Table of Con­tents | Arti­cle doi: 10.17742/IMAGE.IN.11.2.11 | PDF


Can Art Influ­ence Glob­al Health Pol­i­cy? Patrick Fafard

Can Art Influence Global Health Policy?

Patrick Fafard

This arti­cle exam­ines the influ­ence of art on glob­al vac­ci­na­tion pol­i­cy, with a spe­cial focus on con­tem­pla­tive art, designed to get us to look at issues dif­fer­ent­ly, and advo­ca­cy art, mak­ing the case for quite spe­cif­ic poli­cies or pro­grams. Ulti­mate­ly it argues that because pol­i­cy choic­es are influ­enced by ideas and emo­tions, there is room for art to be indi­rect­ly influ­en­tial when com­bined with action by social move­ments, at least those built around spe­cif­ic dis­eases.

Cet arti­cle exam­ine l’influence de l’art sur les poli­tiques publiques de vac­ci­na­tion, avec un accent par­ti­c­uli­er sur l’art con­tem­platif, conçu pour nous amen­er à regarder les prob­lèmes dif­férem­ment, et l’art de plaidoy­er, plaidant pour des poli­tiques publiques ou des pro­grammes assez spé­ci­fiques. En fin de compte, il fait val­oir que, parce que choisir entre les poli­tiques publiques est influ­encé par les idées et les émo­tions, l’art peut avoir une influ­ence indi­recte lorsqu’il est com­biné avec l’action des mou­ve­ments soci­aux, du moins ceux con­stru­its autour de mal­adies spé­ci­fiques.


I am not in any way a polit­i­cal sci­en­tist. I can only refract what­ev­er I take in and com­mu­ni­cate that to peo­ple. I don’t know if we can inspire polit­i­cal change […] [but] we can get peo­ple to think more polit­i­cal­ly.”
—She­hza­ad Jiwani, “Race, Punk, and Rock & Roll,” TVO, The Agen­da

Infec­tious dis­eases and vac­ci­na­tions to pro­tect against them are rou­tine­ly dis­cussed at glob­al sum­mits of heads of gov­ern­ment and senior min­is­ters. For exam­ple, at a meet­ing of G7 finance min­is­ters in Lon­don in June 2009, the min­is­ters agreed to grant $1 bil­lion to phar­ma­ceu­ti­cal com­pa­nies devel­op­ing vac­cines for dis­eases that pri­mar­i­ly affect devel­op­ing coun­tries (“G7 Finance Min­is­ters Approve Vac­cine Pro­pos­al”). At the 2010 G8 Sum­mit in Cana­da, the assem­bled heads of gov­ern­ment agreed to the $5 bil­lion Musko­ka Ini­tia­tive on Mater­nal, New­born and Child Health and restat­ed their sup­port for polio erad­i­ca­tion (Group of Eight). At the 2012 meet­ing of the World Health Assem­bly, min­is­ters of health from 194 coun­tries endorsed a Glob­al Vac­cine Action Plan, described as “a roadmap to pre­vent mil­lions of deaths by 2020 through more equi­table access to vac­cines for peo­ple in all com­mu­ni­ties” (World Health Orga­ni­za­tion). Final­ly, tack­ling antimi­cro­bial resis­tance and infec­tious dis­eases, along with health sys­tem strength­en­ing, were fea­tured at the G20 sum­mit in 2017 (McLeod et al.). These exam­ples speak to the fact that much of what is done by way of glob­al health and glob­al vac­ci­na­tion is the result of deci­sions tak­en at major sum­mits of glob­al pol­i­cy mak­ers, not tech­ni­cal meet­ings of health experts, includ­ing those meet­ings at which min­is­ters of health are not the prin­ci­pal play­ers.

What influ­ences deci­sions at glob­al sum­mits? This is a ques­tion that has been explored at length by oth­ers, even spawn­ing a small sub­field of “sum­mi­tol­o­gists” who focus intense­ly on these meet­ings (see Lar­i­ono­va and Kir­ton). My broad inter­est is in explor­ing the oppor­tu­ni­ties and modal­i­ties through which these deci­sions can be bet­ter informed by pow­er­ful evi­dence not always pre­sent­ed or bet­ter chal­lenged by impor­tant voic­es not usu­al­ly heard. Specif­i­cal­ly, in this arti­cle, I assess the poten­tial con­struc­tive role that art can play as polit­i­cal inter­ven­tion into glob­al health pol­i­cy-mak­ing process­es. I focus on art because of its long his­to­ry as a chal­lenger and instru­ment of polit­i­cal pow­er, as well as its suc­cess in empow­er­ing dis­ad­van­taged or vul­ner­a­ble pop­u­la­tions who are too often left out of pol­i­cy deci­sion mak­ing. Also, prac­ti­cal­ly, there is rea­son to believe that art may be par­tic­u­lar­ly influ­en­tial at glob­al sum­mits. With today’s secu­ri­ty envi­ron­ment, only a small num­ber of peo­ple gain entry to these meet­ings, and advi­sors, advo­cates, and sci­en­tists get shut out of most sum­mits. How­ev­er, there is often a cul­tur­al com­po­nent to major meet­ings that lets artists get through the secu­ri­ty gates.

Do these artists have a real­is­tic oppor­tu­ni­ty to inform or chal­lenge the deci­sions of sum­mi­teers? If so, at what stage and in what way? Those are the ques­tions I seek to answer. But rather than look ret­ro­spec­tive­ly at one or more cas­es of the mak­ing of glob­al health pol­i­cy, I rely on pub­lic pol­i­cy the­o­ry to look prospec­tive­ly at future meet­ings. Mine is an exer­cise in try­ing to imag­ine cre­ative inter­ven­tions in glob­al health pol­i­cy mak­ing. Build­ing on ear­li­er efforts to intro­duce the use of artis­tic works to influ­ence health pol­i­cy (and, in par­tic­u­lar, inspired by the role of artists’ col­lec­tive efforts in the AIDS move­ment that forced change in HIV/AIDS pol­i­cy), this arti­cle seeks to shed light on the ques­tion of whether art, broad­ly defined, can influ­ence deci­sion mak­ing about vac­cines at glob­al sum­mits. Draw­ing on what we know about glob­al sum­mits and research on pol­i­cy mak­ing, the argu­ment that I make here is that yes, art can be influ­en­tial. In short, the poten­tial influ­ence of art on glob­al vac­ci­na­tion pol­i­cy mak­ing is unlike­ly to be direct and will depend on the type of sum­mit; and not all art and art exhibits will be influ­en­tial. Rather, to the extent that artis­tic works express emo­tion and evoke an emo­tion­al response, under the right con­di­tions they can exer­cise indi­rect but poten­tial­ly pow­er­ful influ­ence on pol­i­cy deci­sions about glob­al vac­ci­na­tion, par­tic­u­lar­ly if, as was the case for HIV/AIDS, broad-based social move­ments are will­ing and able to make nor­ma­tive claims and advance emo­tion­al claims for pol­i­cy change.

