Disease Prevention as Social Change

Disease Prevention as Social Change: The State, Society, and Public Health in the United States, France, Great Britain, and Canada

Constance A. Nathanson
Copyright Date: 2007
Published by: Russell Sage Foundation
Pages: 344
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    Disease Prevention as Social Change
    Book Description:

    From mad-cow disease and E. coli-tainted spinach in the food supply to anthrax scares and fears of a bird flu pandemic, national health threats are a perennial fact of American life. Yet not all crises receive the level of attention they seem to merit. The marked contrast between the U.S. government’s rapid response to the anthrax outbreak of 2001 and years of federal inaction on the spread of AIDS among gay men and intravenous drug users underscores the influence of politics and public attitudes in shaping the nation’s response to health threats. In Disease Prevention as Social Change, sociologist Constance Nathanson argues that public health is inherently political, and explores the social struggles behind public health interventions by the governments of four industrialized democracies. Nathanson shows how public health policies emerge out of battles over power and ideology, in which social reformers clash with powerful interests, from dairy farmers to tobacco lobbyists to the Catholic Church. Comparing the history of four public health dilemmas—tuberculosis and infant mortality at the turn of the last century, and more recently smoking and AIDS—in the United States, France, Britain, and Canada, Nathanson examines the cultural and institutional factors that shaped reform movements and led each government to respond differently to the same health challenges. She finds that concentrated political power is no guarantee of government intervention in the public health domain. France, an archetypical strong state, has consistently been decades behind other industrialized countries in implementing public health measures, in part because political centralization has afforded little opportunity for the development of grassroots health reform movements. In contrast, less government centralization in America has led to unusually active citizen-based social movements that campaigned effectively to reduce infant mortality and restrict smoking. Public perceptions of health risks are also shaped by politics, not just science. Infant mortality crusades took off in the late nineteenth century not because of any sudden rise in infant mortality rates, but because of elite anxieties about the quantity and quality of working-class populations. Disease Prevention as Social Change also documents how culture and hierarchies of race, class, and gender have affected governmental action—and inaction—against particular diseases. Informed by extensive historical research and contemporary fieldwork, Disease Prevention as Social Change weaves compelling narratives of the political and social movements behind modern public health policies. By comparing the vastly different outcomes of these movements in different historical and cultural contexts, this path-breaking book advances our knowledge of the conditions in which social activists can succeed in battles over public health.

    eISBN: 978-1-61044-419-4
    Subjects: Health Sciences, Political Science, Sociology

Table of Contents

  1. Front Matter
    (pp. i-vi)
  2. Table of Contents
    (pp. vii-viii)
  3. About the Author
    (pp. ix-x)
  4. Acknowledgments
    (pp. xi-xiv)

    • Chapter 1 Introduction
      (pp. 3-24)

      Stories of public health are stories about how individuals, communities, and states recognize and respond to the threat of disease. These stories have a dramatic form. Actors—experts, officials, aroused citizens—emerge on the public stage in the first scene, sounding the alarm and demanding action to contain some perceived threat. As the action proceeds, the threat is defined and redefined, its reality contested, and its source disputed. In subsequent scenes, public authorities may or may not respond. Citizens may or may not take matters into their own hands. Dramatic resolution may or may not be achieved. The public’s health...

    • Chapter 2 The Nineteenth Century: From Miasmas to Microbes
      (pp. 25-46)

      Public health as an enterprise distinct from curative medicine is a product of the nineteenth century, as are—not coincidentally—nation-states and social movements as we know them today. Through complex and mutually reinforcing processes, industrial and geographic expansion created increased and novel demands on governments, greatly enlarging the reach and capacity first of European and much later of North American states, and offered new opportunities and targets for citizen organization and protest. Confronted with the palpable costs of urbanization—masses huddled together in conditions of appalling brutality—and persuaded not only of the relation between misery and disease but...


    • Chapter 3 Infant Mortality
      (pp. 49-79)

      Infant mortality—the number of babies who die in the first year of life—had been identified by the middle of the nineteenth century as a “particularly sensitive index of community health and well-being and of the effectiveness of existing public health measures” (Meckel 1990, 5). John Simon, then medical officer of health for the City of London, noted in 1851 that “there was no better index of sanitary condition than the infant mortality rate” (Lambert 1963, 165). Further, as Richard Meckel observes and as the narratives that follow will show, infant mortality “also came to be seen and employed...

