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Chapter 7 Engines of Policy Change: The State and Civil Society 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 arrive at an understanding of the social and political processes that drive policy making in public health, and to explain why countries otherwise comparable in so many respects reacted differently to essentially the same threats. My strategy is to move back and forth across the narratives in an effort to discover and account for both common and contrasting patterns. Although this entails an inevitable loss of contextual detail and chronological sequence, the compensating gain—if my intention is realized— comes in understanding how structure, opportunity, and human agency interact to create, or inhibit, the possibility of change. Strong States, Weak States, and Public Health In the dramas of public health, nation-states play multiple roles. They are dominant policy actors with the power, if they choose, to make or break public health initiatives. At the same time, states shape the social and cultural context for nonstate actors—members of civil society including (but not limited to) social movement and other forms of collective organization— that seek to advance their own public health agendas. As I explained earlier , I employ the notion of strong and weak states as developed by John Peter Nettl, Herbert Kitschelt, Theda Skocpol, and others as a heuristic device both to illuminate and to raise questions about the behaviors of the actual states whose actions I studied. Although these scholars’ ideas had suggested the initial hypothesis that state strength would be associated with more aggressive and effective public health policy making (see, for example, Nathanson 1996), it became apparent early in my research that this hypothesis was magnificently—but instructively—wrong. 203 The first step in my analysis is to order the four countries according to their relative state strength. France is the ideal-typical strong state. It is possible to regard the contemporary state in France as a close approximation to the model of the strong state. From the time of the absolute monarchy to Gaullism—and even to recent socialist policy—appeal to the state has seemed to be a natural course for all those in positions of political power. The state is the seat of legitimacy upon which aspiring future elites set their sights; its educational socialization operates more or less satisfactorily, and its control over society is extensive. Such a state renders the introduction of mechanisms of participatory democracy almost impossible. (Haas 1992, 63–64) The French state is and has long been strong institutionally: centralized geographically and politically and guided by a corps of officials impervious (ideally, if not in fact) to outside pressure. Inseparable from these institutions is a political culture that identifies the state as the sole repository of legitimate power, specifically the power to initiate and implement public policy, and that delegitimizes other voices, making it difficult for those voices to be heard. Among the four countries included in this project, France anchors the strong-state end of the strong state–weak state continuum . Yet France’s capacity to act in the domain of public health has been, as the narratives have shown, surprisingly limited. I will return to the questions raised by this paradox once the remaining three countries have been located on the strong state–weak state continuum.1 Just as France has been the exemplary strong state, the United States is the quintessentially “weak state.” “The absence of a sense of the state . . . has been the great hallmark of American political culture,” Stephen Skowronek has observed, though he located that sense of absence in the early twentieth century, suggesting that much has changed since then (1982, 3). Other scholars emphasize enduring structural characteristics—geographical and political fragmentation and the near absence of a cohesive and politically independent officialdom—to argue that the American state acts to minimize capacity for policy innovation and implementation and to maximize the access of non-state actors to policy gatekeepers (Kitschelt 1986; Walker 1991). A state’s capacity in the abstract may be less important, however, than the disposition to exploit that capacity for policy making purposes: “governments [have] routinely expanded capacities when their policy prescriptions called for it” (Dobbin 1994, 229). Aversion to the use of federal...

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