To devel­op this gen­er­al argu­ment this arti­cle has two main sec­tions. The first sec­tion exam­ines the three con­stituent ele­ments of the gen­er­al claim: name­ly, that art (e.g., kinds of art and art exhi­bi­tions) can have influ­ence (e.g., direct­ly on nego­tia­tors vs. indi­rect­ly on gov­ern­ments) on deci­sions tak­en at glob­al sum­mits (i.e., gen­er­al vs. more tech­ni­cal). The sec­ond sec­tion draws on pol­i­cy the­o­ry to make a series of linked claims: first, glob­al health pol­i­cy mak­ing is inher­ent­ly polit­i­cal; sec­ond, the influ­ence of dif­fer­ent types of gen­er­al ideas are more influ­en­tial than mere empir­i­cal evi­dence; third, social move­ments play a crit­i­cal role in glob­al health pol­i­cy mak­ing; and final­ly, emo­tions play an impor­tant role in pol­i­cy mak­ing and artis­tic works can be a con­duit for intro­duc­ing poten­tial­ly pow­er­ful emo­tions into glob­al vac­ci­na­tion pol­i­cy mak­ing. The con­clu­sion sum­ma­rizes the argu­ment and points to the lim­its of vaccination—as opposed to a spe­cif­ic com­mu­ni­ca­ble disease—as a ral­ly­ing point for a social move­ment inter­est­ed in forc­ing pol­i­cy change. Sim­ply put—and echo­ing the open­ing quote from Cana­di­an indie rock musi­cian She­hza­ad Jiwani—music, and by exten­sion art more gen­er­al­ly, may well influ­ence pol­i­cy and pol­i­tics. How­ev­er, the influ­ence is not usu­al­ly going to be direct and instru­men­tal via health sum­mits or any oth­er pol­i­cy-mak­ing venue.

I—Linking Art, Influence, and Global Health Summits

Art”

The propo­si­tion that art—say, for exam­ple, an art installation—could influ­ence nego­ti­a­tions at an inter­na­tion­al health sum­mit requires care­ful atten­tion to the three key terms in the claim: “art,” “influ­ence,” and “glob­al health sum­mit.”

It is not pos­si­ble or desir­able in this arti­cle to define what “art” is and what it is not. What is more, in what fol­lows I am focussing main­ly on visu­al art, not per­for­mance art or oth­er forms of artis­tic expres­sion. Instead, I want to sug­gest a (pre­lim­i­nary and high­ly pro­vi­sion­al) typol­o­gy that divides artis­tic works into three cat­e­gories linked to the ques­tion of pol­i­cy influ­ence, specif­i­cal­ly pol­i­cy influ­ence on glob­al health and vac­ci­na­tion pol­i­cy. This typol­o­gy is meant only to facil­i­tate analy­sis of the poten­tial of artis­tic works to be influ­en­tial on glob­al health pol­i­cy mak­ing. Of course, this stance assumes that art can or should inter­vene in the polit­i­cal or in pol­i­cy mak­ing in a direct way, con­ceiv­ing of art as a tool to influ­ence pol­i­cy and social change. Many would dis­agree with this under­stand­ing of art. Again, I can­not address this issue here, aside from sim­ply observ­ing that artis­tic works have been so used in the past and will con­tin­ue to be deployed as agents of polit­i­cal change.

The first cat­e­go­ry is what one might call “con­tem­pla­tive” art, art meant to raise issues and ques­tions about, for exam­ple, vac­cines and vac­ci­na­tion, and encour­age us to think about them in poten­tial­ly new and dif­fer­ent ways. The artis­tic work may elic­it dif­fer­ent intel­lec­tu­al and emo­tion­al reac­tions from dif­fer­ent peo­ple, but the gen­er­al goal is to make vac­cines more rather than less com­plex and chal­lenge some of our indi­vid­ual and col­lec­tive assump­tions about vac­ci­na­tion.

The sec­ond cat­e­go­ry is what I have labelled broad­ly “pro­mo­tion­al” art that seeks to make a rel­a­tive­ly sim­ple state­ment about the world, in this case, affirm­ing that vac­cines and vac­ci­na­tion are a good thing. While posters and oth­er graph­ic art com­mis­sioned by gov­ern­ments often play this role, we should nev­er­the­less allow for the pos­si­bil­i­ty that an artist might take the mer­its of vac­cines as giv­en. That is to say that it is quite pos­si­ble that an artist is inter­est­ed in the enor­mous poten­tial of vac­cines to save lives. Alter­na­tive­ly, the focus might be on the chal­lenges asso­ci­at­ed with deploy­ing them effec­tive­ly (e.g., tech­ni­cal chal­lenges asso­ci­at­ed with the need to keep some vac­cines cold; vac­cine hes­i­tan­cy if not out­right oppo­si­tion to vac­cines, etc.). In either case, the under­ly­ing mes­sage is that vac­ci­na­tion is a good thing. For exam­ple, many if not all of the pieces that were part of the vac­ci­na­tion-relat­ed exhi­bi­tion <Immune Nations> would fall into this cat­e­go­ry (<Immune Nations>).

