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Chapter 10 Conclusion P UBLIC 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 by individual, were revolutionary. The movements these men helped set in motion transformed conceptions of disease and contributed—albeit haltingly and unevenly—to a vast expansion of public responsibility for its prevention. Change was sometimes dramatic. In 1905, the New York City health commissioner, Hermann Biggs, dumped “the entire milk supply of several large firms” into the city sewers on grounds of contamination (Winslow 1929, 194). A little less than a hundred years later, the city’s health commissioner and the mayor (against objections from his staff) announced a complete ban on smoking in New York’s bars and restaurants. In 1995 in Vancouver, British Columbia, the Vancouver Area Network of Drug Users was created as a political movement to pressure local politicians on behalf of injection drug users; seven years later, it took credit for the landslide election of a highly sympathetic mayor. It is these and other examples of public health action that I have sought in the preceding chapters to deconstruct and explain. Central to the idea of social change is innovation.1 My focus in this book has been on innovations in “community action to avoid disease and other threats to the health and welfare of individuals and the community at large” (Duffy 1990, 1). Consistent with John Duffy’s definition, I have concentrated on social actors—individuals, organized groups, and states—as the principal agents of change in public health and have been interested 247 primarily in innovative forms of action. VANDU is a good example. As reflected in the examples cited, innovation has taken many forms and has occurred at different levels of organization, from social movements organized in front parlors and basement meeting rooms to legislatures and parliaments. Arguably, the most significant of these innovations in the long term were not the programmatic or policy outcomes achieved—package warnings, say, or educational brochures mailed to expectant mothers— but the recognition that public health was political and the invention of new forms of political advocacy to achieve public health goals. At the most general level, the conclusion I draw from my work is that the obstacles to public health action, even such superficially noncontroversial action as pasteurization, are formidable. Or—stated in more positive terms—given these obstacles, it is remarkable that anything in the way of community action to avoid disease was accomplished. I begin with a brief review of the obstacles evident from the narratives and interpretation I have presented. Obstacles Opposition to public health action by powerful groups—economic, professional , moral, religious—that saw the measures proposed as inimical to their own interests has a long history. These groups—dairy farmers and milk dealers, tobacco manufacturers, medical syndicats, the AMA, the Catholic church—derived their power from their extensive economic and organizational resources, from their insertion (with the debatable exception of the tobacco industry) in local communities, and from their close ties with state bureaucrats and politicians. Often the principal intended beneficiaries of these same measures belonged to poor or stigmatized populations with relatively few resources and with little elite support or political access. Wherever they may have seen their interests to lie, their voices were seldom heard. The beneficiaries—intended or otherwise—of the antismoking movement are an obvious exception, helping to account for the movement’s success. With important but limited exceptions, public health as a state function was marginalized relative to other activities. Authorities with the power to override opposition to public health measures had competing priorities, did not see important political interests as threatened (or perceived the threat of action as greater than that of inaction), were ideologically committed to some form of market liberalism that precluded state action, were afraid of stirring up popular panic or incurring expenses they perceived to be unaffordable, or were simply uninterested. Conditions for Public Health Action Under what circumstances, then, has...

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