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Disease Prevention as Social Change

The State, Society, and Public Health in the United States, France, Great Britain, and Canada

Constance A. Nathanson

Publication Year: 2007

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.

Published by: Russell Sage Foundation

Title Page, Copyright, Dedication

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pp. vii-viii

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About the Author

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pp. ix

Constance A. Nathanson is a sociologist and professor of clinical sociomedical sciences in the Columbia University Mailman School of Public Health.

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pp. xi-xiv

This book is the outcome of a project not only ambitious—too ambitious, it often seemed—but also very long in the time it took to accomplish. Neither the research nor the writing would have been possible without the financial support—reflecting a belief in the project’s ...

PART I. Setting the Stage

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pp. 1

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Chapter 1. Introduction

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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 ...

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Chapter 2. The Nineteenth Century:From Miasmas to Microbes

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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 ...

PART II. The Turn of the Nineteenth Century

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pp. 47

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Chapter 3. Infant Mortality

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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 ...

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Chapter 4. Tuberculosis

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pp. 80-105

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 ...

PART III. The Late Twentieth Century

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pp. 107

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Chapter 5. Smoking

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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 ...

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Chapter 6. HIV/AIDS in Injection Drug Users

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pp. 160-200

THE FIRST five cases of what later came to be known as Acquired Immune Deficiency Syndrome (AIDS) were reported in the Morbidity and Mortality Weekly Report (MMWR) on June 5, 1981, under the enigmatic title, “Pneumocystis pneumonia—Los Angeles.” On June 12, 1981, the ...

PART IV. Structures, Movements, and Ideologies in the Making of Public Health Policy

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pp. 201

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Chapter 7. Engines of Policy Change:The State and Civil Society

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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

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Chapter 8. Experts and Zealots

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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 ...

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Chapter 9. Political Cultures and Constructions of Risk

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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 ...

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Chapter 10. Conclusion

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pp. 247-257

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 ...


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pp. 259-287


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pp. 289-316


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pp. 317-328

E-ISBN-13: 9781610444194
Print-ISBN-13: 9780871546449
Print-ISBN-10: 0871546442

Page Count: 344
Publication Year: 2007

Research Areas


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Subject Headings

  • Health promotion -- Cross-cultural studies.
  • Medicine, Preventive -- Cross-cultural studies.
  • Preventive health services -- Cross-cultural studies.
  • Medical policy -- Cross-cultural studies.
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