Type Common/likely? Direct Influ­ence on Nego­tia­tors Indi­rect Influ­ence on Nego­tia­tors
Con­tem­pla­tive Yes Low Low to mod­er­ate
Pro­mo­tion­al No Low Mod­er­ate to high
(gen­er­al sum­mits)
Pre­scrip­tive No Mod­er­ate Mod­er­ate
(tech­ni­cal sum­mits)

Fig­ure 1: Cat­e­gories of Pol­i­cy-Relat­ed Art

The third and final cat­e­go­ry might be called “pre­scrip­tive” art that makes the case for rel­a­tive­ly spe­cif­ic vac­cine-relat­ed pol­i­cy and pro­gram choic­es. This cat­e­go­ry is meant to cap­ture what I expect to be rel­a­tive­ly uncom­mon artis­tic works that are ful­ly inte­grat­ed into world of glob­al health pol­i­cy and engage with very spe­cif­ic issues and choic­es asso­ci­at­ed with, for exam­ple, vac­ci­na­tion pol­i­cy (e.g., intel­lec­tu­al prop­er­ty issues asso­ci­at­ed with the pro­duc­tion of low-cost gener­ic vac­cines; the cri­te­ria for how to fair­ly allo­cate scarce resources to spe­cif­ic vac­cines in par­tic­u­lar coun­tries; rais­ing aware­ness of vac­cine-con­trol­lable dis­eases like measles or polio). As indi­cat­ed in Fig­ure 1, it is like­ly that the vast major­i­ty of artis­tic works that seek to address vac­cines and vac­ci­na­tion will fall into the first cat­e­go­ry of what I have called con­tem­pla­tive art. Much less like­ly will be works that are pri­mar­i­ly pro­mo­tion­al or pre­scrip­tive.

Influence”

In very gen­er­al terms, an art exhib­it can have influ­ence on glob­al vac­cine-relat­ed pol­i­cy mak­ing direct­ly or indi­rect­ly. As out­lined in Fig­ure 2, one could imag­ine a sit­u­a­tion where an art exhib­it, strate­gi­cal­ly locat­ed on the mar­gins of a glob­al health sum­mit, could have an influ­ence on the nego­ti­a­tions. This chan­nel of influ­ence assumes, not implau­si­bly, that gov­ern­men­tal or civ­il soci­ety nego­tia­tors would expe­ri­ence the art exhib­it and that this would influ­ence the con­duct and out­come of the nego­ti­a­tions. How­ev­er, it is much more like­ly that the poten­tial influ­ence of an art exhib­it would be indi­rect; that is, the influ­ence would derive from the fact that the exhib­it is expe­ri­enced by a wider group of peo­ple beyond the actu­al nego­tia­tors. Mem­bers of the glob­al vac­ci­na­tion pol­i­cy net­work who expe­ri­ence the exhib­it could then be moti­vat­ed to push for cer­tain pol­i­cy choic­es in their inter­ac­tions with nation­al gov­ern­ments (or, for that mat­ter, NGOs with access to the nego­ti­a­tions). An over­lap­ping vec­tor of influ­ence would be when peo­ple who iden­ti­fy as part of a vac­cine-relat­ed social move­ment (e.g., Malar­ia No More) are inspired by the art exhib­it to redou­ble their efforts to put vac­cines on the pol­i­cy agen­da and/or push for spe­cif­ic pol­i­cy and pro­gram change. Alter­na­tive­ly, there are prece­dents for glob­al health-relat­ed social move­ments using art to advance their advo­ca­cy efforts. A very good exam­ple of this might be the Kei­th Har­ing paint­ing includ­ed in Fig­ure 3 and used, among oth­ers, by AIDS ACTION NOW! in a 1996 poster cam­paign call­ing for a nation­al AIDS strat­e­gy in Cana­da. Anoth­er exam­ple would be the art cre­at­ed by the Cana­di­an art group Gen­er­al Idea (Bor­dowitz). Since Gen­er­al Idea, there have been a num­ber of poster cam­paigns by var­i­ous AIDS/HIV groups to raise aware­ness of the dis­ease and/or con­front alleged­ly unfair or inef­fec­tive gov­ern­ment poli­cies (Tay­lor).

Fig­ure 2: Direct and Indi­rect Influ­ence of Art on Glob­al Vac­ci­na­tion Pol­i­cy.
Fig­ure 3: Kei­th Har­ing, Igno­rance = Fear / Silence = Death, off­set lith­o­graph, 61.1 × 109.4 cm, 1989 © Kei­th Har­ing Foun­da­tion.

Of course, this indi­rect influ­ence can also occur when mem­bers of the gen­er­al pub­lic expe­ri­ence the art exhib­it and are moti­vat­ed to push for pol­i­cy and pro­gram change. The more gen­er­al point is that an art exhib­it could be a tool of agen­da set­ting designed to raise the pro­file of vac­cine-relat­ed issues and, hope­ful­ly, influ­ence gov­ern­ment and par­tic­i­pat­ing NGOs who would, in turn, instruct their nego­tia­tors at a glob­al health sum­mit. The very idea of the indi­rect influ­ence of art on glob­al vac­ci­na­tion rais­es the ques­tion of time and access—specifically how long an art exhib­it (or a spe­cif­ic piece of art) needs to be avail­able to be seen by the pub­lic. Sim­ply put, if the influ­ence of a piece of art is to be indi­rect, it is crit­i­cal that mem­bers of the pub­lic and more specif­i­cal­ly of vac­cine-relat­ed social move­ments and pol­i­cy net­works have the time and abil­i­ty to actu­al­ly engage with the art. In this sense, a one-time exhib­it, on the mar­gins of a glob­al health sum­mit, might allow for the pos­si­bil­i­ty of direct influ­ence on nego­tia­tors, but would do lit­tle to allow for indi­rect influ­ence (see Fig­ure 4). While the exhib­it may have some ongo­ing influ­ence via an exhib­it cat­a­logue or an online pre­sen­ta­tion or dis­cus­sion, this influ­ence is like­ly to be more mut­ed since the inter­ac­tion with the exhib­it is medi­at­ed and less like­ly to elic­it the deep inter­ac­tion that hap­pens with a live exhib­it.

