What is public health, and to whom?
I mentioned the other day that I’ve started Christopher Hamlin’s history of public health in the mid-19th century UK. As I said there, Hamlin argues that in the late 18th and early 19th centuries there was substantial overlap between medicine as it was organized then and what EP Thompson has called the moral economy. The moral economy was EPT’s term for a situation where food production was regulated by an explicit set of social norms according to which a) people ought to have enough food not to starve b) deprivation, or at least foodsellers pricing food at prices high enough that they threatened starvation, was a moral outrage, and c) acts of protest out of step with ordinary social behavior - ie, fairly serious collective militancy - were justified responses to that sort of outrage. (I’ve written on this before arguing that the norms involved were order-preserving and obedience promoting until the context changed, in which case those norms facilitated collective action of a defensive and somewhat nostalgic character - keep the old deal, basically.) Over time those norms broke down in relation to those three facets I lettered a, b, and c: there became less of a social consensus that people deserved food, deprivation of food became coded as less of an outrage and more a fact of quasi-nature (with the emergence of a sense that there was a social domain called ’the economy’ which operated relatively independent of any control and so was in effect a kind of nature), and the resources for carrying out collective action in situations of deprivation or threat thereof got more scarce. The overlap with medicine that Hamlin highlights amounts to medical professionals lamenting some harmful changes baked in to industrialization and growing dependency on waged employment specifically, and so taking some (and only some) actions or venturing criticisms of the emerging new condition.
I was thinking about this today and began to wonder about the beginning of the pandemic. It’s not an exact correspondence, but there are resonances. (‘History doesn’t repeat but it does rhyme,’ is the phrase, I think.) Up until some time in 2020 or maybe even 2021, I’m unsure exactly when, I certainly believed that there was some sort of set of social norms (I’ll call it ‘a normative consensus’ as a shorthand) analogous to the social norm of the old moral economy Thompson wrote about, related to public health. I thought there was a system of public health institutions, in which there were employed public health professionals, organized around some degree of real commitment to values of promoting health and protecting people. According to these values I assumed existed, the kinds of things that we’ve seen happen in the last few years would be a deep outrage, and I assumed those values were action-guiding in two ways: action-guiding for that system and its personnel such that outrages would be avoided or at least retroactively responded to in a corrective fashion, and action-guiding for the population as a whole such that outrages would result in massive social unrest.
In retrospect that was obviously wrong, but I’m not sure in what way it was wrong, exactly. Was there never any such normative consensus? Or did I get the content of it wrong? Or did the normative consensus evaporate suddenly in ways I didn’t expect and couldn’t account for? I expect it’s a little of each, but I don’t know. This has been one source of distress, a sense of dislocation and bewilderment - ‘how can this be happening?!’ - and a sense of betrayal - ‘how could they?!’ In case it’s not obvious, none of this was a matter of consciously held beliefs that I knew I held, let alone worked out positions I could articulate explicitly and argue for, these were implicit assumptions strongly held (arguably, they gripped me, and to a significant degree they still grip me, coming out in my continued muttering of versions of ‘what the FUCK’ in my internal monolog; this makes me think there’s something here to do with ideology and this isn’t just a set of mistakes, but here too I’m unsure). I’m sure I’m not alone in this, I see and hear lots of people saying things that indicate they made or still make those assumptions. I don’t know how to prove this, but I suspect that this early-in-the-pandemic yet long-lingering belief that public health professionals are on top of everything has also been demobilizing - after all, if the system works, no need for anyone else to do the work, and if the system works as long as there’s some degree of pressure on it or lobbying of it, then mobilizing is mostly just a matter of entreating those good state personnel to do their good jobs. It turns out, of course, as Richard Pryor once said, there ain’t no justice, just us. That is: we’re on our own, actually. And many of us - certainly me - didn’t see that coming, nor were we, collectively and for many of us individually - certainly me - ready for that.
Thinking about this assumption - myth? - of a genuinely governing and stably dependable normative consensus informing (or backed up by) the action of public health made me think again about Hamlin’s remarks on the usage of the term public health. As I talked about last time, Hamlin distinguishes three such usages. The term sometimes means the actual health of the actual populace (with ‘health’ and its opposites as well as the populace and those outside the bounds of membership in it both being subject to dispute and change over time), sometimes means the set of institutions we call public health institutions - health departments and so on, and sometimes means a standard of health as a kind of moral and/or political benchmark that we hold developments in the world up to. So far as I can tell so far from what I’ve read in the book, I think Hamlin’s goal is to show the variations among those usages, how each usage changes over time, and, following from those variations and changes, showing that we could have ended up with some different version(s) of public health than the one(s) we ended up having.
