Speculations fumbling for a grasp of actually existing public health
As I’ve mentioned, I’m slowly (glacially, holy moly) reading around in the history of public health, mostly focused on the US. I’m doing this, obviously, because I want to know more about public health as it has developed over time. I keep getting distracted along the way by different claims made that situate the field in time in different ways. I may have mentioned this before on here, I don’t remember, but it seems to me there are four basic ways to situate the field in time. Frankly I’m unsure how much this is something I made up in my head vs something I’m finding in the literature, an uncertainty I don’t like but which isn’t worth the time to unpick just now. Briefly, one way is to just do the work now and not think much about the field’s history. A non-situating, so to speak. Another is to say public health is present any time people live in a group, because group life necessarily involves doing public health, such that life in a group is understood evidence that public health exists. This is in important respect just a circuitous route to non-situating, since to conceptualize an activity as a matter of unmediated human nature is to conceptualize that activity with no regard to particularities of time and place. A third is to treat public health as synonymous with modernizing or developmentalist projects of remaking parts of social life to bring them up to date in some way, and/or to treat it as synonymous with any form of management of group life in a political sense (‘biopolitics’) where the ‘life’ involved is understood as an aggregate of some kind. That’s abstract. I mean things like large scale infrastructure construction, factory inspection, and a great deal else. This third way of treating public health has a lot to recommend it (‘Area Marxist Denounced For Sympathy With The Third Way!’) but in my view it’s not specific enough. The fourth way is public health as it currently exists, understood as beginning roughly in the 19th century, depending on the country. That’s not just a thing I say; I’ve seen multiple historians of the field (and I regret not tracking this better) say something along the lines of ‘this is when public health really began’ or ‘this is the origin of public health properly speaking.’
This may be obvious but part of what I’m trying to get at is that anything that affects people’s health (understood any which way, and noting that ‘people’, ‘people’s’, and ‘health’ are themselves all interpretively up for grabs and conflict/tension-laden over time!) has an important bearing on public health, but not all of it is public health. Ditto for state management or collective activity that affects people’s health - only some of it is or is in public health, much of it (even when consciously conducted in very public health proximate ways like use of statistics etc) is important for public health but not necessarily in/of the field.
My current working assumption is that we should think of public health as something analogous to, I don’t know, employment discrimination law or cellphones or the edtech industry: it’s something capacious but also something that doesn’t exist in all times and places, nor in all times and places within capitalist society. It’s something particular to a specific span of time in capitalist societies, with those spans of time not just understood quantitatively as a number of years but qualitatively as a specific lived particularization of capitalist social relations, institutionalized in specific ways with something of a real texture lived out, shaping lives and experiences and politics and so on within that particularization. By, again, clumsy analogy, more regulated ‘keynesian’ capitalism and neoliberal capitalism have different textures of life, and even more so when we account for everything summarized by the addition of national labels like ‘in Britain’ or ‘in the US’ etc (ie, neoliberal Britain and the new deal US involve - or just are? - different textures and rhythms and tissues of life as actually lived). This is all me fumbling for a degree of concreteness re: public health as I mean the term, but I think there’s a there there, so to speak, it’s not just me having weird hang ups - there are real differences in the actual world that I’m trying to figure out how to articulate.
I agree with that 4th sense of the term and part of what’s on my mind as I read the history of the field is trying to sort out what I’d call an adequate Marxist conceptualization of this 4th sense of the field. Put in very compressed form I’d like to be able to situate the field broadly within a historical arc analogous to, and within the theoretical framework laid out in, Simon Clarke’s book Keynesianism, Monetarism and the Crisis of the State and his contributions to the volume he edited called The State Debate. It seems to me that work implies public health is partially an institutionalized form of class collaboration insofar as it helps maintain the current lives of some members of the working class, addresses some grievances of some members of that population, divides that population up into segments and atomizes it into individuals, helps keep workers showing up at their jobs regularly and helps facilitate the reproduction of labor power as a commodity available on the labor market, and presents a good deal of the above as a matter of apolitical givens (to the degree that health and what produces it is understood in any given time and place as a known thing rather than something that’s both terrain and product of struggle) and when it presents elements of these matters as political that politics tends toward the technocratic.
There’s also some significant degree of top-down power involved: public health can involve coercion, including coercion on powerful actors (the CDC’s eviction moratorium early in the covid pandemic is a case in point). This latter element is closely related to public health being a creature of the state, and being part of the state’s role as manager of the social in service of capital accumulation (which includes managing capital accumulation to some extent - the state steps in to restrain some individual capitalists sometimes in order to preserve the general conditions conducive to capital accumulation). This is as far as I know how to get with this characterization so far, and I suspect there may be some limitations to how much specification of public health can be done at this degree of theoretical abstraction - that is, I suspect that to some degree the field has to be understood in more concrete terms that, hmm, well, hang on. I was about to say ‘has to be understood in more historical terms’ but I think that’s not quite right because everything I said abstractly is also historical in an important way. What I really mean is not ‘more historical’ but rather ‘more historianly.’ Historians’ generally preferred fairly concrete level of analysis isn’t the only way to think historically. I suspect that adequately thinking historically actually involves moving back and forth between degrees of analytical abstraction: to bluntly oversimplify, it requires some theorist-type inquiry and some historianly inquiry in a kind of back and forth.
