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“Towards Justice in Health”: An Exemplar of Speaking Truth to Power

Falk-Rafael, Adeline PhD, RN, FAAN; Bradley, Patricia A. PhD, MEd, RN

doi: 10.1097/ANS.0000000000000034
Original Articles

A critical textual analysis of the 6 issues of Towards Justice in Health, a magazine published by Nurses for Social Responsibility (NSR) between 1992 and 1995, makes visible their work. True to their purpose, NSR provided an alternative and courageous voice on the political nature of health and health care that was largely missing in mainstream nursing literature at that time. Towards Justice in Health both documents the emergence of the new economic world order and concomitant shift to the right in Canadian politics during the early 1990s with its impacts on health care and the nursing workplace and provides a grassroots response.

School of Nursing, York University, Toronto, Ontario, Canada.

Correspondence: Adeline Falk-Rafael, PhD, RN, FAAN, School of Nursing, York University, 4700 Keele St, Toronto, ON M3J 1P3, Canada (

The authors have disclosed that they have no significant relationships with, or financial interest in, any commercial companies pertaining to this article.

WALKING IN a Women's International Day march in 1985, a Toronto, Ontario-based group of nurses were inspired to organize themselves as Nurses for Social Responsibility (NSR) (Towards Justice in Health [TJH] 4(1), pp 18-19).* The seeds for NSR were planted a year earlier when nurse Cathy Crowe prepared a resolution for the 1984 Annual General Meeting (AGM) of the Registered Nurses Association of Ontario (RNAO), calling for its support of multilateral nuclear disarmament (TJH 4(1), p 8). The resolution was adopted at the AGM and later also at the Canadian Nurses Association AGM. The next year, the Women's Day march acted as the catalyst to formalize NSR as a group committed to becoming a “distinct and unified” nursing voice to support social causes (TJH 4(1), p 8). The NSR's first action was to prepare another resolution for the 1985 RNAO meeting, calling for it to lobby politicians to support multilateral nuclear disarmament. The RNAO adopted the resolution, took the required action at both the federal and provincial level, and “made a monetary contribution to the Peace Movement” (TJH 4(1), p 8).

From its inception, NSR operated as a collective with a 5-person steering committee that welcomed “RNs, RNAs [Ontario equivalent to Licensed Practical Nurses at the time], nursing students, and individuals who support our philosophy and objectives” (TJH 4(1), p 8). It made links with other “peace, social justice, and women's organizations” (TJH 4(1) p 18), one of the first being the Toronto Disarmament Network. Over the years, it supported many groups, including the Canadian Abortion Rights Action League, the National Action Committee on the Status of Women, the Ontario Family Allowance Coalition, the Toronto Birth Centre, the Alliance for Non-Violent Action, and the Canadian Physicians for the Prevention of Nuclear War's Peace Lantern Project (TJH 4(1), pp 18–19). Highlights of NSR activities between 1985 and 1994 reveal an early preponderance toward propeace, antiwar, and antiweaponry initiatives that ranged from providing educational sessions and participating in peaceful protests, to engaging in civil disobedience (TJH 4(1), pp 18–19). In the later years, NSR's focus expanded to embrace more diverse social injustices and its activities included supporting abortion rights and needle-exchange programs; opposing violence against women, apartheid in South Africa, and economic globalization; and exposing nursing workplace issues, such as elimination of nursing jobs and racism (TJH 4(1), pp 18–19).

The purpose of this article is to make visible the work of this extraordinary group of nurses who were committed to political activism in the pursuit of social justice and health. Toward that end, a critical textual analysis of NSR's 6 published issues of its magazine, TJH, was undertaken. Freire's1 concept of conscientizaçäo; the critical awareness of one's social, political, and economic realities; and concomitant action to change those realities informed our understanding of emancipatory praxis. Elo and Kyngas' process for inductive content analysis2 guided the 3 phases of analysis. Each magazine entry, for example, report, editorial, and opinion piece, was considered the unit of analysis.

