Thoughts in response to Fairchild and Smillie
I continue to slowly make my way reading around in the history of public health (in the US mostly, at least so far), most recently Amy Fairchild’s book Science at the Borders: Immigrant Medical Inspection and the Shaping of the Modern Industrial Labor Force, and Wilson Smillie’s Public Health Administration in the United States.
Fairchild’s book is excellent and dovetails well with Molina’s book on the history of public health and racism in Los Angeles. Put very briefly, the book argues that medical inspection of migrants was a practice pulled between excluding migrants and socializing migrants to discipline them into being usable labor power. How that tension worked out concretely, and the practices of health and border policing officials changed over time as the book details. As with the Molina, I came away thinking about public health as a political project of making states, both shaping and enacting their agendas, in response to the larger context of capitalist society as it exists dynamically in concrete times and places. The final paragraph of the book’s epilogue describes the authority of the US Public Health Service as laying with its “power to focus the medical gaze as it deemed fit.” In turn, “[t]he medical gaze (...) transformed problems of labor, race, class, and international politics into medical problems” and shaped what counted as ‘solving’ those problems. (276.) These lines bear the marks of the context Fairchild is investigating, namely the use of medicine, and the participation of public health institutions, in border policing in the early 20th century US, but they also are thought provoking as generalizations. More in a moment.
Smillie’s book is a textbook on public health administration, first published in the 1930s, with a second edition in 1940 and a third in 1947. It’s a bit dry and dull to read but as object it’s interesting. It larges focuses on what I’d call technical matters of managing health (understood relatively technically!) and administering (again, understood technically) the logistics of institutions that do that management. The prefaces to the second and third editions highlight the late 30s and the 1940s as eras of massive change in various ways, including both expansion of state capacity and increased knowledge of various realities of health due to the second world war and military’s knowledge of troops. This resonates with my gut feeling I mentioned in my notes in response to Molina’s book that public health and state formation make sense to think about in tandem.
Smillie does two things I found helpful. One is that he notes that changing knowledge of causes of various health harms shapes their prioritization in health policy and health work. This is obvious in one sense - if some condition is just taken as given then it’s not addressed; if its causes are (believed to be) known then it can be addressed, and there can be politicking over whether or not to address it, with that politicking occurring in complex ways involving changing social conditions, cultural sensibilities about what is/isn’t acceptable, and so on. The other is that he tries to comprehensively list all the facets of health to be managed by health officials over time, from clean water and removal of sewage to maintaining food supplies at quantities and qualities acceptable under given conditions, to preventing communicable disease. It’s very expansive and draws out that in important respects ‘health’ is a way of saying ‘decent life’ or ‘acceptable conditions’ or something (obviously a matter of no little politicking). How ‘health’ as a standard is determined - meaning, is the definition of health relatively democratic or not, what knowledges inform it, etc - and what it consists in at any given time is all subject to investigation and is all, as I said, really a matter of complex political processes, in an expansive sense of ‘political’. Two other closely related matters are, first, what kinds of actions and ways of being treated as authorized by status as healthy or not, and, second, what parts of ‘health’ are understood as subject to intervention or shaping by human action, and more specifically are areas where there’s some degree of obligation on (or interest by) the government regarding the matter vs. being something to just be resigned over - I mean ‘we all get old die,’ kinda thing by the latter and I mean ‘it is outrageous that XYZ preventable condition obtains!’ kinda thing by the former. The latter is health as fixed and something to be resigned over, the former is health as malleable and to some extent political, thus something to do something about or expect authorities to do something about.
Getting back the lines I quoted from Fairchild re: public health authorities determining where to apply the medical gaze, it was a good accident of timing to look at the Smillie right after because of his emphasis on sewers and managing food supply and so on. Public health isn’t intrinsically but rather historically medical - or, the medical aspect of public health changes as medicine changes historically. Part of what I mean here is that in terms of sewers, the application of the medical gaze just isn’t the whole story, there’s also the application of the engineering gaze, so to speak. Ditto re: maintaining food supply (agricultural gaze?) or inspecting workplaces (factory inpectors’ gaze?) or educating supposedly deficient subaltern populations about hygiene (pedagogical gaze?). What I mean to say is that it looks like we find over time historically in/around/related to public health processes that do all of the following: select some problems for address, justify those selections as well as the selections not made (‘we’re not doing that one’ kinda thing, though I think this is more often implicit than said out loud), select a domain of expert knowledge with which to address the problem, and decide what counts as a solution to that problem. ‘Select a domain’ is badly worded as it makes it sound like people are knowledge-shopping when I suspect more often what happens is that different forms of expert knowledge enter into the problem-defining and success-defining processes. In any case, my point is in part that over the longer view anyway historically we find public health authorities drawing on, speaking with, and borrowing ideas from/thinking similar to a range of experts in addition to medical experts, and the field includes, I think, at least some degree of resources for if not exactly consciously deciding which expertise to prioritize, at least a means for those different sorts of expertise to be discussed, to co-exist in dialog and to be resources for addressing problems, making claims on public officials with money and decision-making power, making criticisms and justifications, etc.
There’s a degree to which the field is on a meta-level, so to speak, again at least over the longer term anyway, rather than being intrinsically and narrowly medical. And the different knowledges used are also part of political processes in terms of defining what’s feasible, what counts as success, etc. I’m thinking again of Goran Therborn’s ideology book, where he says ideology is always a matter of presenting some things/actions as (im)possible, (un)acceptable, and/or (non)existent. (That’s a paraphrase but a faithful one!) Those different presentations are in part baked in to different sorts of knowledges and problem selection, such that emphasis on sewer building vs infectious disease control vs shaping working conditions tends to involve different implicit (and sometimes explicit) claims about possibility etc. To put it another way, across time and place as public health’s big priorities shift from sewer building to factory legislation to infection control there are attendant shifts in values and politics, at least implicitly (and often explicitly, as with Fairchild’s and Molina’s discussions of racemaking and management of migrants via public health). Probly obvious but I’d stress how much those shifts are significantly externally driven, being responses to development in capitalist society, and are pulled/pushed in negative directions by capitalism’s imperatives.