I’m probably repeating myself here but what I’m trying to get at is that public health in this sense has its origins as, on the one hand, a set of responses to a variety of developments arising from capitalism’s tendencies to crisis and conflict, specifically a set of responses lived out within (and transformative of!) a set of resources (broadly construed) at hand at the time of those crises and conflicts, and, on the other hand, a mechanism for both reproducing aspects of those initial responses and the resources informing them (this is part of what I had in mind when I said ‘semi-medicalized’) and for helping manage/steer/live within/govern/whatever the word is capitalist social relations subsequent to the development/institutionalization of public health. (That’s part of what I mean by the comparison in passing to employment discrimination law.) Novel developments scramble life in big ways and lead to novel responses which then become part of the tissue of life in, part of the context for, subsequent developments.
Anyway. What I was fumbling for is that I think everything I said here is right but also the account of public health as I gestured toward it here is inadequate without more reference to concrete developments. Put generally for now, intended as a way to help me think about this stuff as I continue the glacially paced literature review, I think there are relative disruptions of, or threats of disruption of, capital accumulation and/or threats to the political order, which then lead to new changes in state institution. Basically shit gets crazy and that provokes conversations about how to restore governability (and it’s not necessary for participants in those conversations to understand themselves that way: people in struggle very reasonably tend to be willing to go back to relative normal when their demands are met; that is implicitly them having/being in a conversation about the conditions of governability). Those conversations lead to innovations of various kinds, some of which get institutionalized. This is the story of labor law, the welfare state, anti-discrimination law, and public health. To say ‘public health arose as crisis-response, then became institutionalized’ seems to me more right than wrong though a lot of that crisis response occurred within existing institutions so ‘arose and then’ is a little misleading, as it’s also a matter of existing institutional actors organizing themselves differently.
Part of what I’m trying to draw out here is that I think there’s something of a plot line or narrative arc here that’s baked in, really exists in the world as unfolding process or dynamic logic, where there’s a problem leading to some aspects of social life becoming up for grabs politically in a relatively new way, then there’s a relative solution which locks down those aspects of social life so they’re not up for grabs in the same way, and once normal (new normal, relative normal) is temporarily introduced (normal is always temporary in capitalism because there’s always two clocks ticking, one related to the rapidity of drift/evolution in social life - think about the changes in the last 30 years re: cell phones, computing, social media - and one related to capitalism’s tendencies to crises and large scale struggles). Under the restored normality, what was a relative solution now forms part of the complex of techniques of governance in place. And this is sort of a one way street: institutional innovations resulting from past openings (openings that were relatively forced by the dynamics I mentioned in my last parenthetical!) will not produce new openings in the future, generally speak. Governance-serving normality-fostering reforms are not in fact the thin end of any wedge toward a better future. Any such wedging open of a space possibility is exclusively the action of large scale collective action, appearances to the contrary are misleading and/or magical thinking. I think because past reforms were often introduced by people who at least in part meant well, and in so far as they did arise in response - they did in a nontrivial way address some aspects of the suffering people endured - those reforms and the institutions/professions/bodies of knowledge/milieus related to them get a kind of aura of left/emancipatory politics. There’s a kind of myth, one that’s widely held including by a lot of historians, about labor law in the US that the National Labor Relations Act in 1935 was this massive emancipatory move full of great promise which was later lost or closed down by subsequent developments. (I mean this as analogy so I won’t get into the details but I will say, this myth has some plausibility because there was a real opening at the time but it was entirely a matter of the working class disrupting capital and exploring new possibilities for living; state actors were opponents of that opening and ones who seemed like its allies were in the role of good cop, regardless of how they understood themselves.)
