messaging in a richer way that appeals to a broader spectrum of moral concerns.

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The Psychological Context of Advocacy

“Evolutionary moral psychology” rests on the generally accepted current paradigm of how human beings make judgments about what is or might start happening in the world around them. It is well settled that our brains deal with the complex task of filtering and evaluating the significance of stimuli by using shortcuts. These “heuristics,” in the famous formulation of Amos Tversky and colleagues,2 evolved to help us: “on the savannah, when something rustled in the tall grass, one jumped first and reflected later.” The familiar—in food, people, weather—was usually safe; new things were best treated with suspicion. These automatic processes are mostly inescapable, and still essential to our functioning, but they are not all for the best. The shortcuts bring predictable biases, such as rating the risk of losses higher than gains and inflating the frequency of bad events that get vivid news coverage. Shortcuts evolved in simpler times and are unsuited to untangling the spaghetti we encounter in complex social systems. We are generally not aware we are taking shortcuts, so we don't see the bias in the conclusions our intuition presents us with.

Haidt's great insight, based on years of cross-cultural research, was that our morality also rests on a set of shortcuts. These heuristics evolved in the last 10 000 years as an adaptation to the demands of social cooperation. Following E. O. Wilson and colleagues,3 Haidt argues that groups made up of individuals who were loyal, cooperative, altruistic, and accepting of group beliefs and norms were more likely to survive than groups whose members could not trust each other. Through genes and millennia of socialization, we are wired to respond to moral dilemmas with intuitions that, like our risk assessments, feel accurate and carefully considered but in fact are snap judgments based on simple heuristics.

We present these basic shortcuts—or as Haidt calls them “moral matrices,” later. For now, the important point is that “moral reasoning” is a far too polite a term for what we do when we judge right and wrong. We think we reason, but in truth we intuit without conscious thought. Worse, once armed with a moral judgment, we do bring to bear our rational mind—but only to lawyer for our intuitive belief. Rather than listening and reasoning together, moral conversations all too often consist merely of 2 sides, twisting facts and torturing logic in an effort to sell a snap judgment as a philosophical essay.

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Six Moral Foundational Values

As identified by Haidt, there exist 6 moral foundational values that are hardwired by evolution into our intuitive, mostly subconscious social decision making. These 6 moral foundations (each with positive and negative components) are as follows:

1. Care/Harm: This first foundational value includes our drive to have the fundamental physical necessities such as security, shelter, food, water, and warmth required to provide care. The reciprocal component is the intuitive reflex to protect ourselves and our community against threats and harm.

2. Liberty/Oppression: This value encompasses our positive desire for physical and psychological freedom of action. It simultaneously contains the more aggressive component of social intolerance toward bullies.

3. Fairness/Cheating: For this foundational value, the common positive component supports equality of opportunities. The reciprocal aspect that goes with fairness is the general distaste for cheaters and “free riders” in a social system.

4. Loyalty/Betrayal: The common positive aspect of this intuitive value embraces personal trust and group identity. The scope of our group identity can range in different situations among family, friends, neighborhood, community, state, nation, or even the entire world. Sometimes it may be viewed as simply as sports team loyalty, whereas at other times it may extend to national patriotism. The negative component is the application of social isolation or stronger sanctions we apply against those who betray us.

5. Authority/Subversion: Reflecting the competitive advantage of well-organized groups, this value embraces the social deference we accord to “good” authority figures who can lead us toward success. Conversely, we can become very intolerant of those who subvert the order and structure of our social systems.

6. Sanctity/Degradation: It should be noted that Sanctity extends broader than just the boundaries of religious belief. It also incorporates our intuitive respect for honoring the human spirit even in a more secular sense. The reciprocal dimension of this value is widespread social aversion to personal degradation by individuals of themselves or others.

Haidt found that these 6 traits can be reliably measured and discovered different value profiles in various cultural/ethic cohorts in Philadelphia, India, and South America. When this methodology is applied to examine a wide sample of the US population, a striking difference is found between 2 groups: political liberals and political conservatives. These contrasting profiles are depicted by the authors in the Figure.

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Important Political Implications of These Moral Foundational Values

The general characteristic of the liberal profile is that the overarching value of liberals is care for victims of oppression. Furthermore, analysis of data demonstrates that US liberals score high on the first 3 fundamental values, Care, Liberty, and Fairness, and score low on valuing the second 3 categories, Loyalty, Authority, and Sanctity. This resulting profile of liberals does not seem surprising when presented to both liberal and conservative audiences.

