This blog post was originally published on the BMSG website.
What makes some health policies feel controversial while others are embraced as common sense? It’s not the data — it’s the narrative. Strong public health narratives are why people today overwhelmingly accept drunk-driving laws or tobacco regulations that keep airplanes, restaurants, and other common spaces smoke-free. But those policies — and the narratives surrounding them — were not always popular. It took decades of advocacy and coordinated efforts across institutions and sectors to shift people’s beliefs about health from one of personal choice to one of shared responsibility. Now, the freedom to travel safely and breathe clean air is the norm.
We can similarly change the narrative around other public health issues like racial equity, health care access, and housing security by applying lessons from previous public health battles and working strategically to create strong coalitions across institutions, organizations, and media. This form of power is known as narrative infrastructure, and it’s the basis for a recent perspective by BMSG Director Lori Dorfman and co-authors Sarah Gollust, Makani Thema, Pritpal S. Tamber, and Anthony Iton. The perspective, published last month in Milbank Quarterly, discusses how tactics from community organizing can help shift the public’s values and beliefs to better support policies that improve health.
To learn more about narrative power and why public health needs an infrastructure to build it, I sat down with Gollust, Professor of Health Policy and Management at the University of Minnesota School of Public Health.
Q&A
Responses have been lightly edited for length and clarity.
Could you tell me a little bit about what you do, your background, and what brought you to this work?
The predominant role I have in research is as one of the co-directors of the Collaborative on Media and Messaging for Health and Social Policy, an interdisciplinary research group based at the University of Minnesota, Wesleyan University, and Cornell University, which seeks to do responsive communication research around health equity and social policy. That’s been a major part of my research over the last three years, although I’ve been researching the intersection of health communication and health policy for well over 15 years.
My academic training is in health policy, but communication has long been a core interest of mine — specifically, understanding the role of communication in shaping health policy and politics. I’ve always been really interested in understanding how messages in the media shape the public’s attitudes about health policy, and, consequently, how the public’s opinion shapes political possibilities for systems and policy change. In my academic training, I’ve been really steeped in the fields of health policy and health communication, and the subfield of political communication within political science. I’m a relative newcomer to community organizing — that’s really where the ideas of narrative power that shaped this article come from. I recently became engaged in learning about community organizing as a field of practice when I started attending organizing trainings. I then started a partnership with Center for Health Progress, a community organizing nonprofit in Colorado, to do a community-based participatory research project with them. It was then, through my own education and training, and this research partnership, that I became much more open to the ideas from community organizing — particularly, how the ideas of power and narrative that stem from community organizing practice, rather than traditional academic health communication, can provide a really important complementary understanding of how communication shapes politics.
The perspective emphasizes the importance of narrative power. Can you explain what that means in the context of public health? How is narrative power different from a strong message?
Narrative power is the idea that those who hold sway over the stories we tell about how the world works hold power. For example, the idea that we’re personally responsible for our health or that we deserve health care when we work hard are the narratives that we call dominant narratives. Dominant narratives are a form of power because they shape what policies and politics are possible.
As a concrete example, we know that in 2025, work requirements for Medicaid have been passed at the federal level. One of the reasons that the policy is politically possible and viewed as common sense is because of the widespread dominant narrative that links health care with hard work and deservingness. Without that narrative, it might not make sense to condition health insurance on work. This deep-seated narrative about what it means to be hardworking — and that when you’re hardworking, you deserve what comes to you — allows that policy to exist.
The reason it’s different from a powerful message or persuasive message is because these fundamental narratives about deservingness are held up across so many different areas in society: In law, in schools, in popular culture, in the news media, in political speech. While we definitely need all the persuasive messages we can to shift public understanding about health and health care — those are necessary — they’re not sufficient to change the overall big picture, the big narrative about how we understand health and wellbeing.
You and your co-authors argue that public health needs something called narrative infrastructure. What does this infrastructure entail, and how does it support movement-building?
If we’re to make narratives that support health equity the common-sense narratives, then these stories have to be sustained across many different arenas of meaning-making — not just within a narrow public health understanding. In the paper, we define narrative infrastructure as the set of institutions, actors, organizational networks, and systems of cultural meaning-making that build and maintain the narratives that we use to make sense of the world. So it’s really, really broad. Thinking about changing narratives and changing policies and systems requires us to think really big and think beyond public health as one sector. One thing I really enjoyed about working on this article was learning more about Lori’s extensive experience in tobacco control that informed our understanding of narrative power and narrative infrastructure. One of the key messages of the article is that changing narratives is absolutely possible when you have the right infrastructure in place.
If we think back to the middle of the 20th century, the dominant narrative about smoking tobacco was that it was a choice. It was even fashionable; it was normative. Everyone did it. By the end of the 20th century, the dominant narrative of smoking became that it is a health hazard. It is bad for you, and government and society all have responsibilities to address smoking and reduce the prevalence of smoking. It was a light-bulb moment while working on this paper to realize that the shift of the dominant narrative of smoking as a personal choice to one of a collective health hazard was a really, really giant narrative shift. We take it for granted now, and that is the point of narrative power: When an idea becomes this sort of common-sense, unquestioned thing, like tobacco being a health hazard, that signifies that a narrative shift has happened. And it wasn’t an accident. It happened because of a lot of synergistic work across various sectors of society.