That myth at least implicitly treats the early personnel involved as a heroic generation/cohort existing in a moment rich in possibility, followed on later by less heroic cohorts in moments of reduced possibility. The implication of this sort of implied hero myth is that the field could become newly heroic in some fashion. That’s generally just false - new openings are possible but only due to capital’s crisis-and-struggle dynamics, not as something that can arise from within any particular field or institution nor something that can arise through ordinary in-system politicking like voting and lobbying and so on. That’s not to say nothing can be won ever via systemically-normal politics, it’s that what can be so won, while very high stakes for people, literally life and death sometimes, is, on the one hand, all system-compatible in a way that doesn’t make any contribution per se changing the political terrain from a socialist perspective, and on the other hand all seriously constrained by the logic of the system: there’s a reason the heroic generation keeps not returning and it’s not simply lack of political will. It’s that the logic of the process - this is what I meant by ‘narrative arc’ goes in the direction I mentioned. It goes disruption, opening, restoration, closure, with the disruption a) not generated within any fields/institutions of social management (and health is in part a category of social management) but rather arising from capital’s struggle-and-crisis dynamic as I said and b) a cause rather than effect of changes in those fields. More simply: real change comes when very large numbers of people step outside ordinary life’s ordinary scripts in a way that is massively disruptive to business as usual, and there just is not a pathway for fields like public health to generate such a stepping outside. The only pathways for such are either relatively conscious collective activity like in protests etc, or relative unconscious collective activity like in various crises (the marxist account of capitalism as crisis-prone is implicitly a story about relatively unconscious collective activity plus a story about processes that produce certain specific kinds of action-informing consciousness, like of the ‘oh shit I can’t afford to live as I way anymore, what now?!’ variety).
As I’ve mentioned on here before I’m a huge fan of Jack Copley’s book Governing Financialization. Everyone interested in capitalism should read it. I don’t recall if I’ve mentioned this on here but when I reviewed the book for Legal Form I had the thought that Copley’s book implicitly treats policy as effect of crisis - not mechanically so but in a nuanced way: people make context-influenced choices. I said something like this means we can treat policy as the detritus of crisis. Part of what I’m fumbling for here is to say that this extends to public health. It too is a detritus of crisis. And a closely related part of what I’m fumbling for here is fleshing out a little more what I mean by this, in a non-mechanical way. Basically I think after crises (whether due to capitalism’s tendency to tie tourniquets around important areas of social life via financial meltdowns and similar - crisis in an especially negative sense - or whether due to large scale collective action which constitutes a crisis from the perspective of the state and capitalists) responses to the crisis tend to stick around as newly institutionalized and as new additions to the ensemble of techniques and institutions of governance. (This doesn’t mean the number of such techniques and institutions only grows, they can die off too. Churches haven’t died off but they are less important socially now in a lot of the world than they used to be. Likewise the sorts of local political boss ‘machine politics’ that once characterized many US cities in a big way still exists but less so than before. The same goes for declines in unionization after the Second World War.)
As I said, or maybe tried unsuccessfully to say, I think there’s work to be done (and it may well have already been done, I’m not trying to make claims about work I’ve not read yet) in theorist mode to abstractly place public health within an abstract/general understanding of capitalist social relations and work in historianly mode to account for important concrete elements of the field and how those concrete elements are maintained over time. That latter element means getting to know some of the specifics including concepts of science and medicine that were in play, which partially influenced and partially were vehicle for/served to mediate the more general tasks of public health. As in, insofar as public health’s institutionalization was a crisis response, the doing of that response was conditioned by or conducted with or lived out through the specific set of ideas, techniques, institutions available before and during the significantly conditioning crises in question. This is very hard to specify because there wasn’t just one crisis nor was there just one place and time where this happened, rather there were multiple problems over time that were increasingly dealt with by early public health practitioners and institutions as they became increasingly self-conscious as a field. Like, over time there became a growing capacity for people to say ‘hey this is a public health problem’/‘this one’s for the public health people’.
I think medicine is a big part of the story here and one I’ve been hesitant to address because the reading list already too big. (Ugh!) I’m inclined to say, with great trepidation given how little I feel like I actually know here, that public health in the contemporary sense of the term refers to a practice, really a set of practices, by state personnel involving a semi-medicalized conception of the practices. As I assume I must have said a bit about on here before, this means the ‘public health’ of the era of sewer building is not the ‘public health’ of the era of maternal mortality regulation that Natalia Molina talks about in her book. Even if the two may overlap in time to some degree, they’re different practices involve different theories, outlooks, paradigms, etc. I also assume that degree of semi-medicalization is itself a line of tension and conflict within the field at least to some extent.
I’m sort of looping back to my earlier ‘there’s four ways to think of public health…’ thing here, unfortunately, but I dunno what else to do. A related thing that I’ve only alluded to a little is the popular conceptions of public health. I suggested the field is of the ‘good cops’ to an important degree. A friend of mine used to say that the society we’re in trains us into an impulse like ‘when in doubt, look up.’ That impulse works worse if there’s no one up above to look to. Public health is part of the ensemble of personnel to which we can look up, to speak. That’s not automatic though (and it’s subject to contestation in important ways, and not only in an emancipatory direction, more on this in a moment). It has to be built and maintained actively and the field can’t necessarily accomplish that alone. Put simply, public health is conducted as it is in part in context of some degree of belief in the field such that the field has some degree of a popular base or a constituency that is its clientele. I suspect that the border between public health and ‘the population that is public health’s clientele or base’ is genuinely blurry but I’m not going to get into that further now. Likewise, not going to get into it, but I think there’s likely useful work to be done sifting public health actions via Goran Therborn’s typologies of how ideology operates in his book on ideology: for instance, when does public health produce resignation - like around covid! - vs when it produces a sense of fear vs a sense of being well represented, etc. And as I wrote about a long while back now Steve Kettell and a collaborator ran an analysis of the different modes of depoliticization that UK government officials used in doing various forms of pandemic policy.