In the preparatory phase, each of the 6 issues of the magazine was read thoroughly by both authors. One author summarized each article/column and the summaries were discussed by both authors. In the organizing phase, the summaries were coded using Ethnograph v.6.03 software to identify broad categories. During this time, the authors again discussed the data, frequently returning to the magazines themselves, to gain a holistic understanding of the content and draw inferences from the data to the context.2 In the reporting phase, the data were further abstracted by grouping categories under higher order headings.

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During its 10-year existence, NSR first published a series of newsletters (1986-1991) for its members and then, from 1992-1995, produced and published a glossy-covered magazine, TJH. The term “magazine” was deliberately chosen by NSR who intended to sell it on newsstands to the general public. The magazine was available initially by subscription or membership in NSR3 and by 1993 (Volume 2, issue 1) was for sale on newsstands across Canada. Although the intent of NSR was to publish quarterly, only 6 issues of TJH were published between 1992 and 1995, when publication stopped for lack of human and financial resources (Personal communication, Cathy Crowe, May 14, 2012).

The deliberate change to a magazine format in 1992, encouraged by positive feedback regarding the NSR newsletters, was led by a 4-woman steering committee, consisting of Laura Cowan, Cathy Crowe, Kathy Hardill, and Carolyn Montgomery.4 Each magazine issue had an identified “NSR Working Group” comprising some or all of the steering committee members and other NSR volunteers as they were available. The working group shared all tasks related to issue production, including generating story ideas, soliciting or writing articles, editing, choosing graphics, etc. All of these women had full-time jobs and, lacking funding for the magazine, they sold sweatshirts to fund each issue.4

The inside cover of each issue of the magazine included a statement of purpose, that is, “to provide an ‘alternate voice’ on the politics of health and health care.” Magazine contents conveyed information in diverse formats: editorials; articles; interviews, presumably by 1 or more members of the working group, of persons who offered a valued perspective on a topic of interest; letters to the editor; reviews of books, magazines, and videos; poems; photographs and graphic illustrations; reprints of previously published materials; and editorial notes and updates on previously reported issues. Many articles were written by individual members of the NSR Working Group and took the form of opinion pieces, critical analyses, or journalistic reporting. Although a number of guest articles were included, it is not clear whether they were solicited or submitted voluntarily. The magazine made no pretense of using a peer-review process, so it is reasonable to assume the NSR working group responsible for each issue both solicited articles and made decisions for inclusion of unsolicited articles.

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Five of the 6 issues contained the NSR Basis of Unity statement. No information is provided in the magazine to indicate how it was formulated or by whom, but it appears to represent the final metamorphosis of a NSR philosophy statement appearing in a few of the earlier newsletters, which were located:

We believe that health is fundamentally political in nature. Health for all requires adequate food, shelter, income, equality, a stable ecosystem and peace as its most basic prerequisites. As such, we work for social justice through education, lobbying and direct political action.

Health can only be achieved by working to eliminate oppression based on gender, race, class, age, sexual preference and ability and by working to eliminate militarism, poverty and environmental destruction.

We understand that power is used to maintain and expand privilege at the expense of the health of most of the world's population, including people in Canada. We seek to educate ourselves and others about relevant issues in order to foster a critical analysis of the world around us.

We seek to lobby both nursing and other individuals and groups in order to hold them accountable to a commitment to health for all. We believe that opposing oppression, inequality, militarism, poverty and environmental destruction means being will to confront power and hierarchical systems on which it is founded. As a result, we also use direct political action to work towards health for all, which we believe is possible in a just world.

We work with and support other individuals and groups striving for similar objectives and include nurses and others in our membership. We are committed to a process of consensus decision perspective. We seek to unite those with a similar analysis of health in the hope that out of such unity will come empowerment and the creation of a just world in which health is not the preserve of a privileged few.5

This manifesto clearly articulates the group's beliefs and intentions for action. As such, it provides a useful context for understanding the contents of the 6 issues of TJH. The influence of critical social theories is seen throughout the statement in the acknowledgement of the political nature of health, with specific reference to issues of power, oppression, and privilege, and in the commitment to taking action to bring about changes necessary to improve health for all. The prerequisites for health and the language of “health for all” are clearly informed by the Ottawa Charter for Health Promotion6 of 1986.* Indeed the prerequisites listed in the first paragraph of the statement represent 6 of the 9 prerequisites identified in that document, although the word “equality” replaced the Charter's word “equity.” Social justice, another Charter prerequisite for health, is acknowledged in the statement's next sentence and reflected throughout the magazine. Indeed, it is the basis of social responsibility, the meaning of which is explicated in the first issue of the magazine (TJH 1(1), pp 2, 12–15). Two of the Charter's prerequisites, sustainable resources and education, are not explicitly included in the Basis of Unity statement.