  Nature of the Exhib­it / Nature of Influ­ence    
    One-time / Focused Runs over time / Dif­fuse
Vec­tor of Influ­ence Nego­tia­tors Low to high Low to medi­um
  Glob­al vac­ci­na­tion pol­i­cy net­work (elite opin­ion) Very low Very low to high
  Gen­er­al Pub­lic Very low Very low to high

Fig­ure 4: Nature of the Exhib­it and Poten­tial Pol­i­cy Influ­ence

Global Health Summits

When con­sid­er­ing the poten­tial influ­ence of art exhibits on glob­al health sum­mits, it is crit­i­cal to observe that there is con­sid­er­able vari­a­tion in their nature, and, by exten­sion, their pol­i­cy influ­ence. For our pur­pos­es it is use­ful to dis­tin­guish between two kinds of sum­mits. On the one hand, there are what we might call “gen­er­al” sum­mits: meet­ings involv­ing heads of gov­ern­ment (e.g., G7/G20 sum­mits; APEC meet­ings) or health min­is­ters (e.g., World Health Assem­bly; G7 Health Min­is­ters). In these meet­ings, often involv­ing pres­i­dents and prime min­is­ters, health in gen­er­al and vac­ci­na­tion in par­tic­u­lar are two sub­jects among many. More­over, there is a chal­leng­ing process to get a giv­en issue on the agen­da. In con­trast, there are more “tech­ni­cal” sum­mits or meet­ings where the pri­ma­ry focus is some aspect of vac­ci­na­tion, or at least infec­tious dis­eases for which vac­cines are a key tool. Exam­ples here might include pledge meet­ings for the Glob­al Fund to Fight AIDS, Tuber­cu­lo­sis and Malar­ia or the World Health Assem­bly. At these meet­ings, the issue is not so much the rel­a­tive place of vac­cines and vac­ci­na­tion but instead more detailed ques­tions about vac­ci­na­tion pol­i­cy and pro­grams.

Linking Art, Influence and Summits

Gen­er­al­ly speak­ing, it seems to me that con­tem­pla­tive art is not like­ly to be par­tic­u­lar­ly influ­en­tial, at least in the short or even the medi­um term, sim­ply because it does not con­vey a par­tic­u­lar­ly clear or direc­tive mes­sage. While this kind of art is about get­ting us to think dif­fer­ent­ly about vac­cines and vac­ci­na­tion, the result is a some­what muf­fled or mud­died mes­sage that is less like­ly to be influ­en­tial, except inso­far as it puts vac­cines “on the map.” Con­verse­ly, in the longer term, it is pos­si­ble that the most pow­er­ful art is not clear or direc­tive but rather forces us to think, con­tem­plate, and see things dif­fer­ent­ly. More­over, in some cas­es, it may be that the long term can be mea­sured in months or just a few short years.

On the mat­ter of direct influ­ence, as out­lined in Fig­ure 5, there are a series of pos­si­ble sce­nar­ios for influ­ence giv­ing rise to a set of propo­si­tions:

  • The direct influ­ence of an art exhi­bi­tion on pol­i­cy mak­ing at a gen­er­al sum­mit involv­ing heads of gov­ern­ment or health min­is­ters is like­ly to be low, giv­en the sim­ple fact that they are unlike­ly to see the exhib­it and, in the case of G7, APEC, and oth­er sum­mits involv­ing heads of gov­ern­ment, the out­comes and deci­sions are large­ly decid­ed well in advance of the actu­al sum­mit.

  • At a more tech­ni­cal sum­mit involv­ing gov­ern­ment (and pos­si­ble NGO) rep­re­sen­ta­tives mak­ing pol­i­cy and pro­gram deci­sions about vac­ci­na­tion, the influ­ence of con­tem­pla­tive and pre­scrip­tive art will be low to mod­er­ate, and much will depend on the fit between the issues raised by the art exhib­it and the actu­al pol­i­cy and pro­gram issues under dis­cus­sion (i.e., no or lim­it­ed fit = lim­it­ed influ­ence).

  • At a tech­ni­cal sum­mit on, say vac­ci­na­tion, the influ­ence of pro­mo­tion­al art will be very low sim­ply because the par­tic­i­pants do not, by def­i­n­i­tion, need to be con­vinced of the mer­its of vac­cines, for that is why they are get­ting togeth­er.

    Type Direct Influ­ence Indi­rect Influ­ence    
      Gen­er­al Tech­ni­cal Gen­er­al Tech­ni­cal
    Con­tem­pla­tive Very low Mod­er­ate Low Low
    Pro­mo­tion­al Very low Very low Low Low
    Pre­scrip­tive Very low Low to mod­er­ate Mod­er­ate Low

Fig­ure 5: Cat­e­gories of Pol­i­cy-Relat­ed Art and Like­li­hood of Direct vs. Indi­rect Influ­ence

The indi­rect influ­ence of art on (glob­al vac­ci­na­tion) pol­i­cy is also going to be mod­est. At a tech­ni­cal sum­mit, the influ­ence of most types of art will be very low except in the rare case of high­ly pre­scrip­tive art (i.e., do this, now!). At a gen­er­al sum­mit of heads of gov­ern­ment or even health min­is­ters, the posi­tions they take will, at least to some extent, be the cul­mi­na­tion of a domes­tic (and glob­al) polit­i­cal process where the var­i­ous actors seek to set the agen­da and, in the case that con­cerns me here, try to put vac­cine-relat­ed issues on the agen­da with a spe­cif­ic set of ideas for action. In the­o­ry, a well-pub­li­cized art exhi­bi­tion or even an indi­vid­ual art­work could be influ­en­tial if it gal­va­nizes pub­lic opin­ion in a par­tic­u­lar direc­tion. In this sce­nario, pro­mo­tion­al art could be influ­en­tial because the first task is to estab­lish the rel­a­tive impor­tance of vac­ci­na­tion for heads of gov­ern­ment who have a myr­i­ad of oth­er issues to dis­cuss and a very crowd­ed agen­da. How­ev­er, pre­cise­ly because of this crowd­ed agen­da, the chances of suc­cess are there­fore much low­er.