    • Chapter 4 Tuberculosis
      (pp. 80-106)

      In 1815, an English physician, Thomas Young, wrote, “of all hectic affections, by far the most important is pulmonary consumption, a disease so frequent as to carry off prematurely about one-fourth part of the inhabitants of Europe, and so fatal as often to deter the practitioner from attempting a cure” (cited in Dubos and Dubos 1987, 9). About the same time, a French physician, Antoine Portal, observed that “there is no more dangerous disease than pulmonary phthisis [the Greek word for this condition], and no other is so common . . . it destroys a very great part of the...


    • Chapter 5 Smoking
      (pp. 109-159)

      The connection between smoking and lung cancer was established, to all intents and purposes, simultaneously by British and American investigators following virtually identical scientific pathways. An “alarming” rise in death rates attributed to cancer of the lung was observed in both countries in the late 1940s, in England by statisticians employed by the registrar-general’s office and in the United States by epidemiologists at the American Cancer Society (Lock, Reynolds, and Tansey 1998; Nathanson 1999; Kluger 1996). In 1950 retrospective casecontrol studies concluding, in the words of the British study, that “smoking is a factor, and an important factor, in the...

    • Chapter 6 HIV/AIDS in Injection Drug Users
      (pp. 160-200)

      The first five cases of what later came to be known as Acquired Immune Deficiency Syndrome (AIDS) were reported in theMorbidity and Mortality Weekly Report(MMWR) on June 5, 1981, under the enigmatic title, “Pneumocystis pneumonia—Los Angeles.” On June 12, 1981, the “afternoon mail brought from the United States [to Dr. Willy Rozenbaum, Paris physician and infectious disease specialist] theMMWRdescribing the pneumonia outbreak in Los Angeles” (Shilts 1987, 72). Earlier that same day, Rozenbaum had diagnosed Pneumocystis in a gay man and, as Shilts describes, based on his interviews with Rozenbaum, immediately made the connection with...


    • Chapter 7 Engines of Policy Change: The State and Civil Society
      (pp. 203-220)

      I now turn from data—the sixteen stories of public health I have recounted—to analysis and interpretation organized around the three broad determinants of public health action proposed in chapter 1: states, collective actions, and constructions of risk. The goals of this analysis are to arrive at an understanding of the social and political processes that drive policy making in public health, and to explain why countries otherwise comparable in so many respects reacted differently to essentially the same threats. My strategy is to move back and forth across the narratives in an effort to discover and account for...

    • Chapter 8 Experts and Zealots
      (pp. 221-232)

      At a symposium on the history of smoking and tobacco control, the medical historian Roy Porter commented on the difference between Britain and the United States in patterns of mobilization against smoking. “My suspicion [is that] relatively speaking . . . the medical profession has actually played a larger part in mobilizing anti-smoking opinion; and, relatively speaking, energetic zealots . . . have played a smaller part in Britain as compared with the United States” (1998, 226). He went on to suggest that these different patterns were of long standing, not limited to smoking but reflected in campaigns against earlier...

    • Chapter 9 Political Cultures and Constructions of Risk
      (pp. 233-246)

      Public recognition of dangers to health and judgments concerning if, when and how to respond are the outcome of social processes, as I observed in chapter 1. Among the major sources of variation in recognition and response were the political cultures of nation-states. States’ political practices and the ideologies associated with those practices, Frank Dobbin argues, “were socially constructed as constitutive of political order. . . . And in each state, state structure designated particular evils that threatened order” (1994, 22). Dobbin was writing about railway policy in the nineteenth century, but his point applies with equal force to public...

    • Chapter 10 Conclusion
      (pp. 247-258)

      Public health originated as much from fear of social change—the revolutionary potential of the desperate poor huddled together in the teeming cities of the nineteenth century—as from the desire for social reform. Public health was conceived as a means to public order. Yet the social changes initiated by Edwin Chadwick, when he embarked on improvements to the sanitary environment of the poor to defray the tax rates of the rich, and by Robert Koch, when he and Pasteur and other late nineteenth-century pioneers of biomedicine, launched—perhaps unwittingly—the search for magic bullets that would target disease individual...

  9. Notes
    (pp. 259-288)
  10. References
    (pp. 289-316)
  11. Index
    (pp. 317-330)