Introduction: New Perspectives on Public Health Policy

The makers of public health policy face enormous challenges in the twenty-first century. In the past, their field has been imprecisely defined, deeply conflicted, poorly organized, and constantly changing. Lines of responsibility within the field are blurred at best, and groups with similar goals sometimes find themselves at cross-purposes. In the United States, state and local agencies interact with each other, with federal programs, and with powerful private interests. Many decisions that profoundly affect the health of the public are made for reasons largely unrelated to public health per se. Since the human and financial stakes involved in public health policies are immense, these challenges are, to say the least, serious issues. Underlying this volume is the belief that historical analyses and international perspectives can help policymakers understand, and hopefully begin to address, some of those old challenges in new ways.

The first two essays analyze what actually happened when two significant, well-intentioned public health initiatives were implemented on the ground in real-life situations. James Colgrove examines the tragic debacle that followed efforts to expand public health services in New York City during the 1960s, despite what appeared to be ideal conditions and an unprecedented infusion of federal funds. Virginia Berridge and Alex Mold explore similar developments in UK cities during the 1980s, when national health officials reoriented their approach to drug addiction. In neither case did the policies have the intended results, and these authors explain what actually happened and why. Both articles are cautionary tales that reemphasize the need for policymakers at the national level to understand the specific cultural and historical realities with which they are dealing.

The next three essays look at some of the factors that have determined how public health policy has actually been made in the past. Howard Kushner explores the role of powerful drug companies in the United States, and raises the chilling prospect that their already self-interested activities in the field of public health policy may have been operating historically within a set of widely accepted assumptions that were fundamentally flawed in the first place. Constance Nathanson examines the contingent nature of expertise in the formation of public health policy in the United States, the UK, and France, showing the different ways in which policymakers in those nations determined the "best" way to deal with two public health issues they all faced: antismoking and AIDS-prevention programs. In the third essay, Harold Pollack illustrates one of Nathanson's conclusions by showing how policies designed to help intellectually disabled persons in the United States emerged not primarily from governmental or professional initiatives, but in large part from shifts in public perception and the pressure of grassroots organizations. Although largely successful, that ad hoc process also had its own strengths and weaknesses.

In the final essay, Brett Walker uses contemporary system theory to illustrate six intriguing ways in which socioeconomic decisions in the past have affected the long-term environmental health of Japan. By implication, of course, the makers of public health policy elsewhere need to consider similar dynamics in their own nations as well. Together, these six essays reveal important interactive factors that have influenced the history of public health policy, and they help to situate the making of public health policy in a transnational context.