To sum­ma­rize the argu­ment thus far, the influ­ence of art on glob­al vac­ci­na­tion pol­i­cy will be high­ly vari­able depend­ing on the type of art (con­tem­pla­tive, pro­mo­tion­al, or pre­scrip­tive) and the type of sum­mit (gen­er­al or tech­ni­cal). More­over, this influ­ence or poten­tial for influ­ence can be both direct—on the par­tic­i­pants at the summit—or indirect—via the gen­er­al pub­lic. On bal­ance, it would appear that, based on this analy­sis, the influ­ence of art on glob­al vac­ci­na­tion pol­i­cy will gen­er­al­ly be quite mod­est with per­haps two excep­tions. First, con­tem­pla­tive art designed to get us to look at issues dif­fer­ent­ly might have an impact at more tech­ni­cal, health-only glob­al sum­mits. Sec­ond, pro­mo­tion­al art mak­ing the case for quite spe­cif­ic poli­cies or pro­grams might have some mod­est, indi­rect influ­ence at gen­er­al sum­mits involv­ing heads of state and heads of gov­ern­ment if the art has been acces­si­ble to mul­ti­ple publics in a num­ber of influ­en­tial coun­tries over a mod­er­ate peri­od of time (or if the online pres­ence of the exhib­it has had some endur­ing effect). How­ev­er, as pre­sent­ed so far, the glob­al pol­i­cy-mak­ing process is rather lin­ear and straight­for­ward. Decades of research demon­strate that this is not, in fact, the case. Work on the­o­ries of pol­i­cy change and on social move­ments open up the pos­si­bil­i­ty of a more nuanced dis­cus­sion of how art might influ­ence glob­al vac­ci­na­tion pol­i­cy.

II—Lessons from Policy Theory

How does pub­lic pol­i­cy get decid­ed? Why do gov­ern­ments choose some poli­cies and not oth­ers? What explains the pol­i­cy choic­es made by gov­ern­ments act­ing alone or in con­cert with oth­er states on the glob­al stage? Both schol­ars and pol­i­cy prac­ti­tion­ers have debat­ed ques­tions like these, and many more besides, for decades. One of the results is a body of polit­i­cal sci­ence and inter­na­tion­al rela­tions the­o­ry that offers a vari­ety of dif­fer­ent expla­na­tions for dif­fer­ent kinds of deci­sions (for an intro­duc­tion, see Cair­ney, Under­stand­ing Pub­lic Pol­i­cy; Howlett et al.). Gen­er­al­ly speak­ing, the goal of such the­o­riz­ing is to offer expla­na­tions for pol­i­cy change or the lack there­of. Draw­ing selec­tive­ly on this research, in this sec­tion of the arti­cle I will argue, first, that pol­i­cy mak­ing is not a tech­ni­cal mat­ter alone, and that pol­i­tics are key to pol­i­cy and must be incor­po­rat­ed into the explana­to­ry mod­el (King­don; French). This most cer­tain­ly applies in the case of glob­al health pol­i­cy. Sec­ond, I will argue that in polit­i­cal deci­sion mak­ing, what mat­ters most is often less a case of prop­er empir­i­cal or sci­en­tif­ic evi­dence, but, rather, vary­ing sets of pow­er­ful ideas (K. Smith). Third, the vec­tor for ideas is often social move­ments. In pub­lic health, the case of HIV/AIDS is a pow­er­ful indi­ca­tion of this basic fact. In that case, what hap­pened in the ear­ly years of the response to HIV can­not be under­stood with­out at least some ref­er­ence to the pow­er­ful agen­da set­ting and pol­i­cy role of ACT UP and oth­er orga­ni­za­tions. Final­ly, I will argue that the key to social move­ments and their pol­i­cy influ­ence may be that they are not afraid to engage with pol­i­cy issues on an emo­tion­al lev­el (Orsi­ni and Kel­ly; Good­win et al.). And it is this last element—emotion—that cre­ates an open­ing for art to be influ­en­tial. Sim­ply put, art both express­es emo­tions and can elic­it a strong emo­tion­al response from those who engage with it. For this rea­son, artis­tic works about glob­al vac­ci­na­tion pol­i­cy could poten­tial­ly have a pow­er­ful agen­da-set­ting role.

On the Primacy of Politics in Policy Making

The last decade has seen a resur­gence of inter­est in the role of sci­en­tif­ic evi­dence in pol­i­cy mak­ing. An enor­mous lit­er­a­ture has devel­oped that tries to under­stand how, when, and why sci­en­tif­ic evi­dence is and is not influ­en­tial in pol­i­cy process­es (Oliv­er et al.; Parkhurst; Cair­ney, Pol­i­tics of Evi­dence-Based Pol­i­cy Mak­ing). How­ev­er, no mat­ter how effi­cient or effec­tive, there are lim­its to what can be accom­plished by way of knowl­edge trans­fer for pol­i­cy, which is to say get­ting the rel­e­vant sci­en­tif­ic evi­dence in the hands of those who shape and make deci­sions about pol­i­cy, in this case glob­al health pol­i­cy. For one thing, too often the focus on get­ting sci­en­tif­ic evi­dence to so-called pol­i­cy mak­ers assumes that the issue is a knowl­edge deficit or what Weiss has called the “enlight­en­ment” hypoth­e­sis. On this argu­ment, pol­i­cy mak­ers often do not know the rel­e­vant sci­ence, and if they did, they would decide dif­fer­ent­ly and act on the basis of sci­ence rather than “pol­i­tics” or “ide­ol­o­gy.” This claim is based on the erro­neous assump­tion that pol­i­cy mak­ing is an exer­cise in bound­ed ratio­nal­i­ty (Cair­ney, Pol­i­tics of Evi­dence-Based Pol­i­cy Mak­ing). In fact, pol­i­cy mak­ing is inher­ent­ly and appro­pri­ate­ly a polit­i­cal process, and polit­i­cal deci­sion mak­ing involves evi­dence, yes, but it also must grap­ple with a num­ber of oth­er con­sid­er­a­tions besides (Pielke Jr.; French).

One mod­el of the pol­i­cy-mak­ing process that gives pride of place to the role of some­thing called “pol­i­tics” is the so-called mul­ti­ple streams mod­el devel­oped by John W. King­don. Based on a care­ful analy­sis of pol­i­cy mak­ing at the nation­al lev­el in the Unit­ed States, Kingdon’s expla­na­tion of agen­da set­ting and pol­i­cy mak­ing focused on three cat­e­gories of inde­pen­dent (and inter­de­pen­dent) vari­ables that inter­act to pro­duce “win­dows of oppor­tu­ni­ty” for agen­da set­ting. These prob­lem, pol­i­cy, and polit­i­cal streams flow inde­pen­dent­ly along dif­fer­ent chan­nels and oper­ate more or less inde­pen­dent­ly of one anoth­er until, at a spe­cif­ic point in time, a pol­i­cy win­dow opens. Only then do the streams cross. The cre­ation of a pol­i­cy win­dow is the result of the influ­ence of “pol­i­cy entre­pre­neurs” and the pow­er­ful effect of unre­lat­ed focussing events (e.g., crises, acci­dents) or insti­tu­tion­al­ized events (e.g., elec­tions, bud­gets). The util­i­ty and applic­a­bil­i­ty of Kingdon’s mod­el has been much debat­ed (Béland; John; Zahari­adis; Jones et al.). Nev­er­the­less, the frame­work has been suc­cess­ful­ly used to explain agen­da set­ting and pol­i­cy change in a num­ber of coun­tries and pol­i­cy sec­tors, includ­ing pub­lic health (Mamudu et al.; Guld­brands­son and Fos­sum).