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Despite the lack of an overt inclusion of sustainable resources in the Basis of Unity statement, magazine contents suggest that sustaining both physical and social environments were NSR priorities. Opposition to environmental destruction is identified in the penultimate paragraph of the statement and speaks to sustaining the physical environment. To that end, NSR raised awareness of the environmental health hazards of nuclear energy (TJH 1(1), p 22), dioxins and other organochlorines (TJH 1(2), pp 24–25; 4(1), p 20), often concluding articles with information for readers to contact politicians and policy makers. Acknowledgement of human interconnectedness with and responsibility for the health of the planet were also a feature of articles primarily addressing other issues, such as democracy (TJH 4(1), p 4) and native land claims (TJH 4(1), p 22).

Concern for the sustainability of social resources was an even more prominent feature of the magazine. The emerging new global economic order, ushered in by Reagan and Thatcher (TJH 4(1), p 3) and manifesting itself through increasing corporatization and a proliferation of trade agreements, was beginning to undermine and threatening to destroy the very fabric of the Canadian social safety net. Through TJH, nurses, working at point of service and witnessing the effects on patient care and the public's health, bore witness to the changes (TJH 4(1), p 5; 3(1), pp 10–17; 1(1), pp 19–21) and/or railed against them, often lashing out against nursing and its leaders (TJH 2(1), pp 6, 7–10; 3(1), pp 3–4). More systematic, critical analyses at times complemented the point-of-service experiences and exposed the ideology and greed of the responsible multinational corporations, politicians, and others benefiting from the changes (TJH 2(1), pp 12–16; 3(2), pp 3, 6–15).

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The omission of education from the Basis of Unity statement is interesting and may reflect an attitude of anticredentialism. Provision of authors' professional and/or academic credentials is erratic across the 6 issues. Articles written by members of the steering committee omit both their professional and academic credentials in 5 of the 6 issues (except for (2)1, which includes their RN designation only). Most often, the same is true for other nurse authors, whose articles are generally preceded with an introductory editorial note identifying them variously as “nurse,” “registered nurse,” or “registered nursing assistant” and providing a brief context for the article. In the few instances in which guest contributors' academic credentials are provided, they acknowledge only graduate degrees. This may reflect authors' preferences or an absence of baccalaureate-prepared authors; however, a number of pejorative comments toward baccalaureate entry-to-practice in the early issues suggest the omission of credentials might reflect a conscious editorial decision.

Nurses for Social Responsibility was clearly committed to education in terms of informing its readership about issues relevant to health and its political context. Its magazine included the perspectives of several nursing academics on social responsibility (TJH 1(1), pp 3–6), justice in nursing (TJH 1(1), pp 12–15), a nursing journal review (TJH 3(1), pp 24–26), and the relative ineffectiveness of nursing education in the preparation of social activists (TJH 1(1), pp 9–11). However, experiential and informal education appeared to be more highly valued than formal education, particularly baccalaureate nursing education. One author includes in 2 of her articles, a quote attributed to Oscar Wilde that “ is well to remember from time to time that nothing worth knowing can be taught” to support that point (TJH 1(1), pp 7–9; 2(1), pp 7–10). The author, Lowry, who is identified as an RN and, according to the editorial introductory note, “is contributing an impassioned analysis of the dichotomy between caring (or trying to) and the increased corporatization of the health care system” (TJH 2(1), p 7). However, the article is less an analysis than a series of examples of poor practice Lowry has witnessed or become aware of, held together with repeated attacks on nursing leaders, nursing education, and professional nursing associations. Her own feelings toward nursing education are captured in the gratitude she expresses for having “kept myself away from all those ‘..ology’ courses, and from all that ‘what is a nurse really’ crap” (p 7). She lashes out against the RNAO: “For years they have been telling us that “by the year 2000 all nurses must have their degrees, leaving us, chopped livers, working away in the most denigrated, despairing circumstances possible” (p 10). Despairing with how the profession has evolved, she chides “these women [who] think that by getting more and more schooling...they would be able to become equal in power and influence.” (p 9).