It is also not that surprising that, in general, conservatives view their social world differently. The overarching value of conservatives seems to be the preservation of the institutions and traditions of a moral community. It is most revealing that US political conservatives score about the same on all 6 foundational values—with conservatives scoring almost at the same level as liberal cohorts on the first 3 moral values of Care, Liberty, and Fairness. Moreover, conservatives have a much higher regard than liberals for valuing the last 3 foundational categories of Loyalty, Authority, and Sanctity.

It is surprising to many liberals that conservatives seem to score almost as high on Care, Liberty, and Fairness as do liberals. On the contrary, this value profile does not come as a surprise at all to conservative audiences. This divergence is accentuated by the final striking characteristic that most liberals inaccurately predict that conservatives would score low on the first 3 moral values (Care, Liberty, and Fairness) and high only on the last 3 (Loyalty, Authority, and Sanctity). Conversely, most conservatives accurately understand that liberals score high on the first 3 values and low on the second 3.

This striking divergence leads to what Haidt describes as “The Conservative Advantage” and contains the key concept of “the Three versus the Six.” This comparison of the liberal and conservative profiles is summarized in the Figure.

The important implications of this key divergence is that in political discourse and advocacy, conservatives more often intuitively tend to address all 6 moral foundational values that motivate the broad US population. However, liberals gravitate toward framing political issues in only addressing the first 3 values of Care, Liberty, and Fairness—generally ignoring or only giving superficial attention to Loyalty, Authority, and Sanctity. This phenomenon gives conservatives a distinct advantage because liberals are only using 3 of the intuitive motivating values contained in our spectrum of 6 motivating categories. Our natural intuitive attraction to the second trio of moral values is left out of the picture when liberal messaging only addresses the 3 values in the first domain. This imbalance creates “the conservative advantage.”

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Intuitive Values and Changes in Community Situations

Haidt's used his theory to examine the paradox described in Thomas Frank's4 earlier work, What's the Matter With Kansas?. The perplexing question presented was why a historically liberal state such as Kansas has steadily moved to the political right over the past 50 years in the face of consistent economic policies offered by the Democrats that strongly favor the working-class middle-American Kansas farmers. This shift has led to a somewhat simplistic conclusion voiced by some liberals that conservative political messaging has duped the farmers of Kansas to vote against their personal best interests.

Using the lens of the 6 moral foundational values, a compelling argument can be made that the shift to the political right observed in Kansas was not a matter of blue-collar white farmers being manipulated by an abundance of conservative political messaging to vote inadvertently against their own interest. Haidt contends that the conservative political messaging has more effectively been resonating not only to the values of Care, Liberty, and Fairness but also to the other 3 domains of Loyalty, Authority, and Sanctity.

With the Midwest economies faltering, the family farm being displaced by the agribusiness model, and the younger generations leaving for the cities, then the preservation of the Kansas rural community way of life has been facing a profound threat of change. The overarching conservative moral value of preservation of the institutions and traditions of that moral community consistently seems to outweigh the persuasiveness of the narrower liberal political messaging that has tended to focus more upon economic and fairness issues.

A similar example has been witnessed most recently in the 2015 Kentucky gubernatorial election, where the second economic quintile of “working poor” also has shifted to the political right at the same time that rural communities in Kentucky are experiencing economic stress and social change.5 These illustrations underscore the importance that messages designed to change opinions need to be predicated upon a clear understanding of what is actually taking place inside the community of the target audience.

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Beginning to Construct Richer Messages

Modern public health has been rooted in data, and so in rational, consequentialist arguments that can be supported by data, disciplined inference, and probabilistic prediction. One has only to look at our emblematic political documents, such as to take the great American example—Lemual Shattuck's6 1850 Report of A General Plan for the Promotion of General and Public Health Devised, Prepared and Recommended By the Commissioners Appointed Under a Resolve of the Legislature of Massachusetts, Relating to a Sanitary Survey of the State. Shattuck's last chapter is a roster of arguments in favor of action, and they would not be out of place on a public health website or issue brief today: a comprehensive sanitary law should be saved because it will save lives and dollars, reduce substance abuse and sedentary behavior (“vice” and “sloth”), and promote economic growth. Whether it is our discipline or our socialization, we in public health tend to frame arguments first and foremost in terms of preventing harm. Although not of concern to Shattuck, we modern sanitarians are also very concerned about disparities and so about fairness in the distribution of the conditions required for health. And that's pretty much the extent of our morality. We experience the rest of the moral spectrum as an inconvenience at best. We give short shrift to the “liberal” sanctity intuition that points to thimerosal as taboo, to the conservative sanctity that keeps kids from getting sex education, or to the intense group loyalty that animates calls to close our borders to people coming from countries hit with Ebola.