For our pur­pos­es, what mat­ters is the fun­da­men­tal obser­va­tion that some­thing called pol­i­tics is a pri­ma­ry influ­ence on pol­i­cy mak­ing, includ­ing glob­al health pol­i­cy. This opens up the pos­si­bil­i­ty that in this and oth­er pol­i­cy fields, the out­come is not the result of sim­ple gath­er­ing and appli­ca­tion of the best avail­able sci­en­tif­ic evi­dence. Trac­ing the pre­cise influ­ence of pol­i­tics on pol­i­cy mak­ing is an essen­tial part of explain­ing pol­i­cy change.

On the Primacy of Ideas

If pol­i­tics mat­ters to pol­i­cy mak­ing, then how? Part of the answer lies in the pow­er of a small num­ber of sim­ple ideas to gal­va­nize and ani­mate the pol­i­cy-mak­ing process. In her analy­sis of UK poli­cies for tobac­co con­trol and health inequal­i­ty, Kather­ine Smith shows how pub­lic pol­i­cy is dri­ven less by sci­en­tif­ic evi­dence and much more by research-based ideas. To do so, she sur­veys the polit­i­cal sci­ence lit­er­a­ture on the role of ideas in pol­i­cy mak­ing and then draws on an exten­sive body of qual­i­ta­tive evi­dence (i.e., 141 inter­views and an exten­sive analy­sis of doc­u­ments) to look more close­ly at the role of evi­dence and ideas in her two case stud­ies. In the case of tobac­co, she argues that rather than a sim­ple evi­dence mod­el, pol­i­cy change is best explained with ref­er­ence to how the tobac­co con­trol coali­tion suc­cess­ful­ly deployed a series of pol­i­cy frames that helped expand sup­port for spe­cif­ic pol­i­cy and pro­gram ini­tia­tives. In point of fact, tobac­co con­trol mea­sures were intro­duced before the research evi­dence was avail­able. Hav­ing made the case for the pri­ma­cy of ideas (rather than evi­dence), the three sub­se­quent chap­ters devel­op a sec­ond core argu­ment of the book—namely, that the rela­tion­ship between research and pol­i­cy is a “con­tin­u­al exchange and trans­la­tion of ideas” (K. Smith 75). She elab­o­rates this to sug­gest that there are four types of ideas: insti­tu­tion­al­ized, crit­i­cal, charis­mat­ic, and chameleon­ic.

In her schema, insti­tu­tion­al­ized ideas are those that have become “unchal­lenge­able” and embed­ded in pol­i­cy and dis­course. They enjoy the sta­tus of “facts” and are wide­ly accept­ed with­in the pol­i­cy net­work. In glob­al vac­ci­na­tion pol­i­cy cir­cles, an exam­ple of an insti­tu­tion­al­ized idea might be the mer­its of vac­ci­na­tion itself or, more specif­i­cal­ly, the idea that where pos­si­ble it is desir­able to com­plete­ly erad­i­cate a dis­ease and do for polio and guinea worm what we have done with small­pox.

In con­trast, Smith also under­scores the impor­tance of what she calls crit­i­cal and, much more rare, charis­mat­ic ideas. These ideas chal­lenge the sta­tus quo in dif­fer­ent ways and seek to usurp or at least under­mine insti­tu­tion­al­ized ideas. She argues that crit­i­cal ideas are often dis­missed by most actors as irra­tional, are not evi­dent in the main­stream media, and are unlike­ly to lead to sig­nif­i­cant change. In glob­al vac­ci­na­tion pol­i­cy, a crit­i­cal idea might be the notion that we should not, in fact, allo­cate lim­it­ed resources to erad­i­cat­ing a few dis­eases and instead real­lo­cate these funds to fight­ing more preva­lent com­mu­ni­ca­ble dis­eases (Tay­lor et al.). Con­verse­ly, a charis­mat­ic idea might be the notion that vac­cine hes­i­tan­cy (as dis­tinct from out­right denial of the ben­e­fits of vac­cines or exag­ger­a­tion of the risks) is a rea­son­able response by some par­ents who are under­stand­ably con­cerned about the effects of mul­ti­ple vac­ci­na­tions on their chil­dren (Lar­son et al.).

This is not the place to can­vas the range of ideas that ani­mate glob­al health pol­i­cy and the spe­cif­ic roles they play. How­ev­er, for the moment, it is impor­tant to acknowl­edge the poten­tial pow­er of some core ideas. How some ideas become insti­tu­tion­al­ized and oth­ers remain in the realm of crit­i­cal or charis­mat­ic ideas is a com­plex process. But one thing is clear­ly under­stood: in glob­al health, and indeed in many oth­er pol­i­cy fields, social move­ments have been a crit­i­cal vehi­cle for bring­ing new ideas to the fore and chal­leng­ing if not desta­bi­liz­ing estab­lished pol­i­cy net­works.

On the Primacy of Social Movements

So how do ideas have an impact on pol­i­cy mak­ing? Specif­i­cal­ly, how might key ideas around vac­ci­na­tion become influ­en­tial in the mak­ing of glob­al vac­ci­na­tion pol­i­cy? With­out a doubt, nation­al gov­ern­ments remain the most influ­en­tial actors involved in the mak­ing of the glob­al approach to using vac­cines to com­bat infec­tious dis­ease. The West­phalian sys­tem, while chal­lenged, is by no means dead. Thus, it is rea­son­able to expect that states will be one of the main vec­tors for main­tain­ing insti­tu­tion­al­ized ideas. Yet in pub­lic health, pri­vate foundations—the Rock­e­feller Foun­da­tion in the 20th cen­tu­ry, the Gates and Bloomberg foun­da­tions in the 21st century—are also pow­er­ful pol­i­cy play­ers both by virtue of the amounts of mon­ey they spend but also through their abil­i­ty to com­mand the atten­tion of pol­i­cy mak­ers (or, in the case of Bloomberg, become a pol­i­cy mak­er).

