POLITICS OF PUBLIC HEALTH

In implementing health policy, the United States government began by taking care of its own—its armed forces and veterans. In the early years of the nation, the health of the general population was addressed only in activities aimed at the control of epidemics. The National Quarantine Service Act was passed by Congress in 1878, the year that 9,000 people died in a yellow fever epidemic in New Orleans, Louisiana, and Memphis, Tennessee. In 1890, Congress passed an appropriation bill for the National Quarantine Service, which became the United States Public Health and Marine Hospital Service in 1902, and ultimately the United States Public Health Service in 1912. In the early twentieth century, when the federal government began taking a more active interest in medicine and public health, its interest was limited to preventing or attacking epidemic diseases, through quarantine and sanitation improvement, with a very modest commitment of public funds.

Over the years, the collection of health statistics evolved as a function of state and local government, mainly in recognition of the need for vital statistics in resolving legal matters. Supported by the American Public Health Association, the National Board of Health, and the Marine Hospital Association, the Office of the Census was created in 1902, but a birth and death registration system did not cover the entire nation until 1933. Over the succeeding years, responsibility for vital statistics within the states was usually lodged within health departments, where the data were used to support maternal and child health programs, to define problems in communicable disease control, and to anticipate the problems of chronic diseases. In 1946, the federal vital statistics function was transferred from the Census Bureau to the U.S. Public Health Service.

Recognizing that records of births and deaths alone would not completely indicate the impact of illness and disease on the population, Congress, in 1893, passed a bill to collect weekly morbidity data from states and cities throughout the country, a practice that continues to this day.

In 1912, two important pieces of health legislation were enacted, one creating the Children's Bureau and inaugurating maternal and child health programs, and the other changing the name of the Marine Hospital Service to the U.S. Public Health Service (USPHS) and authorizing it to conduct field investigations and studies. These two laws have largely defined the roles of federal, state, and local jurisdiction regarding public health activities and programs. In 1915 the first statistician appointed to the USPHS began to conduct household surveys of pellagra, diet, housing, and economic status in the cotton-mill towns of South Carolina. The Great Depression of the 1930s provided the opportunity for a nationwide survey of 700,000 households in eighty-three urban areas, and the results were used over the next twenty years as baseline data for promoting public health programs. This data provided the federal government and the states with an epidemiological basis for the support of public health programs.

Health officials appointed by political leaders and government officials must define public health policy and programs within the framework of pertinent legislation and what is acceptable to the political leadership. This often leads to the politicization of public health issues and results in political debate instead of public health discourse. By contrast, Civil Service appointees, by virtue of their career protection, can more easily take independent positions on controversial public health issues without threats to their professional careers.

Another important milestone in health affairs came with the incorporation of the original Marine Service Hygienic Laboratory into the National Institutes of Health, which became the federal government's major mechanism for performing, funding, and directing medical and health research. Major disease and organ-specific institutes have developed within this framework and have contributed to major advances in our knowledge of health and disease. Some institutes have been created by political leadership from congressional leaders with a particular interest in a certain disease entity.

Interest groups that form around public health issues constitute another source of program advocacy. Many of these are organ-specific, such as the American Liver Foundation and the American Heart Association, while others are disease-specific, such as the American Cancer Society and the American Diabetes Association. These organizations raise funds in support of their interests, but they also exercise political advocacy. Groups at special risks of some diseases also participate in advocacy on their behalf. Political and public health leaders, therefore, are subject to multiple pressures for support of various programs and public health initiatives, and these pressures have the potential for creating inequities in the distribution of resources. It is fortunate when public health leaders have the credibility and stature in their communities to be perceived as sage advisors to the community and the political leadership so that such distortions in the distribution of resources are minimized.

In February 1998, the president of the United States committed the nation to eliminate health disparities among ethnic and racial groups. Following the president's lead, the Surgeon General has formally set a national goal of eliminating health disparities by the year 2010. Although not articulated as a "political" goal, its achievement will require the exercise of a political will whose magnitude has not been seen since the passage of the Social Security Act of 1935 or the Medicare and Medicaid legislation in 1965.

As late as the 1960s, public health students and preventive medicine residents were taught that as public health professionals they should stay clear of politics. Their role was seen to be protecting the public's health within the existing rules. Once those students and residents left their training and entered the world of public health practice, however, they quickly found that the important decisions affecting public health agencies' ability to protect, promote, and assure the public's health were being made in the political arena, and that those public health professionals who eschewed politics would not have the resources to carry out the mandates of public health.

It is odd to note that a nation that prides itself on its concern for human rights and that passed the Civil Rights Act of 1964 does not recognize that the existence of more than 40 million citizens and residents with no health insurance is a civil rights issue, and a human rights issue, of major proportions. Being the only major Western industrial nation that, at a time of unprecedented economic prosperity, does not guarantee its people the right to necessary and appropriate health care is not a distinction the United States should covet. Indeed, as early as 1937, Dr. Thomas Parran, the U.S. Surgeon General, declared that citizens should have an equal opportunity for health as an inherent right, along with the rights of liberty and the pursuit of happiness.

