Locating Medical History: The Stories and Their Meanings

21 From Analysis to Advocacy: Crossing Boundaries as a Historian of Health Policy

C H A P T E R T W E N T Y - O N E From Analysis to Advocacy Crossing Boundaries as a Historian of Health Policy Allan M. Brandt My doctoral dissertation, on which my first book was based, offered a historical assessment of the considerable social, cultural, and political obstacles to the successful treatment of sexually transmitted diseases. At the conclusion of my defense of the dissertation at Columbia University in 1982, historian David Rothman asked pointedly, ‘‘So what would you do?’’ At the time, I was completely nonplussed by the question. What would I do? What difference would it make what I would do? I had just completed narrating and analyzing the complex history of sexually transmitted diseases over more than a century. Certainly, as a historian I need not focus on ‘‘what to do.’’ At the time, I considered it something of a non sequitur; my work was dedicated to illuminating the reasons why STDs persisted in the face of effective treatments. Many of these factors were deeply structural, cultural, and persistent, and it wasn’t the role of the historian—so distant from the levers of power—to propose policy approaches. But the question has continued, nonetheless, to reverberate throughout my professional work. And Rothman certainly had a point. If in fact I now understood why disease persisted as a result of powerful historical forces, might I have some applicable insights about policy approaches in the present and the future? Hadn’t fundamental concerns about contemporary society and policy motivated my work in From Analysis to Advocacy 461 the first place? In the fall of 1982, in the first years of the AIDS epidemic, could I find some utility in my historical work for the looming here and now?1 In the intervening years I have reflected often on this episode and on the relationship between historical inquiry and policy-making. There has been a longstanding engagement between scholarship, politics, and advocacy that is a central element of the emergence of the field of social medicine. The policy process is an unavoidable aspect of studying science and medicine. Perhaps it is the universal aspects of health, disease, and its treatment that have continued to draw recent historians to contemporary policy and advocacy. Ultimately, I believe that many of us sought careers as historians because of our desire to connect the past with the present, our desire to discover approaches to contemporary social problems in a sophisticated recovery of the past. This may not be the only—or even the most important—motivation for historical investigation, but it certainly is one, especially in the instance of the history of medicine, where profound moral and material questions remain so fundamentally unresolved.2 In this chapter, I will identify some of the problems and prospects of defining the policy arena as one of the constituencies for modern historical research and teaching in the history of medicine and public health. I propose that policydirected history falls roughly into three categories: the historian as author of policy-relevant history; the historian as policy participant/consultant; and the historian as policy advocate. Each of these three approaches raises a set of specific questions and problems, and together they help to define a continuum. After all, virtually all historical work—especially in a field such as history of medicine— possesses some ‘‘relevance’’ for contemporary policy questions. Moving along this gradient, some historians have avoided any overt connections, while others have sought to make them explicit. Finally, as I will illustrate, some recent historians have sought to take historical insights explicitly into the realm of social and political advocacy. Policy-Relevant History It is difficult to pick up a book in the field of twentieth-century medical history without finding a blurb on the jacket announcing that this is a book that should be read by all policy-makers. If only all policy-makers had time to read! The central premise of such studies, of course, is not to influence public policy directly but rather to explicate and analyze a series of critical historical developments; few historians working in this mode set out to write histories that have clear and immediate implications for the formation of public policy. Rather than histories 462 After the Cultural Turn being constructed to affect public policy, most of these policy-relevant historical studies are generated by contemporary policy...