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Shaping Public Health Messages to Relate to Broader Audiences

Public health leaders need to understand the importance of aligning our political reasoning in such a manner that not only incorporates the Care, Liberty, and Fairness domains but also frames issues into the context of Loyalty, Authority, and Sanctity. Such a more comprehensive framework enables reaching inside the full spectrum of conservative values. Attentiveness to such details that you were not aware of and perhaps “did not know that you did not know” enables a more in-depth perspective. In the past, a communication gulf has existed. The message of population health needs is too important for public health to be ineffectual in messaging to the entire public, including our conservative elected officials and policy makers.

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Where Does Public Health Go Next?

Public health has always relied on the integrity of strong data when advocating for change. Richer messaging requires addressing more deeply all the foundational moral values that bind us together. Here are several practical suggestions that may point the way to improving our public health messaging across a broader political spectrum:

Control the impulse toward inherent self-righteousness: Remain open to the possibility that conservatives may support the same “liberal” values of Care, Liberty, and Fairness as much as you do.

Seek out areas of empathy for opponents: Do not reflexively assume your opponents are stubborn, selfish, or ignorant. Consider the possibility that they may value other things more highly than you do and/or may be starting with different facts.

Personal relationships matter: Look for “unexpected validators” who agree with your specific issue but come from the opposite side of your political or social spectrum. These individuals can become enormously valuable voices who can effectuate change in ways that you can never match.

Develop community insight: Politicians readily understand that “all politics is local.” We in public health can benefit by thinking deeper about what is happening inside the specific communities we are addressing and shape messages accordingly. We frequently find ourselves addressing communities under stress. In such circumstances, we should be mindful of how our recommendations will resonate (positively or negatively) to the desire for preservation of the institutions and traditions of a moral community that is facing stress.

Use the full range of foundational values: Construct richer public health stories that resonate with all 6 of the fundamental intuitive social values that touch upon the full range of moral intuition. Bring forward Loyalty and Sanctity and rely less reflexively on Care and Authority.

The emerging scholarship of Jonathan Haidt and many others in the field of moral foundations theory is providing public health with interesting new tools that we should be actively exploring.

Even before the arrival of our current overheated political environment, most leaders in public health have been well aware that our “traditional” messaging framework, as most recently tested during the several years of the Great Recession, was not working well. A fresh, candid, thoughtful, respectful, and practical discussion needs to take place—separate from the dueling echo chambers dominated by both ends of the political spectrum.

Initially, the practical application of some of the concepts in this article may seem unnatural, risky, and out of the comfort zone of experienced public health advocates. Nevertheless, fresh approaches have the potential to provide better insight into the US social landscape and can give us useful perspectives to create better messaging for new coalitions to improve the health of our communities. We should use this important moment for beginning some new conversations in public health.

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REFERENCES

1. Haidt J. The Righteous Mind: Why Good People Are Divided by Politics and Religion. New York, NY: Pantheon Books; 2012.
2. Kahnemann D, Slovic P, Tversky A, eds. Judgment Under Uncertainty: Heuristics and Biases. Cambridge, England: Cambridge University Press; 1982.
3. Nowak MA, Tarnita CE, Wilson EO. The evolution of eusociality. Nature. 2010;466(7310):1057–1062.
4. Frank T. What's the Matter With Kansas? How Conservatives Won the Heart of America. New York, NY: Metropolitan Books; 2004.
5. MacGillis A. Who Turned My Blue State Red? Why poor areas vote for politicians who want to slash the safety net. New York Times. November 20, 2015:SR1.
6. Shattuck L. Report of a General Plan for the Promotion of General and Public Health Devised, Prepared and Recommended by the Commissioners Appointed Under a Resolve of the Legislature of Massachusetts, Relating to a Sanitary Survey of the State. Boston, MA: Dutton & Wentworth; 1850.
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