Lowry is not alone in expressing such sentiments. In the first issue, Dilin Baker, identified as the “director and one of the founding members of Street Health” is interviewed by an unknown representative of NSR. Although her critique of RNAO and its inadequacy as a powerful political voice in taking on sociopolitical issues may have been deserved in 1992, Baker's wrath quickly focuses on its baccalaureate entry to practice stance (TJH 1(1), pp 16–18). Like Lowry, she attributes that stance to a desire for more respect and power and to an “agenda of elitism,” which she deems a “vast deception” (p 18). In the next issue, Baker was invited to write a guest editorial (TJH 1(2), pp 3–4). In it, she rejected RNAO's letter to the editor refuting her earlier allegations (TJH 1(2), p 5), charging as follows:

RNAO absolutely refuses to acknowledge or address its own classism and racism. For example, RNAO's proposal that a university degree be the only entry to practice completely fails to consider the elitism of university education and the lack of accessibility this poses for most people (TJH 1(2), p 3).

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The pages of TJH provide information important for understanding the context in which such vehement denigrations of the nursing baccalaureate degree and RNAO were made. Between 1992 and 1995, RNAO and other professional nursing associations in Canada were working diligently toward achieving baccalaureate entry to practice. At the same time, however, the country was experiencing both an economic recession and the neoliberal global shift, manifesting itself as an increasing corporatization of the Canadian health care sector. In the resultant frenzy of downsizing, restructuring, and realignment, many nursing positions were eliminated or reduced to part-time (TJH 2(1), pp 6, 7–10; 3(1), pp 3–4). Moreover, in 1993, the Ontario government enacted legislation known as the “social contract” with a goal of reducing its public sector payroll spending by 2 billion dollars (TJH 3(1), p 7). According to Sutherland (TJH 3(1), pp 7–9), salaried employees, such as nurses, were severely disadvantaged by the legislation in comparison with fee-for-service physicians. For example, he argued, nurses needed to negotiate alongside other health care workers to reach agreements with their employers and those agreements needed (but did not receive) the sanction of the Ontario Hospital Association. Thus, as employees, nurses had little alternative but to accept the measures imposed by the government: a 3-year freeze on wages and increments, as well as 12 days without pay for each of the 3 years. In contrast, Sutherland noted, fee-for-service physicians negotiated directly with the government and were successful in reaching agreement on a number of measures to soften the impact of their fee cuts, including delisting medical services covered by provincial health care and billing for them privately. In addition, Sutherland added, the agreement with the physicians contained a provision that if overall payments fell below a certain level, the physicians' fee schedule would be readjusted to increase their salaries. He noted that no such provisions were provided for other health care professionals.

To further complicate the situation, Steffler noted some downtown Toronto, Ontario, hospitals were moving toward an all-RN staff (TJH 2(1), pp 32–35). From a nursing administrative position, these changes were driven by the desire to improve patient care7 but Steffler traced them to a recommendation for the “gradual phasing out” of Registered Nursing Assistant (RNA) positions made in the 1983 Dubin report on baby deaths at the Hospital for Sick Children (p 32). Steffler, an RNA, was at the time, the Executive Director of the Ontario Association of Registered Nursing Assistants, and attributed the Dubin Report's recommendation to “a certain RN MSc (applied) BN on the committee.”8 (p32) Her vilification of a credentialed nurse on the committee generating the Dubin report comment was echoed in a subsequent letter to the editor (TJH 3(1), p 5). The author, whose credentials are not identified, wrote of experiencing similar trends in Newfoundland and expressed disgust at the way in which “nurses with Bachelors' and Masters' degrees in Nursing are tirelessly working to dump RNAs and their brothers and sisters with diplomas, especially in the face of the unequivocal message from the employer that they are not going to pay for this forced credentialization.” Conversely, in the community sector, the trend was the opposite and RNs were being replaced by less qualified workers, including RNAs, presumably for economic reasons (TJH 1(2), pp 8–10). In reporting this, however, the author was one of the few who, instead of situating the problem within nursing, suggested targeting reductions among the most expensive practitioners, the physicians, and urged readers to pressure RNAO to act on this issue.