The widely praised Institute of Medicine report The Future of Public Health (1988), defined the role of public health in terms of three core functions, assessment, policy development, and assurance. The report also defines public health's mission as "fulfilling society's interest in creating the conditions in which people can be healthy." Thus, public health is inherently political, and society influences public health policy through the people it elects to represent it at local, state, and federal levels. Every time Congress adopts a budget that is signed by the president it is defining public health policy and determining what the nation's chief public health instrument, the U.S. Public Health Service, can do to protect the nation's health.

In every local political jurisdiction, the governing body of the local health department is a political body. Even when there is a local board of health, the local governing body usually selects its members, and by exercising those choices the political leaders influence the definition of public health policy in that jurisdiction. In one large American city, for example, all state or federal grant requests required city council approval before submission to the granting agencies. Having identified and documented an increasing incidence of deaths and injuries due to household fires in an impoverished section of the city, and having learned from the city fire marshal that the absence of smoke detectors in those homes was contributing to the morbidity and mortality, the director of public health instructed his staff to seek a federal grant that could be used to install smoke detectors in the homes in that section of the city, especially in the homes of needy elderly citizens who, by virtue of age and disability, were at greatest risk. When that proposal was presented to the city council for approval, that city council determined that injury and death from fires was not a public health problem, but a problem for the fire marshal, and that the director of public health should stay out of such problems. In that same state, a state attorney general ruled that attending at childbirth was not a medical activity and, therefore, midwives did not need special training or licensure. The result was a high rate of obstetrical misadventures in unregulated birthing centers. These may seem extreme examples of the role of politics in defining public health policy and practice, but they underline the fact that to be successful in protecting the people's health, public health practitioners must actively enter the political environment in which public health decisions are made.

Free and low-cost school lunches have become a tradition in U.S. public schools, and Americans like to believe that this tradition represents our humanitarian concern for the proper nutrition of children from poor families. The reality is that the United States Department of Agriculture (USDA) created the program to provide a market for surplus farm products from U.S. farms. The public health goal of better nutrition for poor children was incidental. Proof of the marginal significance of a public health goal when compared to the political intent was the recent outbreak of hepatitis A among school children in a Midwestern state. When the etiology of the outbreak was traced by the Centers for Disease Control and Prevention to strawberries provided by a school lunch-program contractor who had sold the USDA strawberries purchased from a Central American country, the contractor's crime was not that he had imperiled the health and lives of dozens of U.S. schoolchildren, but that he had injured the income of U.S. farmers by selling a foreign-grown product to the school lunch program.

The determinants of the public's health are not limited to bacteria and viruses and other specific disease factors to which people are exposed. They also include threats that can be controlled only by concerted community action, through the political process, environmental toxins, substandard housing, unsafe working environments, inadequate housing policies, the absence of universal health coverage, and personal behaviors that jeopardize people's well-being—these are all determinants of health, and none, except personal behaviors, are subject to solutions by individuals. All require community action, political responses, and political will.

At the dawn of the twenty-first century, the United States stands as the most powerful and the most wealthy nation on earth—but not the most healthy, despite the highest per capita expenditures for health services. In a study published in 1977 it was shown that "despite the increase in use of medical services by the poor, the gap in health status between the poor and nonpoor as measured by morbidity, disability, and mortality has actually widened" (Elinson, 1977). After twenty-three years, recognition of this continuing gap has led to the Healthy People 2010 goal of eliminating these disparities.

During the period from 1910 to 1920, public discussion of national health insurance began in some of the more progressive states, and a committee of the American Medical Association made a recommendation of such a program. Only in 1943, however, was the first meaningful national health insurance bill introduced in Congress. At that time, U.S. Senators Robert Wagner, Sr. of New York State and James Murray of Montana, together with Representative John Dingell, Sr. of Michigan, proposed what became known as the Wagner-Murray-Dingell bill. Although tentative forward steps in government-financed health care had taken place in 1935 when some health care for the poor was included in the Social Security Act, the Wagner-Murray-Dingell bill was immediately labeled "socialized medicine" by the American Medical Association and others who feared government intrusion into medical practice. The bill never reached the floor of either house of Congress.

After 1965, when Congress enacted the Medicare and Medicaid legislation, it took only a few years for the costs of both programs to become a political battleground. Efforts by the Clinton administration to design a program of universal health coverage met such universal opposition from Congress that it may be a long time before another president will dare to try again. Because public-policy development is a political process, however, public opinion often sets the national agenda, and public health practitioners can take leadership in molding that public opinion.

James G. Haughton

(see also: Community Health; Conflicts of Interests; Equity and Resource Allocation; Inequalities in Health; Landmark Public Health Laws and Court Decisions; Legislation and Regulation; National Health Insurance; Official U.S. Health Agencies; Regulatory Authority; Uninsurance; United States Public Health Service [USPHS] )

Bibliography

Cohen, W. J. (1979). "Policy Planning for National Health Insurance." In Health in America: 1776–1976. Washington, DC: U.S. Department of Health, Education and Welfare.

Elinson, J. (1977). "Have We Narrowed the Gaps in Health Status between the Poor and the Nonpoor?" Medical Care 15(8):675–677.

Institute of Medicine (1988). The Future of Public Health. Washington, DC: National Academy Press.

Steinfeld, J. L. (1979). "The United States Public Health Service." In Health in America: 1776–1976. Washington, DC: U.S. Department of Health, Education and Welfare.