Book Review - Healthy Voices, Unhealthy Silence: Advocacy and Health Policy for the Poor

July-August 2008


Georgetown University Press, Washington, D.C., 2007, 170 pp., $24.95 (paperback) www.press.georgetown.edu

The title of this book aptly captures the notion that silence rarely serves to advance the interests of the poor. What are the reasons the poor often do not have a voice? Why in a nation where public debate is a common occurrence do the benefits of deliberation often fail to meet the needs of the underserved?

These questions were posed and studied by the authors during the implementation of Medicaid Managed Care (MMC) in Connecticut. In 1994, Connecticut's Department of Social Services started planning for MMC. Throughout the long and complex effort to start this program, a persistent and troubling theme remained: the people's choice to not publicly raise or discuss an issue they cared about.

In preparation for writing this book, the authors attended 67 public meetings during an 18-month period. These meetings included MMC council meetings, monthly subcommittee meetings and monthly children's health council meetings. It was at subcommittee meetings that an open forum prevailed, allowing participants to ask questions and speak freely. Observations of meeting behavior were carefully gathered by the authors. These observations were then balanced by 100 private interviews with individuals that attended the meetings. The purpose in conducting the interviews was to understand why certain issues were raised in public conversation and others were not; and, to examine the extent to which interviewees' private concerns matched their public expression.

It was learned that a huge problem observed with MMC was access to mainstream providers. Although the number of providers was frequently generous, actual access to them was extremely limited. It was found that participants that cared about equal access chose not to discuss the topic in public because they felt they lacked political power. However, in the private interviews, 62 percent mentioned it as an important topic.

Another question discussed was the role of advisory boards. Are they an artificial or genuine environment for public discussion? It is estimated that only 1 percent of the poor serve in any type of advisory capacity. When they do attend meetings, they are too intimidated to speak or represent their own concerns. The poor and minority groups are also significantly underrepresented in the U.S. political system including the fact that proportionally fewer poor people vote, thus losing another opportunity for voice.

A related issue noted by the authors is that advocates for the poor also have issues with speaking out. For instance, regarding the tricky issues related to equal access, it was found that open discussion of the topic led to apprehension about offending colleagues in a public forum. Thus, the advocates themselves frequently remained silent.

Although public discussion does not necessarily result in particular policy outcomes or social benefits, it does offer the following benefits:

1) a greater understanding and more tolerance for opposing views.
2) a public-spirited way of thinking about social problems.
3) increased clarification and refinement of participant's positions on issues.
4) learning about the consequences of implemented policies and the reasons for past failures.
5) decisions emerging from an open and inclusive deliberative process.

This book is essentially a study of public discourse, specifically the discussion that emerges out of public meetings. It has much to offer to people, who believe that the encouragement of public voice, especially about issues of concern, is necessary for a healthy democracy. Although the authors offer no real solution to the problem of unhealthy silence, this engaging book provides a heightened awareness that we must find a means to give voice to the powerless, and to learn to speak and listen to the language of the poor.

Sr. Ritamary Brown, OSF, FACHE
Senior Advisor, Community Benefit and Public Policy Support
Hospital Sisters Health System
Springfield, Ill


Copyright © 2008 by the Catholic Health Association of the United States.
For reprint permission, contact Betty Crosby or call (314) 253-3477.

Book Review - Healthy Voices, Unhealthy Silence - Advocacy and Health Policy for the Poor

Copyright © 2008 by the Catholic Health Association of the United States

For reprint permission, contact Betty Crosby or call (314) 253-3490.