The 1990s were a difficult decade for nurses in Ontario.9 A report published by the RNAO in 2001 acknowledged that the “dramatically fluctuating employment opportunities” during that time contributed to “many RNs leaving the province, the country, and even the profession” (p 1). As a result, by 1998, Ontario had the fewest nurses per population of any province in Canada.9 Baccalaureate entry-to-practice must have felt like just 1 more threat to job security and RNAO became the whipping post for all the anger and frustrations the unbearable workplace conditions created. Deriding RNAO and discouraging membership did not improve those conditions but allowed the relatively safe exercise of what little power many nurses felt they had. Understood from the perspective of oppressed group theory, it was engaging in a form of horizontal violence, characteristic of oppressed groups.10 Another characteristic, distancing oneself from one's own group, is evident in the prevailing “them-against-us” attitude. “Them” most often referred to the “nursing elite” and included nursing managers and leaders in the workplace (TJH 2(1), pp 7–10; 3(1), pp 3–4), professional associations (TJH 1(1), pp 7–9; 16–18; 1(2), pp 3–4), nursing education (TJH 2(1), pp 7–10; 4(1), p 5), and the nursing discipline (TJH 2(1) pp 12–16).

It is ironic and sad that despite the seemingly effective partnership with RNAO that marked the beginnings of NSR, such strong antiprofessionalism peppers the magazine. Those who most forcefully expressed such sentiments were subsequently invited to write guest editorials (TJH 1(2), pp 3–4; 3(1), pp 3–4), sending a message of editorial endorsement of their views and overshadowing the examples of authors who spoke more positively about professional associations and argued for working in partnership with RNAO (TJH 1(1), pp 6–7; 1(2), pp 8–10; 2(1), pp 5–6; 3(1), pp 18–20) and the Canadian Nurses Association (TJH 4(1), pp 26–27). The ultimate irony lay in the reality that such attacks on nurses could only have served to increase divisiveness among nurses and possibly further weaken the RNAO, thus undermining the expressed hopes for a powerful and united nursing lobby (TJH 1(1), pp 16–18; 4(1), pp 26–27).

As pressing as they were, workplace issues did not detract NSR from providing courageous and visionary leadership in raising awareness about a number of other contemporary but often controversial nursing issues, such as racism in nursing (TJH 2(1), pp 17–21, 44), the experience of lesbian nurses (TJH 2(1), pp 27–30), and sexual abuse by nurses (TJH 1(2), pp 14–18). The articles addressing these issues most often provided both factual information, such as summaries of related hearings, legislation, or reports and a critical analysis, which drew attention to the underlying political dimensions of the situation. Many reported actions NSR had taken to address a particular issue and provided suggestions and contact information for action by readers. An exception is the issue of lesbian nurses, presented through an experiential account of “a woman who is forced to remain nameless.” Poignantly the author describes not only the social and professional ostracism she experienced but also the denial of common workplace benefits available to heterosexual couples, for example, bereavement leave and family health benefits for partners.

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Health, in TJH, was clearly aligned with the Ottawa Charter's conceptualization of health as a “positive concept emphasizing social and personal resources as well as physical capacities” in the process of reaching “a state of complete physical, mental, and social well-being.”10 The magazine continued its cutting-edge approach in reporting on timely health issues, which were either absent in mainstream discourses of the time or lacking a critical perspective. Such issues included needle-exchange programs, marketing of breast milk substitutes, physician-assisted suicide, and mental health.

