An early candidate for "Article of the Year" in 2010 is Amy Fairchild, David Rosner, James Colgrove, Ronald Bayer, and Linda Fried's piece entitled The EXODUS of Public Health: What History Can Tell Us About the Future. Published in the January 2010 (vol. 100, no. 1) issue of the American Journal of Public Health, here is the abstract:
We trace the shifting definitions of the American public health profession's mission as a social reform and science-based endeavor. Its authority coalesced in the late nineteenth and early twentieth centuries as public health identified itself with housing, sanitation, and labor reform efforts. The field ceded that authority to medicine and other professions as it jettisoned its social mission in favor of a science-based identity. Understanding the potential for achieving progressive social change as it moves forward will require careful consideration of the industrial, structural, and intellectual forces that oppose radical reform and the identification of constituencies with which professionals can align to bring science to bear on the most pressing challenges of the day.
The authors are core faculty at Columbia's Center for the History & Ethics of Public Health, and are unquestionably among the most important public health scholars in the U.S. today.
This article is a tour de force. It provides a succinct snapshot of the evolution -- or, to the critics' mind, the devolution -- of public health in the U.S. from its origins in the mid-19th century to the present. While the authors eschew outright polemic, their perspective is never hidden, as the title itself makes clear (an "exodus" of public health). Where did this flight originate? And to where is it going?
You'll have to read the article for the entire story, but the basic idea is that U.S. public health practice has fled from a commitment to population health in terms of social justice to amore individualized, scientistic model of public health that is decidedly noninterventionist:
We argue that the death of progressivism and the advent of the conservative political and social environment of the 1920s pushed public health into the laboratory and the university and away from the traditions that had once been central to its identity . . . the growing power of medical science and narrowly defined "efficiency" continued to push public health away from its reformist roots.
The basic contours of this narrative should not be news to public health scholars, but rarely has it been as carefully, as succinctly, and as expertly related as it is in this article. Of course, the (normative) political stance of this history, and of the others, is quite apparent from this quote. Indeed, that is precisely the point, given that fin-de-siecle and 20th-century public health practitioners grew decidedly uncomfortable with the overtly political stance of the reformist models championed by figures like Engels, Virchow, and W.P. Alison.* The gaze of the laboratory and the clinic on the discrete pathologies deemed to cause disease provided a powerful channel for the reluctance to endorse social and class reform. Indeed, they still do, which is partly why I maintain that understanding the power of the visible lesion or pathology in causing illness is a critical desideratum for the medical humanities. Fairchild et al. explain:
. . . the public health community embraced bacteriology with its focus on the laboratory rather than the social and environmental context, as an authoritative science that did not require political alliances: science spoke for itself.
The idea that scientific evidence "speaks for itself" is, IMO, utter nonsense, though I certainly agree that the belief that it does is sadly ubiquitous, today no less, and perhaps more than it was a century ago. Anyone remotely familiar with the terrible problems in translating evidence into practice (estimates of evidence penetrance into clinical practice hover in the low end of a range from 10-40%) could immediately repudiate the claim. I also have little patience for the frequent calls from all corners to avoid politicizing health care, public health, or science. All of these endeavors, like any human enterprises, are irreducibly and inexorably political. Leigh Turner authored an excellent recent article in which he demonstrated the numerous errors and incoherencies of the claim that "science/health/health care/public health should avoid politics." Of course, there are certain political beliefs, acts, or practices which are and should be ripe for criticism by anyone concerned with the ethics of health and medicine, but to say the latter is quite different from the grandiose claim that science should avoid politics.
Engels and Virchow, to name but two, would either have rejected, ridiculed, or both the idea that advancing population health should be attempted by means as apolitical as possible. This, I take it, is part of Fairchild et al.'s point. They show beyond a shadow of a doubt that the decision to pursue a decidedly noninterventionist model of public health is absolutely political, reflecting a number of social, cultural, legal, and economic beliefs, assumptions, and concerns. Deciding on relative priorities amidst scarce resources is an irreducibly political decision, and it makes little sense to me to pretense to the contrary.
Of course, it does not follow that any particular political or normative stance with regards to the future of public health is persuasive to any particular stakeholder. But once we begin by accepting that our public health practices are fundamentally political, I think we may be somewhat closer to a qualitatively better discourse regarding which choices we ought to prioritize. Even if I am wrong in this and the discourse is unimproved, there is, I think, value in shining some light on the choices we are making, and the consequences therein. Discussing related matters in context of rhetoric, a mentor of mine suggested that one should not underestimate the power of shame as an impetus to positive action.
In any case, read Fairchild et al. Thoughts, as always, are welcome.
(h/t Rick Lippin)
(*Sidenote: Though Fairchild et al. have forgotten more than I will ever know about the history of public health, Christopher Hamlin's work does make clear the danger of presuming, at least as to the U.K., that the Chadwickians were motivated by a strong concern for social justice and vulnerable classes. Quite the contrary, in fact, Chadwick and many of his supporters were primarily interested in sustaining the existing inequitable class structure. I am not certain whether this British history corresponds to the state of U.S. public health in the 19th century, but it is worth noting as a question).
Comments