How­ev­er, as is the case in oth­er pol­i­cy domains, notably envi­ron­men­tal and social pol­i­cy, social move­ments have also become crit­i­cal­ly impor­tant play­ers in pub­lic health at all lev­els, but par­tic­u­lar­ly in the domain of glob­al pub­lic health. Again, space does not per­mit a full account of the pol­i­cy role of social move­ments (see Castells; M. Smith). How­ev­er, it is clear that local, nation­al, and glob­al social move­ments increas­ing­ly have a pow­er­ful impact on pub­lic health pol­i­cy in gen­er­al and vac­cine pol­i­cy in par­tic­u­lar. The best exam­ple of this is, of course, the glob­al HIV/AIDS move­ment (Boyd; Gould). This and oth­er “embod­ied social move­ments” focussing on health con­cerns (Brown et al.) have become impor­tant play­ers in their own right when it comes to the devel­op­ment, and in some cas­es, the imple­men­ta­tion of health pol­i­cy at all lev­els.

The Role of Emotion and Emotion as a Vector for the Influence of Art

The pol­i­cy impact of social move­ments rests in part on their abil­i­ty to gal­va­nize pub­lic opin­ion by encour­ag­ing strong, emo­tion­al reac­tions to crit­i­cal issues. The whole point of some social move­ment protest is to encour­age a strong emo­tion­al engage­ment, often one based on anger (if not out­right rage). Oth­er social move­ments encour­age oth­er forms of emo­tion­al engage­ment, focussing in some cas­es on com­pas­sion (e.g., for the less for­tu­nate; or in the case of the ani­mal rights move­ment, for pets and oth­er domes­ti­cat­ed ani­mals), in oth­er cas­es guilt, and in still oth­er cas­es hope. Many seek to elic­it mul­ti­ple types of emo­tion­al engage­ment from a wide range of peo­ple.

This engage­ment with emo­tion has been, tra­di­tion­al­ly, what dis­tin­guish­es social move­ments from oth­er, more sober and ratio­nal pol­i­cy actors who tend to priv­i­lege sci­en­tif­ic or legal argu­ments and do not, at least on the sur­face, appear to be engag­ing in emo­tion­al appeals. How­ev­er, there are rea­sons to ques­tion the con­ven­tion­al dichoto­my between, on the one hand, the calm, ratio­nal, ordered pol­i­cy dis­cus­sion of insid­ers and tra­di­tion­al inter­est groups and, on the oth­er hand, the emo­tion­al engage­ment of some indi­vid­u­als and some social move­ments. As Orsi­ni and Kel­ly put it, “There is ample sup­port for chal­leng­ing the imag­ined dis­tinc­tion between a world of art and emo­tion from the worlds of pol­i­tics and tan­gi­ble action. But this only holds if we accept that emo­tion and pol­i­tics are dis­crete con­cerns” (22–23). They and oth­ers seek to chal­lenge the sep­a­ra­tion of rea­son from emo­tion and the claim that art and rad­i­cal activism are moti­vat­ed by irra­tional emo­tion­al respons­es (Orsi­ni and Kel­ly; see also Gould; Good­win et al.). On this view there is mer­it in focussing on “the pro­duc­tive ten­sions that might emerge when we merge the artis­tic with the polit­i­cal” (Orsi­ni and Kel­ly 26).

Sim­i­lar­ly, those who focus on the so-called pol­i­cy mak­ers are increas­ing­ly being enjoined to engage with the prac­ti­cal real­i­ty that pol­i­cy mak­ing is not, and has nev­er been, a total­ly cool, ordered, and ratio­nal process (as much as the pro­po­nents of evi­dence-based pol­i­cy might want it to be so). As Cair­ney et al. put it,

pol­i­cy mak­ers do not have the abil­i­ty to con­sid­er all evi­dence rel­e­vant to pol­i­cy prob­lems. Instead, they employ two short­cuts: “ratio­nal,” by pur­su­ing clear goals and pri­or­i­tiz­ing cer­tain kinds and sources of infor­ma­tion, and “irra­tional,” by draw­ing on emo­tions, gut feel­ings, deeply held beliefs, and habits to make deci­sions quick­ly.” (Cair­ney et al., empha­sis added)

In oth­er words, deci­sions about pub­lic pol­i­cy, and, in the case that con­cerns us, glob­al health pol­i­cy, are the result of a process in which those with the pow­er to influ­ence, if not actu­al­ly make, more and less bind­ing pol­i­cy choic­es do so on the basis of things oth­er than the evi­dence. Pol­i­cy mak­ing, then, is a process that often requires a nor­ma­tive if not an emo­tion­al engage­ment with the issues at hand.

It is pre­cise­ly this nor­ma­tive and some­times emo­tion­al dimen­sion of pol­i­cy mak­ing that cre­ates an open­ing for artis­tic works of all kinds to be influ­en­tial, or at least have the poten­tial to be influ­en­tial. To the extent that an art exhib­it, a piece of music, a nov­el, or a play elic­its an emo­tion­al reac­tion from those who engage with it, this same reac­tion cre­ates the pos­si­bil­i­ty of gal­va­niz­ing indi­vid­ual and/or mass opin­ion in sup­port of pol­i­cy change. In the spe­cif­ic case of glob­al health, and more specif­i­cal­ly vac­ci­na­tion pol­i­cy, the sim­ple fact that mil­lions of chil­dren around the world are unable to gain access to the vac­ci­na­tions they need to pre­vent ill­ness is a real­i­ty that, ampli­fied and strength­ened by a giv­en art­work, could gen­er­ate a strong emo­tion­al response of frus­tra­tion if not anger.