The stories on needle-exchange programs and marketing of breast milk substitute follow a similar format: one that provides information and critique to challenge readers to examine the political aspects of the issue. For example, Sutherland (TJH 2(1), pp 22–26), provides information on the benefits of breast milk and denounces the Canadian government's reluctance to adopt the World Health Organization International Code of Marketing Breast Milk Substitutes. He questions the government's motives, suggesting the reluctance may stem from the desire to become part of the North American Free Trade Agreement and a fear of upsetting the United States, the only country to have voted against the Code.

Other articles in the magazine are experientially based. A right-to-die story relates the efforts of Sue Rodriquez, a British Columbia woman suffering from amyotrophic lateral sclerosis, to have the Canadian Criminal Code revised to legalize physician-assisted suicide (TJH 3(2), pp 18–19). Awareness of mental health issues was raised through a review of an anthology of psychiatric survivors' experiences (TJH 1(2), pp 29–30) and through 2 poems. The first describes a nurse's experience with a client with multiple personalities (TJH 2(1), p 11). The second, written by a poet “too vulnerable to give a name,” provides personal insight into living with bipolar disorder and experiencing stigma in the workplace. It begins in a washroom cubicle, with the poet crying and concludes with a self-admonition to “straighten up and fly right, cry baby” (TJH 3(2), p 20).

Other health issues that may be grouped under the broader topic of women's health were equally compelling and controversial. These were issues that either directly affected only women or were discussed from the perspective of women's health. Again, stories generally provided factual information, including current statistics, combined with a critical analysis and a call for action. The issues covered included women and AIDS (TJH 4(1), pp 15–16), bleaching of sanitary products (TJH 1(2), pp 24–25), women's reproductive freedom (TJH 1(2), pp 21–23; 3(2), pp 24–26) and violence against women (TJH 2(1), pp 3–4, 39–40, 41–42), including assault of nurses (TJH 1(2), pp 11–13, 27).

Several approaches to addressing violence against women were used and several facets of this phenomenon explored. The issue of rape as a strategy of war is passionately and forcefully examined in the reprint of Robin Morgan's compelling editorial in Ms. Magazine in early 1993 (TJH 2(1) pp 3–4). Intimate partner violence is explored through a book review (TJH 2(1), p 43) and illustrated through examining the case of a local immigrant woman who was murdered by her husband and whose children successfully fought to have the case re-opened after the initial conclusion that her death was accidental (TJH 2(1), pp 41–42). Societal violence against women takes the form of a critique of the White Ribbon Campaign (WRC), a men's initiative taken after the 1989 massacre of 14 women at the École Polytechnique in Montreal (TJH 2(1), pp 39–40). The author challenges men to become involved in tangible ways that move beyond mere symbolism and suggests a list of activities that would reduce the power imbalance between men and women and with which WRC could become involved. Finally, assault of nurses is included as an example of violence against women. Two reports of nurse assault are reported in the magazine. One summarizes the final report of a province-wide survey on the prevalence and impact of assault on nurses and profiles the group of nurses who conducted the survey and disseminated the results (TJH 1(2), pp 11–13). The second is a commendation of nurses in Sarnia, Ontario, for their successful public protest against the possible hospital reinstatement of a local pediatrician who had been convicted of sexual assault of 3 mothers of his patients and 8 female employees of local hospitals (TJH 1(2), p 27).

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The steadfastness of TJH in being guided by the NSR Basis of Unity is apparent throughout the aforesaid examples. Some of the prerequisites, such as a stable ecosystem, have already been addressed while others, such as social justice and equity, are an aspect of many of the articles, particularly those highlighting oppression on the basis of gender, race, or class.

A number of the prerequisites, such as income, shelter, and food security, are interrelated and may be evident in, but not the focus of, an article. In 2 experiential stories, however, these prerequisites are the primary focus. The first is a public health nurse's account of her social activism in poverty reduction, which she roots both in nursing's legacy and her own experience of witnessing families living in poverty: “the people weren't poor—their context was” (TJH 1(1), pp 19–21). The second is the reprint of the summary of a recent report, which provides a glimpse into the experiences of Toronto's homeless people, outlines their increased risks, and makes recommendations (TJH 2(1), p 26).

