Health researchers in a number of settings are expressing concern about the 'gap' between what we 'know' about the social determinants of health and of health inequalities, and the lack of action based upon this 'knowledge'. Indeed, the 'know-do gap' has become almost a mantra echoed across international and some national institutional sites. This paper examines how the 'problem' of the 'gap' is understood and represented in dominant and sub-dominant conceptualisations. It highlights what is missing from these representations: adequate reflection on changing modes of governance of research management. Where once there was a degree of separation between research production and government policy, increasingly there is congruence between these governmental functions. This congruence means that the problem we face today is not a 'gap' but rather a 'fit' between what we 'know' and what we (don't) do regarding SDH. Social determinants
Received 27 August 2007 Accepted 5 March 2008
Social determinants of health, research utilisation, health services research, governance, knowledge production, priority setting, sociology
The scientist is called upon to contribute information useful to implement a given policy, but the policy itself is 'given', not open to question So long as the social scientist continues to accept a role in which he (sic) does not question policies, state problems, and formulate alternatives, the more does he (sic) become routinised in the role of bureaucratic technician
(Merton and Lerner 1951:306).
Concern about the 'gap' between what we 'know' and what we do about the social determinants of health (SDH) and of health inequalities is widespread and growing. Importantly, this concern is being expressed in two quite different conversations. One is a conversation of some longevity and with significant institutional endorsement, which I refer to as the dominant conversation (see WHO 2005). The aim in this conversation about what is called the 'know-do gap' is to determine 'how knowledge can more effectively be transformed into action', how to increase the 'uptake' of 'evidence' in public policy (ARACY 1995). The second conversation, positioned somewhat at the margins of the first, wants to tackle the perceived lack of government responsiveness to SDH. The concern in this subdominant conversation is the apparent 'lack of will' (Harvey 2006) of those with institutional authority to implement SDH insights and their possible ideological aversion to those insights (Raphael 2005; see also Bambra et al 2005).
This paper examines how the 'problem' of the 'gap' is understood and represented in these two conversations, with a predominant focus on the dominant, institutionally endorsed conversation. It highlights a key silence in both conversations: inadequate reflection on changing modes of governance of research ('knowledge') management. Where once there was a degree of separation between research production and government policy, it argues, increasingly there is congruence between these governmental functions, reflected in the recent endorsement of 'user-driven research' both overseas and in South Australia, with 'users' identified as policy-makers and administrators. This congruence means that the challenge faced by those committed to addressing SDH is not a 'gap' but rather a 'fit' between what we 'know' and what we do. That is, increasingly researchers are 'rewarded' (funded and promoted) for producing research that supports the priorities of governing bodies intent on preserving social cohesion and stability. Hence, it is unsurprising that the deep, structural changes required to address SDH and the reproduction of health inequalities do not occur.
In terms of the theme of this special issue of HSR therefore, my concern is not the preventive paradigm per se. I am not asking how 'prevention' could be thought about differently or better, nor indeed am I putting into question the understanding of health within the preventive paradigm. …