For now, I just want to connect the field’s relationship to constituencies with something in Raymond Williams. In his book The Long Revolutuion Williams talks about the operation of what he calls ‘selective tradition’, which as far as I can tell refers to institutions of reputable curation (or the effects of the actions of those institutions) operating on the past. If you look at a history textbook covering any time and place, you’ll find that it highlights some things, mentions others with less detail, and leaves some things out. That, scaled upward, is selective tradition, I think: it’s the formatting of or production of a representation of a past time and place in a way that forms a reference point for people in a later time and/or different place. There’s nothing wrong with this and there’s a lot good about it, especially when done well, and it’s likely just unavoidable given how capacious and multifaceted social life is. At the same time, the results of the selective tradition tend to skew up upward in negative ways. As Simon Clarke puts it, “the kinds of concepts and assumptions that are most easily taken for granted, that are felt to need critical examination the least, are those of the dominant intellectual tradition and the dominant ideology it expresses” which means there is an important danger of people thinking they are letting “the facts speak for themselves” while actually “letting the dominant ideology speak through the facts.” Critical work has to push against the (effects of?) selective tradition/the dominant ideology, and times when the dominant tradition/ideology seems to turn our way are not stable or to be counted on - what we don’t control is, well, out of our control! That’s put far too vaguely but I have in mind in particular the period early in the pandemic when there was an appearance of a consensus on a solidaristic form of health-promotion. That this was rapidly taken apart is partly evidence that the consensus was more thin/less far reaching than it appeared but it’s also a matter of how that consensus wasn’t ‘ours’, but rather ‘lived’ mostly within (existed significantly within/dependent on dominant institutions subject to being rapidly reoriented, as occurred, rather than being housed/practice/produced/maintained within organized forms of popular power). In the very general terms I’ve used here I don’t think that was a unique period but rather was a type of period/type of sequence of events that recurs periodically in capitalist societies over time. Sometimes what seems like openings and shifts leftward are in important respects a kind of heading off (not cynically and consciously, or not mainly so, but that’s not especially relevant here) of more fundamental changes. I don’t mean just ‘stopping revolution’, I mean ‘working against laying seeds of relative democratization via institutions of popular power to govern more of social life or at least disrupt capital accumulation.’ To put it another way, insofar as an emancipatory opening mostly exists via a set of personnel fairly far up the food chain like those who set policy and oversee the strategies of its enacment, that opening can close quickly when those personnel are replaced or change their minds, which is different from am opening that is more deeply rooted in a widespread social base.
I’m fumbling again (‘open mode’ actually means ‘fumbling circuitously in the hopes of eventually sidewinding forwards’), I think what I’m fumbling for is that public health as actually existing field of practice organized in bodies of knowledge and institutions, went through very tumultuous changes and at the same time it was accompanied by the operation of a selective tradition that sought to provide resources to the field (was a way the field sought to provide resources to itself) to help make sense of and respond to those changes, through a mix of emphasis on what was new and what was old (thinking again of the EP Thompson line, something like ‘values in search of a genealogy’) and simultaneously there’s an ongoing process that serves to situate the field for the larger public. The latter, the processes situating the field for the public, were partly and only partly conducted within the field. The field’s political efficacy, so to speak, is result of the complex interaction of developments in the field, the conception of the field externally, ‘bridge’ elements spanning the inside/outside of the field, and larger systemic dynamics I’ve kept harping on about re: crisis and contestation.
I need to get off here and onto other obligations, but very briefly I did want to get back to what I said above, that public health is subject to contestation in a non-emancipatory direction. I had in mind all the right wing bullshit around vaccination as well as the Biden administration’s use of the unvaccinated as scapegoats. Abby Cartus’s article from Peste (RIP in peace!) on this remains relevant imho. (Googling for that I found this old post of mine where I am again going on about Raymond Williams and how I need to read him more seriously. Glacial pace like I said, god damn - over a year and a half on and still at this same basic point. Maybe the openness of the mode is the space in the mud churned by the tires spinning in place without any forward motion...! But hey, at least there are extended metaphors...? Ugh again.)
Alright, I’m out. Hang in there, good people, and the rest of you as well!