Rudolph Virchow (1821-1902) was one of the foremost leaders in medicine and pathology of the 19th century. He was also a public health activist, social reformer, politician, and anthropologist. Image available as an online-only supplement at http://www.ajph.org. Published with permission of Corbis.
Health has long been understood in a social context. Even in the days of Hippocrates it was recognized that where you live, both socially and geographically, shapes to some extent your vulnerability to disease. More recently, economics and financing have found a niche in health and health care in the United States. The recent surge in health care behavioral economics, the use of incentives to influence health care, and the introduction of Wall Street profit-and-loss rules of trade into heath care management are all manifestations of the increasing role of finances in this arena. Politics, on the other hand, has always been part of human discourse, no matter the subject. Health is no exception. It is said that the great 19th century physician and public health expert, Rudolph Virchow, was once dispatched by the rulers of then Germany to assess a public health crisis faced by a community. After a thorough evaluation, his prescription was simple and to the point: “Let them have freedom.” Virchow’s recommendation was a clear indication of the link between population health and the political structure of a nation.
Politics in health care has reached a new level of intensity and urgency in this age of in-your-face discourse. In the United States, every decade or so there has been intense debate about how best to manage and pay for health care. It pins those who believe health care to be a right and a basic human service that is best provided by government against those who believe it to be fair game for free-market solutions. Which of these viewpoints will prevail remains to be seen, but the debate is unlikely to go away despite the recent US Supreme Court decision on the Affordable Care Act or the 2012 election. Just like democracy itself, the politics of health care will remain with us as long as health remains a social issue and humans remain social beings.
While partisan politics in matters of health and health care policy might be unavoidable, opinion makers are now bringing average voters into the debate. This highly complex subject is difficult to wrap our heads around even for most experts. Elected officials have access to skilled professionals as well as staff who can research issues from independent sources. Throwing the debate to the general public via popular media adds a new complexity to the relationship between politics and health care policy and is at best uneven. The resources required for a fair and thoughtful debate are often out of reach for the average voter. Take, for example, the following remark by a patient of mine who receives all of his health care from the Veterans Health Care system, which is entirely public. At the height of the health care debate, he ventured out of our usual doctor–patient dialogue by admitting, “Doc, I just do not want government in my health care.” A cynical critic might argue that leaving the health care debate to the average voter might risk falling victim to the Churchillian maxim vis-à-vis democracy: “The best argument against democracy is a 5 minute conversation with the average voter.”
This Journal issue devoted to Health in Political and Social Context includes articles that examine policy changes and their impact on infant feeding, bullying, bicycle injuries, and dental services for children, to name but a few. Collectively, they remind us of the necessity of incorporating the political and social context of health into policy decisions, and the gulf that remains between the scientific understanding of what works to improve public health, and the political will to make needed advances a reality.