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As efforts proliferate to adjust to healthcare reform legislation, many new ideas emerge about how to finance change, collect and share better data, change clinical practices, retool our healthcare workforce, and sharpen our collective focus on the social determinants of health. While many of these ideas hold merit, they don’t have the vital, subversive energy needed for significant and lasting reform because they are undergirded by some unchecked assumptions that impede transformation. Look in the mirror and consider these:

Myth: Complex, systemic change is driven by agencies and professionals. Imagine if healthy community partnerships were dominated by patients, parents, youth, caregivers, coaches, teachers, elders, parishioners and volunteers.  What new ideas and demands would be advanced? What benefits would emerge from investing much more heavily in community organizing and grassroots activism and leadership?

Myth: Effective advocacy emerges from skilled assessment and picking the right strategies.  Imagine if, instead of following brokers of information and knowledge, we supported quick, grassroots action on an urgent social determinant of health that aroused the passions of each community. What might some focused chaos unearth, inspire or unleash? And what might we all discover and learn in such a context?

Myth: Tools of control create accountability and results. Imagine if people directly affected by health disparities were organized and demanding accountability. What if they initiated action and gave professionals small subcontracts to support their efforts instead of the other way around? How might that breathe new life and urgency into our timelines, workplans, MOUs, progress reports and evaluations?

Myth: Change is fueled by money and those who control it. Imagine if we understood the primary fuel for lasting change as the energy and organized action of rightly aggrieved people making demands of our failing system? How would money flow and whom would benefit then?

Myth: Power will advance equity without a demand. Imagine if we replaced the polite, technocratic suggestions of the professional classes with the sharp, hot demands of organized and angry citizens and consumers at the bottom of the socioeconomic spectrum? What if those who are running our failing systems were less comfortable and forced into survival mode? Might they become more passionate and vocal advocates and allies for social justice and community prevention?

These imaginings may sound crazy, but look at the crazy we already seem to accept. We expect health care executives to preside over the shrinking of their own revenue, and service providers to advocate for solutions that make them less relevant. We exhort busy clinicians to become public health activists and public officials to take risks for those who often don’t show up to vote. We accept all this more easily because at least these approaches keep us (i.e. the professional middle class) as the drivers of the change.

We live during an exciting (and scary) time of accelerating change, but there is a brake holding back our efforts to advance health equity. It’s the energy and action gap in the public sphere!

Very rarely does the energy behind this work originate where problems are most keenly felt. Instead, those who together could be driving and shaping change remain isolated and often frustrated, spending their energy adapting, triaging, defending, accepting and/or applying band-aid solutions to survive.  If we’re interested in equity and culture change, why don’t we invest more in their collective encouragement, education, organization, skill development and networks? I’m afraid the reason says much more about us than it does them. In any case, we’re going to fall short until “us and them” becomes “we”!

A long track record of carefully managed incrementalism has left us with growing social and health inequality.  Instead of doubling down on our own perceptions and best intentions, we should recall the rich history of social change and invest in a broader, more subversive and potent grassroots approach.

Once we have a true movement with an inexorable set of demands, only then will the good ideas and competent work of reformers be efficacious.