It is not surprising, given NSR's antimilitaristic origins, that a major emphasis on peace as a vital prerequisite to health is evident throughout the 6 TJH issues. ARMX, a Canadian bicentennial weapons fair until 1989 (TJH 2(1), pp 36–38), was the topic of 2 articles. The first provides a critical analysis on the morality of selling “weapons with the ‘lowest cost per kill’” (p 36) to the world's most brutal regimes (TJH 2(1), pp 36–38). The second is a report on NSR's participation in the 1989 protest of the ARMX fair in which protestors were successful in shutting down for a period of time (TJH 4(1), p 14). The nonviolent resistance measures used to protest ARMX were also used by NSR to close down the External Affairs office in Ottawa for 1 day in 1991 to protest the Gulf War, and blockade Canada's War Department in 1990 to show opposition to “low-level flight testing over Innu lands in Labrador” (TJH 4(1), pp 12–13).

The magazine also served to keep readers aware of the activities of other peace activist groups. One story described the activities of 3 international peace organizations, including the Canadian Physicians for the Prevention of Nuclear War, in working to eliminate nuclear weapons through The World Court Project (TJH 3(2), pp 21–23). That group's purpose was to seek a formal opinion from the International Court of Justice on whether or not the use of nuclear weapons would be in violation of international law. The article describes the political posturing by nuclear powers at the United Nations and World Health Organization and urges public involvement.

In some instances, the strong link between feminism and peace activism are emphasized. The review of a lecture given by a well-known Canadian feminist academic, Dorothy Smith, highlights the role of science, technology, and the media in expanding military control and developing the “warfare complex in contemporary males” (TJH 4(1), p 9). On a similar note, Gilchrist, a staff nurse and peace activist, provides an account of her involvement with the Canadian Voice of Women for Peace, challenging readers that “you cannot be a feminist without being a peace activist and you cannot be a nurse without being both” (TJH 3(1), pp 21–22).

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Nurses for Social Responsibility began in 1985, 7 years after the Declaration of Alma-Ata reflected a global consensus that people's health depended as much or more on intersectoral factors, such as agriculture, housing, and income, as on the delivery of biomedically dominated health care.11 Many of the NSR nurses worked either in public health nursing or in outreach programs for homeless and otherwise marginalized urban populations, in an emerging field of nursing known as street nursing.12 It is likely that the language of Alma-Ata resonated with them because, like Nightingale and pioneers of North American nursing,13 they witnessed first-hand the effects of poverty and social disadvantage on their clients. By the time NSR began producing TJH, a second major World Health Organization document, the 1986 Ottawa Charter for Health Promotion, had been produced. Although never explicitly referenced in the magazine, the Charter clearly was influential not only in its conceptualization of health and identification of the 9 prerequisites for health but also in its articulation of the development of healthy public policies (as opposed to public health or health care policies) as a key health promotion intervention.6

Emancipatory praxis involves both the critical awareness of oppressive realities and simultaneous actions to change them.1 Emancipatory nursing praxis, therefore, may be understood as acting on a critical awareness of social structures and processes that systematically disadvantage the health of people with the purpose of changing those structures and processes to promote health. The NSR's emancipatory praxis took 2 forms: (1) publishing its magazine to raise readers' awareness of major issues affecting health and (2) lobbying and taking direct political actions to change oppressive realities, many of which were documented in the magazine. There is little doubt that through these activities, NSR hoped to mobilize a large mass of like-minded nurses and members of the public to help change oppressive realities that adversely affected health.

The efforts of NSR are remarkably visionary for the time. Twenty years later, there is an abundance of research and literature demonstrating unequivocally the adverse health effects of what today are referred to as social determinants of health but, at the time, NSR were pioneers. Currently, professional nursing organizations, such as the RNAO, are in the forefront in advocating for social justice and addressing social determinants of health in their political activities. At the time, however, political activism was not a high priority for such nursing organizations and their knowledge of social determinants of health sparse.

