March 13th, 2021

Development in Rose

PUBLIC HEALTH & MEDICINE

The Covid-19 pandemic has brought attention to the underfunding of US public health infrastructure over the last several decades. Alongside a fragmented system, a gap has emerged between public health and clinical care, with consequences for the public.

A 2000 article by ALLAN BRANDT and MARTHA GARDNER offers insight into the historical origins of this divide, tracing the "antagonism" between public health and medical fields in the US to the early 20th century.

From the text:

"As the medical profession became more homogenous and powerful, medicine increasingly viewed public health interventions as a potential infringement on the doctor-patient relationship. Early 20th-century calls for the reporting of communicable diseases, such as tuberculosis and syphilis, came under sharp attack from physicians’ professional organizations on these grounds. Physicians complained that such reporting requirements would ultimately dissuade patients from seeking care. Public health officials insisted that the public good periodically required the abrogation of individual rights. The interests of the state in policing individuals with communicable diseases now seemed at odds with the sanctity of the doctor-patient relationship.

The delivery of health services by public health agencies appeared to threaten the economic well-being of the rising medical profession. Institutions and programs from outpatient dispensaries to well-baby care, from diagnostic laboratories to school-based nursing, came under attack as incursions into the medical profession’s domain. Public health officials were quick to identify the economic interests behind these protests, labeling such attacks on state authority as mere hypocrisy and medical self-interest. Even so, medicine generally triumphed in direct political conflicts. Innovative programs such as the Sheppard-Towner Act of 1921, which was organized to ensure prenatal and postnatal care for mothers and infants, fell prey to medicine’s lobbying in Congress and the state legislatures. The rise of the hospital, focused on acute tertiary care, as the preeminent institution of modern medicine further separated medicine from public health. Public health officials no doubt chafed at the notion of ending their efforts at the hospital’s door. Instead, legislative and administrative proposals for neighborhood public health centers that could combine public health interventions with clinical care were derailed by medical interests because of concerns about provision of 'free care' to potential paying patients."

Link to the article.

 Full Article

November 7th, 2020

Gathering

WORLD HEALTH ORGANIZATION

With Covid-19 cases again rising around the globe, the World Health Organization (WHO) has faced increased scrutiny from governments on its handling of the early pandemic. Today, the organization plays a key role in defining global public health and coordinating responses to disease, but this mandate has shifted over time.

A 2011 paper by THEODORE BROWN, MARCOS CUETO, and ELIZABETH FEE investigates the origins of WHO's current global public health program and its partnerships with non-governmental institutions.

From the paper:

"In January 1992, the Executive Board of the World Health Assembly decided to appoint a 'working group' to recommend how WHO could be most effective in international health work in light of the 'global change' rapidly overtaking the world. The executive board may have been responding, in part, to the Children’s Vaccine Initiative, perceived within WHO as an attempted 'coup' by UNICEF, the World Bank, the UN Development Program, the Rockefeller Foundation, and several other players seeking to wrest control of vaccine development. The working group’s final report of May 1993 recommended that WHO—if it was to maintain leadership of the health sector—must overhaul its fragmented management of global, regional, and country programs, diminish the competition between regular and extrabudgetary programs, and, above all, increase the emphasis within WHO on global health issues and WHO’s coordinating role in that domain.

In 1998, the World Health Assembly reached outside the ranks of WHO for a new leader who could restore credibility to the organization and provide it with a new vision: Gro Harlem Brundtland, former prime minister of Norway and a physician and public health professional. She established a Commission on Macroeconomics and Health, chaired by economist Jeffrey Sachs of Harvard University and including former ministers of finance and officers from the World Bank, the International Monetary Fund, the World Trade Organization, and the UN Development Program, as well as public health leaders. The commission issued a report in December 2001, which argued that improving health in developing countries was essential to their economic development. The report identified a set of disease priorities that would require focused intervention. Brundtland also began to strengthen WHO’s financial position, largely by organizing 'global partnerships' and 'global funds' to bring together 'stakeholders'—private donors, governments, and bilateral and multilateral agencies—to concentrate on specific targets. A very significant player in these partnerships was the Bill & Melinda Gates Foundation, which committed more than $1.7 billion between 1998 and 2000 to an international program to prevent or eliminate diseases in the world’s poorest nations, mainly through vaccines and immunization programs.Within a few years, some 70 'global health partnerships' had been created."

