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July 27th, 2020

↳ Public+health

Avey From Cane

PUBLIC HEALTH FEDERALISM

Catastrophic deficiencies in the federal response to the Covid-19 pandemic have led to renewed discussion over federalism and its discontents. The divergence among state responses to the crisis in the absence of federal guidance has produced analyses of Trump’s unique, “narrow” sense of federalism, pronouncements of “a new era of federalism,” and hopes for a solidarity-minded “civic federalism.”

In a 1997 article, health law professor JAMES G. HODGE JR. analyzes the impact of state-centric “new federalism” jurisprudence on the government’s ability to realize public health goals. Hodge places new federalism in the context of decades of increasing intrusion by the federal government on states’ power over public health policy:

"The impact of new federalism on the field of public health law is seen in the history of public health regulation. The metamorphosis of public health regulation from purely local to predominantly national means resulted from increased federal presence in the field corresponding to a deemphasis on traditional federalism. It is an inescapable conclusion that an increased federal presence shifted public health goals. National public health priorities dominate local ones. New federalism restrains the federal intrusion on state public health powers by requiring Congress to operate within the constraints of the political process. As a result, state police powers exercised in the interest of public health are strengthened emphatically by the political process confining federal authority to enter the field."

Full paper available here.

  • In an article published this April, Hodge reassesses federal vs. state public health powers in light of disparate responses to the pandemic: "Americans are left wondering, 'which level of government is actually in charge here?' In the face of a pandemic like Covid-19, the answer under principles of federalism is increasingly clear: neither." Link.
  • "American federalism—with its fissures and fractures—haunts the state of emergency." A March post from Phillip Rocco. Link. (See also Rocco's recent post on fiscal federalism in Notes on the Crises.) Along similar lines: Rocco, Daniel Béland, and Alex Waddan on the fiscal barriers to pandemic response. Link. And Nicole Huberfeld, Sarah H. Gordon, and David K. Jones argues that the pandemic has magnified the state-level inequities fostered by federalism. Link.
  • For another view on the relationship between federalism and public health: A 2014 paper by Adam Varvel on the West Nile outbreak of 1999. Link. See also: A post-SARS policy brief on the impact of federalism on international health regulations. Link.
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April 7th, 2020

Big Horse

BOUND SPREAD

Histories of public health

Comparisons of responses to the Covid-19 crisis across national lines yield as many questions as answers. Divergent histories of public health programs, differences in cultural norms, population density, age distributions, and internal migration patterns create a muddy picture for causal understandings of the national variations in impact.

PETER BALDWIN's Contagion and the State in Europe 1830-1930 provides a fundamental historical study on these questions. The book explores the "reasons for the divergence in public health policies in Britain, France, Germany and Sweden" and the "spectrum of responses to the threat of contagious diseases such as cholera, smallpox and syphilis."

From the book's conclusion:

"Since at least the era of absolutism, preventing and dealing with contagious and epidemic disease have together been one of the major tasks of states. Given that, from the first European cholera epidemics to the cusp of the antibiotical era, the problem faced by each country has been much the same in biological terms, why have they responded in markedly different ways? Especially before the bacteriological revolution, etiological knowledge was inextricably bound up with political, administrative, economic, and geographic factors.

The fundamental implication of a political interpretation of public health is that prophylactic strategy and ideology are correlated. Approaches to prevention may be expected to reflect common assumptions held in a society as to where group and individual interests diverge, how much autonomy citizens can rightfully claim, the power of the community over its members. The right to be spared prophylactic imposition was not the only measure of liberty; there was also the freedom from disease. Traditional conservative quarantinists argued this line. Conversely, liberals objected to such interventions when they impinged on personal liberties too drastically or for insufficiently redeeming purpose. There was, also an understanding of public health that transcended such sterile oppositions between community and individual, holding that society’s concern with public health was a positive freedom that, while limiting absolute individual autonomy, returned to each a higher measure of liberation from affliction.

Such political interpretations of preventive strategies appear, however, to have inverted matters. It was not British liberalism or German interventionism (to take again the outliers) that, by themselves, determined prophylactic strategies, but the imperatives of geoepidemiology, and the associated factors identified here, that helped shape not only the preventive precautions they encouraged, but indeed the very political traditions of these nations."

Link to the book.

  • A new podcast from the Cambridge history department discusses Baldwin's book as a guide for thinking through the present crisis. Link.
  • For the classic international history of public health, see George Rosen's 1958 A History of Public Health. Link. And see his 1947 paper "What Is Social Medicine?" Link.
  • "After yellow fever was firmly ensconsed, it underpinned a military and political status quo, keeping South America under Spanish rule. After 1780, and particularly in the Hatian Revolution, yellow fever undermined the status quo by assisting independence movements in the America tropics." A 1999 article by J.R. McNeill on "Ecology, Epidemics, and Empires." Link.
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