- Reform and Its Discontents:Public Health in New York City During the Great Society
The health-care system was one of the most visible and contentious battlegrounds on which the social conflicts of the 1960s unfolded. To an unprecedented extent, health status—especially the stark disadvantage in access and outcomes for racial and ethnic minorities and the poor—became an object of public and governmental concern during the Great Society era, as clinicians, community activists, politicians, and policymakers sought to create new models of medical care that were more equitable and efficient than those of the past. The social science theories that informed the ambitious programs of Lyndon Johnson's administration gave an imprimatur to the idea that illness was both cause and consequence of the "cycle of poverty."1
The ferment of this period raised fundamental questions about the place of public health in American society. For most of the twentieth century, the public health profession, concerned with prevention rather than cure and population-level analysis rather than patient care, was institutionally weak compared with organized medicine, and it struggled to advance a community-focused mission in a civic culture that privileged individualism, the free market, and limited government. In the latter half of the 1960s, grassroots mobilization, coupled with federal and state commitments to health care for the poor, opened a window of opportunity in which public health professionals could argue that their field, by virtue of its unique perspective and experience, had a special role to play in health reform. But the social and political conditions that created this opening also served as countervailing forces that limited what was possible in the new environment. [End Page 3]
Nowhere was this landscape more unsettled than in New York City, which had a long tradition of innovative public health activities. In the mid-1960s, the city became, in the words of an economist who advised Mayor John Lindsay's administration, "one of the country's chief laboratories" for testing a "commitment to the use of the public authority to accomplish social change."2 As part of an effort, now largely forgotten, to rationalize the city's massive and unwieldy health bureaucracy, the Department of Health was consolidated into an omnibus agency that linked it closely with the city's powerful medical and hospital establishment. Department employees sought to use new funding streams and a more open social climate to advance an expansive vision of public health, and forged new relationships with doctors and community members, the two constituencies that had historically bounded their mission. But their efforts at reform were caught between political and economic pressures from "above" and radical resistance from "below."
The social policy innovations of the War on Poverty and the Great Society have been the subject of extensive historical analysis.3 But this literature has given little systematic attention to the health-care arena and virtually no consideration to the role of public health.4 The debates over the appropriate sphere of public health provide a unique vantage from which to gain a fuller understanding of key transformations in American society in the 1960s: the shifting relationship between citizens and government; the expansion of legislative efforts to address the problems of the poor and disadvantaged; the development of a discourse of "rights," including the right to health; and the erosion of paternalistic notions of expertise, especially medical authority. This brief but pivotal chapter also sheds new light on challenges that still define the health-care system, as policymakers continue to debate the place of prevention within the country's technocratic and curatively oriented medical regime.
The Divergence of Public Health and Medicine
The professional and conceptual borders between public health and medicine were erected early in the twentieth century as clinicians in private or hospital practice diverged from sanitary reformers and laboratory-oriented bacteriologists in the public and voluntary sectors. As Allan Brandt and Martha Gardner have argued, the American health-care system was thus shaped by "the division of labor, the differences in theories and skills, and the balance of authority and politics between these two fundamentally related fields."5 Physicians, represented by their increasingly powerful lobby, [End Page 4] the...