Link to the piece.

  • Anne-Emanuelle Birn and Nikolai Kremenstov offer an account of the 1978 Alma-Ata conference, which was hosted by the Soviet Union and advocated for a WHO focus on primary health care. Link. David A. Tejada de Rivero recounts WHO's move to selective primary health care, relying on smaller, low-cost interventions. Link.
  • "Infectious diseases have gained ground as global health priorities, while non-communicable diseases and the broader issues of health systems development have been neglected." By Eeva Ollila. Link.
  • "Although the [World Bank's] role in generating and disseminating global health knowledge is important, its main advantage compared with other international institutions is its ability to mobilize financial resources." Jennifer Prah Ruger looks at the role of the World Bank, which began to increase its influence in global public health in the 1980s. Link.
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October 17th, 2020

Change Point

HEALTHCARE & UNIONS

Explanations for the absence of a universal healthcare program in the United States tend to focus on the obstructive role of the American Medical Association, which, via an extensive lobbying campaign, prevented the passage of a national health insurance plan in 1945. Much less attention has been paid to the diverging and often contradictory interests of organized labor during this period.

In her 2006 book, JILL QUADAGNO considers the relationship between industrial policy and healthcare reform, analyzing how the labor movement came to unify behind private insurance providers by the late 1940s.

From the text:

"Although Taft-Hartley outlawed independent, union-run welfare funds through a provision that employers had to share equally in the administration of any pension or health plan, it had left unresolved the issue of whether employers had to bargain over fringe benefits. In 1948 the National Labor Relations Board ruled that fringe benefits were subject to collective bargaining, a decision that was upheld by the Supreme Court. Then in 1949 the Wage Stabilization Board, whose job was to keep inflation from wage increases under control, determined that fringe benefits were not inflationary. With many options for increasing membership closed off, union leaders made bargaining for fringe benefits a top priority. Fringe benefits became organized labor’s key strategy for recruiting and retaining members. Over half of strikes in 1949 and 70 percent in 1950 were over this issue.

Between 1946 and 1957 the number of workers covered by negotiated health insurance plans rose from 1 million to 12 million, plus an additional 20 million dependents. Close to 95 percent of industrial workers represented by the CIO were covered, compared to only 20 percent of skilled craft workers affiliated with the AFL. As for national health insurance, most industrial unionists now 'gave [it] only lip service.' Private health insurance 'had taken the heat off.' The expansion of private health benefits divided the working class into those who had health insurance and those who did not, and it transformed the way organized labor mobilized politically. Instead of requiring leaders who could inspire the troops to stand by the barricades, the labor movement needed leaders who could master complex financial instruments. The next battle would be won by policy experts with calculators, not charismatic militants who could issue a call to arms."

Link to the book.

  • "Labor unions, senior citizens, socialists, and other groups have certainly participated in campaigns to redesign the health care system, but the campaigns themselves have most often been initiated and run by elite organizations and individuals with little connection to a popular base of support." Beatrix Hoffman on "Health Care Reform and Social Movements in the United States." Link.
  • Maryaline Catillon, David M. Cutler, and Thomas E. Getzen analyze US healthcare provision since 1800. [Link'(https://voxeu.org/article/two-hundred-years-health-and-medical-care).
  • "By the early 20th century, Britain had a strong civil service and competing, programmatically oriented political parties. However, the contemporary United States lacked an established civil bureaucracy and was embroiled in the efforts of Progressive reformers to create regulatory agencies and policies free of the 'political corruption' of 19th century patronage democracy." Ann Shola Orloff and Theda Skocpol compare healthcare provision in the US and UK. Link. And a 2011 article by Howard Glennerster and Robert C. Lieberman argues that "there are more parallels and points of tangency between the two systems than are readily apparent." Link.
 Full Article

March 9th, 2020

Flanked by Two Dolphins

SYSTEM CIRCULATE

An ecosocial theory of disease

The correlation between health, income, and wealth is widely recognized in contemporary research and policy circles. This broadly social understanding of public health outcomes has its origins in a theoretical tradition dating back to the 1970s and 80s, in which scholars began to embed medical research within a political and economic framework.

