Power as an explanation for cancer disparities: a commentary on Krieger et al.

Last year, the Journal solicited manuscripts for a special issue on social determinants of cancer care delivery.1 Given the credence of social determinants,2,3 the Journal particularly encouraged submissions that advance the field beyond disparity reports. Per previous exhortation,4 editors encouraged scholarship describing patient-centered attempts to mitigate disparities. Our Journal predicated our aspirations on previously funded research exploring intervention on select patient-level determinants (eg, transportation barriers), but opportunities remain to address community-level social risks, food insecurity, and housing instability.5 Likewise, our Journal, as our field, remains challenged to increase the volume of reports explicitly testing disparity interventions. The disproportionate volume of disparity reports vis a vis intervention encourages further explanation. Is it possible that cancer care practitioners lack the training or resource awareness necessary to optimize where individuals with cancer work, live, and play?6 Indeed, cancer care delivery research requires a potentially rare constitution of transdisciplinary expertise in multilevel inquiry.7-10 Cancer centers may variably employ or affiliate with scholars who possess necessary competencies,11,12 evidence funding challenges, or exhibit suboptimal tolerance for the perceived care disruption some intervention research produces.13 These real and pressing challenges may partially explain the comparative dearth of disparities in intervention research. More provocatively, is it possible that intervention implementation and reporting compels us to confront latent and disconcerting considerations? Many in our field concede that a “system is perfectly [and intentionally14] designed to get exactly the results it gets” (p. 1060).15 Are we loathe to consider the status quo as an intentional rather than a random circumstance? Why do our multilevel considerations often fail to explicitly consider the state and national policy environment Taplin and colleagues8 encouraged years ago? Might we harbor an ambivalence to scrutinizing policy lest we discover that policy is a symptom of a more intractable prerequisite? In this issue of the Journal, Krieger et al.16 explore the relationship between political conservatism and both regional and distant stage at cancer diagnosis. Krieger and colleagues conclude that political metrics are associated with preventable cancer outcomes. Partisanship aside, Krieger et al. probe beyond the typical surface, albeit necessary, service and resources deliberations. They “name” the presumed kernel driving wellness circumstance, and their exposition motivates our field to critically consider—nay, “admit”—the unspoken: power,17 or one empowered, determines, in many instances, who suffers from cancer or benefits from treatment. Per Topp et al.,17 power is the ability or capacity to do something or act in a particular way and direct or influence the behavior of others or the course of events. Krieger et al.’s analysis suggests increasing measures of state-level conservatism, in terms of both representation and policy, is associated with worse cancer outcomes, as measured by advanced cancer stage at diagnosis for screening-amenable cancers and premature cancer mortality. These results suggest that policy decisions more than genetic predisposition drive cancer prevalence and care outcomes (particularly for less resourced groups). The analyses remind us that supra-clinical circumstances are no less impactful to cancer care delivery. Such a reminder may encourage our field to think more broadly about the social responsibility of our clinical enterprise.18 How might we entertain an expanded perspective on cancer care delivery research and practice? Krieger’s earlier work articulated an ecosocial approach to discrimination and health.19 This approach contends that “[e]xplanations of disease distribution cannot be reduced solely to explanations of disease mechanism because the latter do not account for why rates and patters change, in complex ways, over time and place” (p. 937).19 More pointedly, the ecosocial approach reflects on societies characterized by a smaller percentage of the population possessing the majority of power and resources. Under this condition, the ecosocial perspective contends that societies exhibiting social divisions based on property and power will evidence a greater disease burden on individuals with less power and fewer resources because they constitute the majority of the population. This approach—and Krieger et al.’s findings, presented in this issue—encourage our field to more explicitly deliberate 3 empirical sites of power in health policy and systems17: (1) actor relationship and networks (ie, the values, intentions, and relationships of human and organizational actors within them), (2) sources of power (ie, considering how actors draw on power from particular sources and “[surface] the institutions, organizations and attributes that provide a fountainhead of power” [p. 3]), and (3) societal flows and expressions of power (ie, “how power is expressed, leveraged and experienced to impact health policy and systems” [p.3]). The health service research domain increasingly attends to the import of policy relative to health status and intervention implementation.20 Health service research (cancer care delivery research, specifically), however, may benefit from a more explicit consideration of the power behind the policy. The findings of Krieger et al.16 align with other observations.21 These insights underscore previous admonitions22 to exercise our franchise; each vote is a first step toward informing power structure and its activities. Yet, Kreiger et al. temper expectations regarding optimal impact: “Reliance on voter political lean is insufficient, since its impact is distorted by legislative determination of political district boundaries, with evidence indicating that gerrymandering (ie, the redrawing of district boundaries to concentrate the vote of desired voters and dilute the vote of disfavored votes) can shape the lean of the districts’ voters and amplify election of politicians with more extreme political ideologies.” Thus, a single or collective vote may fail to achieve desired outcomes. The findings of Krieger et al.16 encourage multilevel interventions to eliminate care disparities. These interventions also require us to critically consider the power necessary for equitable intervention design and implementation. Per Stanton et al.,23 interventionists may particularly consider 3 attributes of power in intervention design. Discursive power illustrates how dominant perspectives ascend to their position as reality and shape others’ actions and capabilities. Epistemic power is the ability to assert one’s knowledge as integral to a collective set of beliefs or truths (and the definition of evidence). Material power refers to the control over and distribution of critical resources. We contend that sound intervention development, implementation, and reporting require explicit and transparent examination of each power manifestation. It is possible that our field lacks the collective awareness and subsequent reckoning with power differentials, which explains our collective inability to bridge the “disparity discovery to intervention” gap. Considering power and its attributes may help our field develop a “resistance consciousness”14 necessary to disrupt the existing power structure and eliminate health disparities. The work of Krieger et al.16 aligns with this Journal’s commitment to the “intellectual bravery” required to push the boundaries of possibility.24 Kreiger et al.’s work calls attention to existing administrations potentially compromising a fair and just opportunity for everybody to achieve their highest level of health. Perhaps more important, their work encourages each of us to stretch beyond the necessary but comfortable surface considerations (eg, screening methodologies and workforce education). Rather, Krieger et al.16 encourage us to critique our own complicity (and investment) in the existing power structure. We—individually and as a field—should search our hearts and minds to uncover the biases, fears, privileges, and threats compelling either our acquiescence or commitment to the status quo. Kreiger et al. hold a mirror to us and solicit our commitment to the action that produces change. The first step toward the intentional acts necessary to dismantle (or preserve) the status quo requires awareness and willingness to assume individual and collective responsibility for the existing power structure. We hope that your review encourages both personal and collective deliberations of the perspectives shared here and in Krieger et al.16 Matthew F. Hudson, (Conceptualization; Writing—original draft; Writing—review & editing) and James B. Yu (Writing—review & editing) No funding was used for this editorial. The authors have no disclosures. Matthew F. Hudson is a deputy editor in chief of JNCI Cancer Spectrum. James B. Yu is editor in chief of JNCI Cancer Spectrum. Neither was involved in the editorial review of the manuscript or decision to publish the editorial. No new data were generated or analyzed for this editorial.