It is hard to measure the success of such an endeavor. The magazine was true to the NSR Basis of Unity and true to its purpose. For a time, it provided an alternative and courageous voice on the political nature of health and health care. The 6 issues of TJH documented both the emergence of the new economic world order and concomitant shift to the right in Canadian politics during the early 1990s as well as the responses of the magazine's authors to those changes. In its pages are seen the impact of neoliberalism and corporatization on Canadian social programs, including health care and the nursing workplace. The number of nurses and other subscribers whose consciousness was raised in relation to social injustices and determinants of health and the subsequent actions in which they engaged are incalculable. Efforts to have the 6 issues of TJH archived to ensure continued access continue to the present time.

The 10 years of NSR's remarkable achievements are documented in the commemorative sixth issue, published in 1995. It is a celebratory issue but amidst the congratulatory messages and well-deserved pride in NSR achievements are glimpses of exhaustion and sadness. Crowe's editorial titled “Where have all the flowers gone?” after the refrain of the antiwar song, reminds readers of the beginnings of NSR in the peace movement. She notes the expansion of the group's vision for health beyond the absence of war (TJH 4(1), p 4). Yet, the continuing silence of so many nurses troubles her and she asks, “Where have all the nurses gone?” She admits to small numbers at NSR and, considering whether continued production of TJH is possible, returns to the song, “Oh when will they ever learn?”

Both the expressed intent of publishing quarterly and the implied intent of creating a groundswell of nursing and public support were not met. Multiple factors may have contributed to the lack of success in these areas. Lack of adequate funding was an immediate cause; it precluded hiring editorial and administrative staff, resulting eventually in fatigue and burnout of the core group of nurses who juggled creating and publishing each issue with fund-raising to finance it, full-time paid work, and domestic and family responsibilities. Availability of funding for such a venture at the time was likely quite limited and, furthermore, the group may not have wanted to be constrained by requirements of an external funding source, hoping that newsstand sales would eventually provide sufficient funding. Likewise, the strength in numbers they might have gained from working with what they termed the “nursing elite” might have demanded too many ideological compromises. Gender may also have been a contributing factor. In critiquing the male WRC opposing male violence against women, the authors contrast the corporate support it received within a year of its inception with decades of vigorous but unfunded efforts by women with the same goal (TJH 2(1), pp 39–40). They quote Canadian feminist, Judy Rebick, “never before have I seen so clearly how much more power men have than women” (p 40).

What can be learned from the NSR experience? One can only speculate as to why newsstand sales were not adequate to fund continued publication of the magazine. The magazine was somewhat erratic both in its publication schedule and in the content of each issue. Prospective readers might well have become discouraged in looking for quarterly issues of a magazine that produced only 1 or 2 issues annually. The content of each issue varied greatly in length and quality with items varying from critical analyses and documented reporting of issues to experiential opinion pieces with no references. While there may be room for both in a publication, a more consistent organization of content and clear identification of such sections might have been helpful to readers. The language of the magazine was, at times, provocative, strident, and outrageous; whether that deterred any readers is not possible to know. Finally, the distancing of the group from the “nursing elite” may have disadvantaged it in terms of possible funding opportunities and editorial expertise.

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Nurses for Social Responsibility provided an exemplar of emancipatory praxis through speaking truth to power, both literally, in lobbying for social justice and metaphorically in direct political action. Through the magazine they created and published, TJH, they attempted to raise the consciousness of other nurses and the public and mobilize them into collective action. True to their purpose, the women of TJH provided an alternative and courageous voice on the political nature of health and health care that was largely missing in mainstream nursing literature at that time. Most of the issues they raised have not been resolved; the need for speaking truth to power has never been more urgent. We can learn much from their example.

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* As this is a textual analysis of a magazine, Towards justice in Health, data sources are identified in parentheses as (TJH, volume [issue], p or pp).
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* The Ottawa Charter for Health Promotion was created to reflect actions deemed necessary to achieve health for all by the year, 2000. It resulted from the First International Conference for Health Promotion, which built on the Declaration on Primary Health Care articulated in Alma-Ata, USSR, in 1978, as well as other World Health Organization documents and debates at the World Health Assembly. Although still widely used, the Ottawa Charter was followed by others also named for the city, which hosted the conference, for example, Jakarta (1997), Bangkok (2005).
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corporatization; critical textual analysis; neoliberalism; nursing history; social determinants of health; social justice

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