In a 2001 paper, epidemiologist NANCY KRIEGER seeks to strengthen the theoretical foundations of epidemiological research by linking them back to biological study.

From the paper:

"If social epidemiologists are to gain clarity on causes of and barriers to reducing social inequalities in health, adequate theory is a necessity. Grappling with notions of causation raises issues of accountability and agency: simply invoking abstract notions like 'society' and disembodied 'genes' will not suffice. Instead, the central question becomes who and what is responsible for population patterns of health, disease, and well-being, as manifested in present, past and changing social inequalities in health?

Arising in part as a critique of proliferating theories that emphasize individuals' responsibility to choose healthy lifestyles, the political economy of health school explicitly addresses economic and political determinants of health and disease, including structural barriers to people living healthy lives. Yet, despite its invaluable contributions to identifying social determinants of population health, a political economy of health perspective affords few principles for investigating what these determinants are determining. I propose a theory that conceptualizes changing population patterns of health, disease and well-being in relation to each level of biological, ecological and social organization (e.g. cell, organ, organism/ individual, family, community, population, society, ecosystem). Unlike prior causal frameworks—whether of a triangle connecting 'host', 'agent' and 'environment', or a 'chain of causes' arrayed along a scale of biological organization, from 'society' to 'molecular and submolecular particles'—this framework is multidimensional and dynamic and allows us to elucidate population patterns of health, disease and well-being as biological expressions of social relations—potentially generating new knowledge and new grounds for action."

Link to the piece.

  • Krieger's 1994 article takes a closer look at epidemiological causal frameworks, questioning the adequacy of multiple causation. And her 2012 paper asks: "Who or what is a population?" and articulates the analytical significance of this definition for epidemiological research. Link and link.
  • "Disease epidemics are as much markers of modern civilization as they are threats to it." In NLR, Rob and Rodrick Wallace consider how the development of the global economy has altered the spread of epidemics, taking the 2014 Ebola outbreak as a case study. Link.
  • Samuel S. Myers and Jonathan A. Patz argue that climate change constitutes the "greatest public health challenge humanity has faced." Link.
  • A history of epidemics in the Roman Empire, from 27 BC – 476 AD, by Francois Relief and Louise Cilliers. Link. And a 1987 book by Ann Bowman Jannetta analyzes the impact of disease on institutional development in early modern Japan. Link.
 Full Article

February 18th, 2020

The Importance of Being Evergreen

ADMINISTRATION PRIMARY

A comparative overview of national healthcare systems

In an employer-sponsored healthcare system like that of the United States, deteriorating labor market protections have immediate consequences for access to healthcare. Democratic primary candidates have presented a number of proposals to address declining rates of insurance, ranging in degrees of accessibility, coverage, and number of providers.

In her 1992 book, Healthcare Politics, ELLEN M. IMMERGUT seeks to explain America's healthcare system through a comparison of its history to Switzerland's, France's, and Sweden's. From the author's preface:

"I compare the politics of three countries where national health insurance had been proposed, but where, as a result of political struggles, the final policy results are diverse. Medical associations in all three countries had opposed national health insurance on the grounds that doctors preferred to work as private practitioners and not as government employees. How then could one explain the fact that Switzerland rejected national health insurance, France accepted it, and Sweden not only enacted national health insurance, but later converted its health system to a de facto national health service? The history of each case pointed insistently to the role played by standard political institutions. The Swiss referendum, the French parliament, and the Swedish executive bureaucracy emerged as key elements in an explanation of national health insurance politics in those countries.