This influ­ence can, once again, be direct or indi­rect. If this art were, for exam­ple, part of an art exhib­it on the mar­gins of a gen­er­al inter­na­tion­al health sum­mit, it is pos­si­ble to imag­ine it encour­ag­ing heads of gov­ern­ment or min­is­ters of health (either direct­ly or via their close advi­sors) to focus all the more on vac­cines and vac­ci­na­tion and pos­si­bly allo­cate more resources than they might have oth­er­wise. Con­verse­ly, and arguably more like­ly, an art exhib­it that was open to the pub­lic over a long peri­od of time and per­haps in more than one loca­tion could, under the right cir­cum­stances, gal­va­nize pub­lic opin­ion and in turn gen­er­ate pres­sure on nation­al gov­ern­ments to take action. Whether and to what extent this would have a real effect on glob­al vac­ci­na­tion pol­i­cy is hard­er to dis­cern. Much would depend on whether mass publics in more than one coun­try were touched by the art­work and how the result­ing pub­lic pres­sure was man­aged by gov­ern­ments.

Of Art and Social Movements

The pro­vi­sion­al con­clu­sion that this frame­work advances is that art, broad­ly defined, can influ­ence deci­sion mak­ing about vac­cines and vac­ci­na­tion at glob­al sum­mits. That said, the influ­ence of art on glob­al vac­ci­na­tion pol­i­cy will be high­ly vari­able depend­ing on the type of art (con­tem­pla­tive, pro­mo­tion­al, or pre­scrip­tive) and the type of sum­mit (gen­er­al or tech­ni­cal). What is more, pol­i­cy mak­ing is not, and has nev­er been, a par­tic­u­lar­ly ratio­nal process; it is, instead, a polit­i­cal process. And in some kinds of pol­i­tics, includ­ing health pol­i­cy, what mat­ters is less sci­en­tif­ic evi­dence per se and much more ideas, social move­ments, and emo­tion. In gen­er­al, to the extent that an artis­tic work can engen­der an emo­tion­al response from those who engage with it, the more like­ly that that work will have some influ­ence on pol­i­cy. How­ev­er, it is rare that this influ­ence will be direct (e.g., at a sum­mit) and is more like­ly to be indi­rect via pub­lic opin­ion which, as we all know, can be quite volatile and sub­ject to change quite quick­ly based on small (and in some cas­es quite irra­tional) inci­dents or events.

How­ev­er, and this is a crit­i­cal issue, it is high­ly unlike­ly that sup­port for vac­cines and vac­ci­na­tion are some­thing around which a pos­i­tive social move­ment is going to be cre­at­ed or for which an emo­tion­al engage­ment can be gen­er­at­ed. Of course, there is a loose­ly orga­nized move­ment of peo­ple who are res­olute­ly opposed to vac­ci­na­tion based on dis­cred­it­ed claims that vac­cines cause autism and have oth­er major neg­a­tive health effects.1 A larg­er and much less orga­nized group of cit­i­zens in sev­er­al coun­tries are unsure about spe­cif­ic aspects of vaccination—for exam­ple, the vac­ci­na­tion sched­ule for chil­dren (Mac­don­ald). These are, to some extent, emo­tion­al respons­es, but ones root­ed in a neg­a­tive, or at least a skep­ti­cal view of vac­ci­na­tion.

The claim being made here is that the more pos­i­tive view of vac­cines is unlike­ly to be the basis of a social move­ment. Vac­cines are a tool to pro­tect peo­ple from infec­tious dis­eases and, in some cas­es, to erad­i­cate dis­eases alto­geth­er. For the vast major­i­ty of peo­ple, large­ly uncon­cerned about vac­ci­na­tion, they are a use­ful but uncon­tro­ver­sial part of the health care sys­tem. For the strong major­i­ty who under­stand the role and effec­tive­ness of vac­cines, they are not a mat­ter for con­cern and do not elic­it a strong emo­tion­al response. Con­verse­ly, the dis­eases that vac­cines are meant to pre­vent are more like­ly to gen­er­ate an emo­tion­al response. Thus, what is like­ly, and, indeed, is the case, are social move­ments orga­nized around spe­cif­ic vac­cine-pre­ventable dis­eases. Ear­li­er ref­er­ences were made to ACT UP, the move­ment cre­at­ed to fos­ter action on HIV/AIDS.2 Today, there are sev­er­al more, includ­ing social move­ments aimed at address­ing the chal­lenges of dengue fever and malar­ia (Turn­er and Robin­son). The pain and suf­fer­ing and death asso­ci­at­ed with these and oth­er dis­eases are more like­ly to be at the heart of a social move­ment. The tools to address those dis­eases, includ­ing but by no means lim­it­ed to vac­cines, are less like­ly to fos­ter the ener­gy and com­mit­ment required for a social move­ment to be sus­tain­able and suc­cess­ful.

What then of the role of art, and by exten­sion artists, in influ­enc­ing glob­al vac­ci­na­tion pol­i­cy? This role is like­ly going to be mod­est. While direct influ­ence on world lead­ers at a glob­al sum­mit is too much to expect of an indi­vid­ual work of art, there is a role for artis­tic cre­ation in the mak­ing of glob­al health pol­i­cy if linked to larg­er social move­ments.

Acknowledgements

Patrick Fafard would like to acknowl­edge the sup­port of the Uni­ver­si­ty of Ottawa, his friends and col­leagues in the Glob­al Strat­e­gy Lab, the Vac­cine project con­sor­tium, and espe­cial­ly Steven Hoff­man who invit­ed him to be part of this most inter­est­ing exper­i­ment.

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Image Notes

Fig­ure 1: Cat­e­gories of Pol­i­cy-Relat­ed Art

Fig­ure 2: Direct and Indi­rect Influ­ence of Art on Glob­al Vac­ci­na­tion Pol­i­cy.

Fig­ure 3: Kei­th Har­ing, Igno­rance = Fear / Silence = Death, off­set lith­o­graph, 61.1 × 109.4 cm, 1989 © Kei­th Har­ing Foun­da­tion.

Fig­ure 4: Nature of the Exhib­it and Poten­tial Pol­i­cy Influ­ence

Fig­ure 5: Cat­e­gories of Pol­i­cy-Relat­ed Art and Like­li­hood of Direct vs. Indi­rect Influ­ence

Notes


  1. Editor’s note: For more on this issue, see the dia­logue between Sean Caulfield, Tim­o­thy Caulfield, and Johan Holst, “Dis­cussing The Anato­my Table and The Vac­ci­na­tion Pic­ture,” in this vol­ume.

  2. Editor’s note: See also Hoff­man et al., “The Role of Art in Polit­i­cal Advo­ca­cy on HIV/AIDS,” in this vol­ume.