Abstract
Public health is politically paradoxical because its core conceptual components — the exercise of public authority and the promotion of population health — stand in practical tension that belies their theoretical promise. Across Western nations, public policymakers stand accused of failing properly to honor and support the crucial contributions that public health makes to the improvement of health outcomes and of overinvesting in acute medical care services, the need for which timely interventions in prevention and health promotion might have averted. The dramatic budgetary discrepancies in Western nations between the massive funds devoted to medical care and the minuscule sums allotted to public health are often taken as evidence that in such matters, political leaders are irrational (or perhaps uninformed, or captured by big-moneyed medical interests) and that good public policy would have epidemiologists and other public health experts running, or at least orchestrating, the show.
This paper explores the sources of this tension between population health and political power within the concept of public health and seeks to show why these strains prove to be so durable, indeed irresolvable. The argument and evidence draw largely on the United States, but the supposition — yway, the hope — is that the analysis will also throw light on the politics of public health in other nations.
Key Words: Public Health, public policy, political power, health reform
References
- 1.Rilke MR. In Gadamer Hans-Georg, The enigma of health. Stanford (CA): Stanford University Press; 1996. p. 75. [Google Scholar]
- 2.Kaufman H. The political ingredient of public health services: a neglected area of research. Milbank Mem Fund Q. 1966;44:13–44. doi: 10.2307/3349058. [DOI] [PubMed] [Google Scholar]
- 3.Oliver TR. The politics of public health policy. Annu Rev. Public Health. 2006;27:195–223. doi: 10.1146/annurev.publhealth.25.101802.123126. [DOI] [PubMed] [Google Scholar]
- 4.Institute of Medicine. The future of the public health. Washington (DC): The National Academies Press; 1988. [Google Scholar]
- 5.Tulchinsky TH, Varavikova EA. The new public health: an introduction to the 21st century. Second. San Diego: Elsevier Academic Press; 2008. [Google Scholar]
- 6.Institute of Medicine. The future of the public’s health in the 21st century. Washington (DC): The National Academies Press; 2002. [Google Scholar]
- 7.Corburn J. Toward the healthy city: people, places, and the politics of urban planning. Cambridge (MA): MIT Press; 2009. [Google Scholar]
- 8.Brown L. Impermanent politics: the Hillsborough County Health Care Plan and community innovation for the uninsured. Health Aff. 2006;25:w162–72. doi: 10.1377/hlthaff.25.w162. [DOI] [PubMed] [Google Scholar]
- 9.Brown LD, Stevens B. Market Watch: Charge of the right brigade? Communities, coverage, and care for the uninsured. Health Aff. 2006;25:w150–61. doi: 10.1377/hlthaff.25.w150. [DOI] [PubMed] [Google Scholar]
- 10.McKeown T. The role of medicine: dream, mirage or nemesis. Second. Princeton: Princeton University Press; 1979. [Google Scholar]
- 11.Cutler DM. Your money or your life: strong medicine for America’s health care system. New York: Oxford University Press; 2004. [Google Scholar]
- 12.Fogel RW. The fourth great awakening and the future egalitarianism. Chicago: University of Chicago Press; 2000. [Google Scholar]
- 13.Kreig JP. Epidemics in the modern world. New York: Twayne Pub; 1992. [Google Scholar]
- 14.Fox DM. The determinants of policy for population health. Health Econ Policy Law. 2006;1:395–407. doi: 10.1017/S1744133106006037. [DOI] [PubMed] [Google Scholar]
- 15.Brown LD. Health determinants, policy indeterminacy? Health Econ Policy Law. 2006;1:409–14. doi: 10.1017/S1744133106006013. [DOI] [PubMed] [Google Scholar]
- 16.Nathanson CA. Disease prevention as social change: the state, society and public health in the United States, France, Great Britain, and Canada. New York: Russell Sage Foundation; 2007. [Google Scholar]
- 17.Leichter HM. Free to be foolish: politics and health promotion in the United States and Great Britain. Princeton (NJ): Princeton University Press; 1991. [Google Scholar]
- 18.Oliver JE. Fat politics: the real story behind America’s obesity epidemic. New York: Oxford University Press; 2006. [Google Scholar]
- 19.Nathanson CA. The contingent power of experts: public health policy in the United States, Britain and France. J Policy Hist. 2007;19:71–94. doi: 10.1353/jph.2007.0005. [DOI] [Google Scholar]
- 20.Laugenson M. Personal communication.
- 21.Fassin D. Faire de la santé publique. Rennes (France): EHESP; 2008. [Google Scholar]
- 22.Markowitz G, Rosner D. Building a toxic environment: historical controversies over the past and future of public health. In: Stevens RA, Rosenberg CE, Burns LR, editors. History and health policy in the United States: putting the past back in. New Brunswick (NJ): Rutgers University Press; 2006. pp. 130–50. [Google Scholar]
- 23.Proctor RN. Cancer wars: how politics shapes what we know and don’t know about cancer. New York: Basic Books; 1995. [Google Scholar]
- 24.Kingdon JW. Agendas, alternatives, and public policies. second. New York: Longman; 2002. [Google Scholar]
- 25.Lohr S. New York Times. 2009. Watch the walk and prevent a fall. [Google Scholar]
- 26.Fee E, Brown TM. The unfulfilled promise of public health: déjà vu all over again. Health Aff. 2002;21:31–43. doi: 10.1377/hlthaff.21.6.31. [DOI] [PubMed] [Google Scholar]
- 27.Lalonde M. A new perspective on the health of Canadians: a working document. Ottawa: Government of Canada; 1974. [Google Scholar]
- 28.Russell LB. Preventing chronic disease: an important investment, but don’t count on cost savings. Health Aff. 2009;28:42–5. doi: 10.1377/hlthaff.28.1.42. [DOI] [PubMed] [Google Scholar]
- 29.Russell LB. Is prevention better than cure? Washington (DC): Brookings Institution; 1986. [Google Scholar]
- 30.Brown LD, Kraft MK. Active living as an institutional challenge: lessons from the Robert Wood Johnson Foundation’s “Celebrate Fitness” program. J Health Polit Policy Law. 2008;33:497–523. doi: 10.1215/03616878-2008-006. [DOI] [PubMed] [Google Scholar]
- 31.Compos P. The obesity myth: why America’s obsession with weight is hazardous to your health. New York: Gotham Books; 2004. [Google Scholar]
- 32.Morone JA. Hellfire nation: the politics of sin in American history. New Haven (CT): Yale University Press; 2003. [Google Scholar]
- 33.Kersh R, Morone J. The politics of obesity: seven steps to government action. Health Aff. 2002;21:142–53. doi: 10.1377/hlthaff.21.6.142. [DOI] [PubMed] [Google Scholar]
- 34.Thaler RH, Sunstein CR. Nudge: improving decisions about health, wealth and happiness. New Haven (CT): Yale University Press; 2008. [Google Scholar]
- 35.Marteau TM, Ashcroft R, Oliver A. Using financial incentives to achieve healthy behavior. BMJ. 2009;338:983–5. doi: 10.1136/bmj.b1415. [DOI] [PubMed] [Google Scholar]