The resulting book argues for the primacy of these institutions in explaining policy outcomes precisely because they facilitate or impede the entry of different groups into the policy-making process. In Switzerland, the public interest on any specific policy issue is viewed as the sum of the demands of individual citizens as expressed in national referenda. In Sweden, on the other hand, proper representation for policy issues is a matter of consensual agreements between interest groups, whose large memberships and democratic procedures ensure their responsiveness to the public. In France, the rules of representation stress the importance of an impartial executive standing above the particularistic claims of interest groups. But there is no linear relationship between a specific set of political institutions and the interest groups that will succeed or the health system that results. These histories are filled with unexpected events, sudden about faces, and new strategies. This book is a call to look at these histories, not just at the broad sweep of major events, but also at the seemingly minor struggles that make up daily political life. These are the battles that establish the constraints on politics, but they are also the junctures that extend the limits of the possible."

Link to a downloadable copy of the book.

  • "The postwar growth of public expenditures in the health sector and the growth of universalism in coverage of benefits is tied to the strength of the labor movement in each country." Vincent Navarro's influential 1989 paper situates healthcare policies within a broader distributional framework. Link.
  • "The idea of a British hospital system funded by its users is one which emerged only late in the 19th century. Before this, care was provided through thousands of voluntary hospitals." Martin Gorsky, John Mohan, and Tim Willis on "Mutualism and Healthcare" in the UK. And in a similar vein, David T. Beito's 2000 book on the fraternal societies which provided healthcare to millions of Americans throughout the 19th and early 20th centuries. Link and link.
  • A recent paper by Stefan Bauernschuster, Anastasia Driva, and Erik Hornung uses "the introduction of compulsory health insurance in the German Empire in 1884 as a natural experiment to study the impact of social health insurance on mortality," finding that "Bismarck’s health insurance generated a significant mortality reduction." Link.
 Full Article

January 27th, 2020

Preparation

PATTERN MANAGE

Re-thinking industrial policy

Deindustrialization is a global phenomenon taking place more rapidly in middle- income countries than in high-income ones. Despite the global decline of manufacturing employment, "industrial policy" is increasingly salient in research and policy debates. But deindustrialization poses significant challenges for industrial strategy—particularly as it relates to direct state investment in productive capacity.

In a new article, "Industrial Policy in the 21st Century," Ha-Joon Chang and Antonio Andreoni lay the groundwork for a new theory of industrial policy:

"Since the 18th century, the debate surrounding industrial policy has been one of the most important in the political economy of development. We discuss a number of issues which cannot be accommodated within the neoclassical framework and which are also often neglected by evolutionary and structuralist contributions—namely, commitment under uncertainty, learning in production, macroeconomic management, and conflict management. We also address three new challenges for industrial policy makers in a changing world: the global value chain, the increasing financialization of the world economy, and changes in the rules of the global economic system.

Despite differences across countries in terms of their stages and levels of industrialization, their macroeconomic regimes and their political economy settings, the three sets of neglected issues we focus on are and will remain of paramount importance. The need to address long-term grand challenges like climate change calls for massive and coordinated investments in energy systems, production practices and mobility. The achievement of these global transformations still depends on micro-level structural changes in productive organizations and government interventions in creating new worlds of production as well as managing industrial and social restructuring."

Link to the piece.

  • "Industrial policy can no longer be about industry or manufacturing per se. As the world economy turns increasingly towards services, it is clear that we will need a conception of industrial policy that addresses the need to nurture and develop modern economic activities more broadly, including but not limited to manufacturing." Karl Aiginger and Dani Rodrik's introduction to the special issue of Industry, Competition, and Trade. Link. In the same issue, Nathan Lane presents a "New Empirics of Industrial Policy." Link.
  • In Industrial and Corporate Change, Mario Pianta, Matteo Lucchese, and Leopoldo Nascia assess the post-crisis industrial policies of the European Union and examine the potential for more active public investment policies in the years to come. Link.
  • John Waterbury's extensive comparison between the industrial strategies of Nasser and Sadat. Link. From 1993, Hajoon Chang on the importance of state intervention in the "political economy of industrial policy in South Korea." Link.
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