How, exactly, did this narrative change happen, and what can we learn from efforts to shift mindsets on smoking cessation and the tobacco industry?
What we can learn from that history is to remember all the different inputs and all the different components that had to be aligned for this shift to happen. We itemized them in the paper. The body of scientific research documenting the health harms of smoking and the harms of secondhand and thirdhand smoke was very important. Then, there was money. So much money was invested into funding that science in the federal NIH budget, and public dollars were collected through excise taxes on cigarettes. There were huge investments by philanthropy, and charitable and advocacy organizations like the American Cancer Society or the American Heart Association. There was litigation and regulation, like marketing restrictions, taxes on cigarettes, clean indoor laws, no-smoking sections, and then, finally, no smoking indoors generally, which created this huge societal shift.
There was organizing to build that legal infrastructure and then diffuse it across states. Relationships, coalitions, and networks were built and sustained to do this advocacy and education. As a health communication scholar, I would have first thought about public service announcements. That traditional public health communication played a role, but there was also all of this other infrastructure. Within the communication space, there were working strategic relationships with Hollywood to change how pop culture depicted smoking. All of these things add up to show how society began to and, ultimately, did change the meaning of smoking. The case reinforces that it wasn’t just a compelling message; it wasn’t just saying that smoking is bad for health, it was this aggregation and coordination across different components of the narrative infrastructure that ultimately made the difference.
The perspective notes that narrative change is necessary to address other public health issues like structural racism. Isn’t it more complicated to address problematic narratives surrounding racism than those surrounding a specific product?
It’s absolutely more complicated to address narratives about structural racism, in part because the dominant narrative that needs to change — the idea of a racial hierarchy — is even more deeply, historically entrenched in the fabric of U.S. history and society. So, like tobacco control, the idea that racism is a hazard to health has to confront the idea that health is mainly an issue of personal responsibility, but that’s just one aspect of it. The narrative of structural racism linked to health tells us that health is the consequence not only of personal choices, but also of the structures and environments that often advantage some people and disadvantage others because of their race. The narrative of racism as a public health crisis began to emerge with a lot of momentum in 2020, during the uprisings for racial justice, and offers lessons that we document in the paper about how this emergent narrative infrastructure could be sustained.
In the paper, we discuss how, during COVID-19, it was really clear how environments shape health. People’s occupations and living circumstances directly affected who was more likely to get sick and die in the early days of COVID and who was less vulnerable to infection and death. During this time, health departments, county governments, states, and cities constructed this narrative of health as a consequence of racism through more than 260 declarations that racism is a public health crisis. That was an emergent narrative seed linking structural racism to health. During this time, as we document in the article, we saw a whole host of new coalitions and partners that came together. There were new funding mechanisms to put the spotlight on structural racism and health in both public and private dollars and private philanthropy dollars. There was — and still is — an enormous amount of research being produced identifying the mechanisms through which structural racism harms health.
We saw attention to these issues in health agencies, in private corporations, and in our public health schools, where attention to racism became commonplace in courses like the ones that I teach. This is the start of building narrative infrastructure. Unfortunately, this momentum is really threatened by political backlash to these ideas. But, as we say in the article, these narrative seeds were planted across all different sectors with the strategic focus on racism as a public health crisis in 2020 and 2021.
Are there emerging examples of narrative work happening to shift people’s understanding of racism?
The structural racism story is about going upstream. We must think about the upstream causes of so many of our health, public health, and health care issues, which stem from who has access to power, who has power, and who doesn’t have power. This work is happening in lots of different sectors, for example, racism within criminal justice, or the power that shows up in the housing sector. Tenant organizing is a really important example of where power is being built among renters who tend to also be members of minoritized, racialized groups as well. There are so many different sectors that point toward the upstream structural determinants of health that include, but are not limited to, racism. The answer to this question is complex because it’s happening in so many places.
Why is now the right time for public health to focus on narrative infrastructure?
The attacks on health equity and the concepts of equity, diversity, inclusion, and beyond are all the more reason to focus on thinking strategically and long-term. This will allow coalitions to maintain focus on these concepts and build the necessary momentum for narrative — and policy — change when it’s politically possible.
There is a lot of nuance to this work, and social change takes a long time. What’s one step public health practitioners can take right away to begin building narrative power?
This goes back to the tobacco control lesson, which emphasizes the importance of building relationships and coalitions across funders, advocacy, philanthropy, entertainment, news, and media. In this time of threat, the worst thing that can happen is to become isolated and atomized. And it’s understandable when that happens, right? Because when you’re afraid or feeling threatened, it’s easy to curl up and dig in. But, for public health practitioners, reaching out to partner with those in education, in schools of public health, in the journalistic community, in other advocacy organizations, and in community organizing, and building those relationships is going to be critical. The infrastructure can only be built on top of those trusted relationships — it can’t come up out of individuals in silos.
To learn more, read the full perspective in Milbank Quarterly: “Changing the Story on Health and Racial Equity: Why Public Health Needs an Infrastructure for Building Narrative Power.”