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Chapter 1 Introduction S TORIES 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 and demanding action to contain some perceived threat. As the action proceeds, the threat is defined and redefined, its reality contested, and its source disputed. In subsequent scenes, public authorities may or may not respond. Citizens may or may not take matters into their own hands. Dramatic resolution may or may not be achieved. The public’s health may or may not be advanced. Tension and struggle—conflicts of power, interest, and ideology—are the hallmarks of the public health drama, just as they are the hallmarks of any circumstance that pits one set of powerful interests , however nobly defined, against another (there is, almost always, another). Dramas of public health presented in narrative form are the raw material for this book. Its subject is the analysis and interpretation of these dramas as forms of struggle for social change. I define public health as “community action to avoid disease and other threats to the health and welfare of individuals and the community at large” (Duffy 1990, 1). The critical phrases in this definition are “community action”—public health is society’s collective response to a perceived common threat—and “avoid disease.” This is a book about the vicissitudes of societies’ collective struggles to avoid disease. It is not about health-care policy as this phrase is commonly used, to mean policies for the provision of medical care to individuals already ill. Nor is the scope limited to the formal structures in which public health is embodied: health ministries, local health departments, designated public health officials. Action to prevent disease takes many forms, ranging from the charismatic individual on the corner handing out clean needles to injection drug users, through the lawyer spearheading a class action suit against the tobacco industry, to the parliamentary debate pitting proponents of disease prevention against opposing economic and moral interests. Public health policies include 3 any public or publicly advocated policy—ranging from immunization to income redistribution—intended in whole or in part to improve health or prevent disease. Public health is inherently political. Attributions of disease causation are statements about the location of responsibility for human pain and suffering and, by the same token, about the measures that should be taken to prevent these maladies from occurring. Major sources of variation in these measures are the extent of their challenge to the existing social order and the degree to which they invoke the power of the state. Witness, for example, the nature of debate about the causes of tuberculosis at the beginning of the twentieth century in France (Barnes 1995). The monarchist right gave its etiological preference to the irresponsible and immoral drinking habits of the working class and resisted social reform. Socialists attributed it to unsanitary housing and exposure to the newly recognized tubercle bacillus, downplayed alcoholism, and demanded parliamentary attention to poverty as the ultimate cause. The increasingly influential revolutionary syndicalists rejected mainstream causal theories altogether. Tuberculosis, they maintained, was “inherent in the logic of capitalism.” Medical prescriptions , clinics, and sanatoriums were scams intended to deflect real reform and sop the conscience of the “compassionate elite.” Defeating tuberculosis required overthrowing the capitalist system. Although this may be an extreme (or just an unusually clear) case, remarkably parallel political commitments continue to be at least implicit, and often explicit, in current intellectual as well as policy debates on disease causation and the role of public health. The public health stories I have selected to relate and to analyze are infant mortality and tuberculosis at the turn of the nineteenth century and the contemporary dramas of cigarette smoking and HIV/AIDS in injection drug users. The narratives in the first part of this book describe how each of four countries—the United States, Canada, Britain, and France—experienced and responded to these common threats to their publics’ health. The goals of the analysis in the second part 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. Background The idea of public health emerged in Britain and France in the first...

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