Along somewhat similar lines, it occurs to me that ‘public health’ in the sense of the actual health of the population and also public health as the normative standard of health used to measure the (in)acceptability of the present is to a significant degree a matter of dissensus rather than consensus. At the same time, I suspect that to an important degree the dissensus is implicit, which is to say, I suspect there is wider disagreement than is widely recognized. By analogy, if you spend twenty odd years as a marxist interacting with marxists (and if you do, they will be odd years, to be sure; please excuse my failing sense of humor, AGAIN), you may, as I have, sometimes find yourselves in settings where people nod to express agreement with something where people in fact have different actual content in mind for that something: ‘we need a revolution,’ a comrade intones seriously, and all of us nod with vigor and gravity, yet some of us mean something like a seizure of state power by a minority of the population or their representatives and others of us mean something like electing lots of socialists to Congress and others of us mean something involving workers’ councils and/or revolutionary unions seizing productive property from capitalists and running production ourselves, and so on. Those are substantively different scenarios which are, depending on how they’re understood, to varying degree compatible or incompatible. The head nods, ‘yes comrade, we do need a revolution!’ don’t make apparent the different content we have in mind for that word. Ditto ‘public health.’
With that in mind, I think it might be valuable to get clearer on the different meanings of ‘public health’ to different people in different positions, or at least to clarify a little how we might go about getting clearer on those differences. I’d like to suggest as a starting point something like a 4 quadrant grid defined by on the one hand a continuum from critical marxist understandings (specifically the understanding of the relatively small number of marxist covid zero zealots - and about that small number, I know it’s depressing and I was about to joke ‘better fewer but better’ but really, fuuuck man, this suck so bad) to cynical yes-man grifter minimizers like David Lyin’heart and his ilk - the sorts who a good society would put on trial after it finished putting on trial the real deciders like Joe and Kamala and Donald (https://www.youtube.com/watch?v=0omgYNxZseA) - and on the other hand a line distinguishing between public health professionals and the rest of us - call it professional/institutional positions and vernacular positions, for lack of better terms.
The assumptions of mine that I talked about above that led to so much bewilderment and sense of betrayal early in the pandemic are an uncritical vernacular understanding of public health. There are right wing libertarian understandings as well - the much reviled antivaxers and all that. There are more critical vernacular understandings (I’ve learned a lot from Health Communism for instance, which is vernacular in the sense that the authors aren’t public health professionals, and also in the sense that it leans on some of the accumulated experience and thinking of various activists around issues of health and disability; I think early on anyway there were also some fights in specific pockets of the labor movement - I’m thinking of the Chicago Teachers Union’s fights with the city over teachers’ and students’ classroom conditions and of some of the efforts of National Nurses United, though the latter especially is arguably professional rather than vernacular since nurses are medical professionals and if I recall correctly the union employed one or more industrial hygienists), and according to these understandings, I think, public health is a matter of contention with outcomes determined significantly by how struggles play out. As I said above, I suspect that the uncritical conceptions like I had early on and which still linger in my mind work to reduce the likelihood of collective action around aspects of the pandemic and also press upon the collective action that does take place so that it’s pushed toward less fruitful directions.
I’m more than a little unsure about all of that but/and I’m even more unsure about professional understandings of public health. This is significantly due to my own ignorance of the field and the set of institutions as someone outside of it and unfamiliar with any of its history beyond the two chapters and change I’ve read of Hamlin’s fine book. From various conversations I’ve been in, including the ongoing and to me very fruitful dialog with Abby Cartus, I get the sense there is a range of positions within the official public health world, with robustly critical positions being, I don’t know, under-represented. I suspect that a lot of, I don’t know, work-a-day public health professionals are significantly unhappy with how this continues to play out, with that unhappiness thinning out higher up the ranks - for instance the CDC directors and White House covid response coordinators seem to feel relatively fine, though this may be me anthropomorphizing those dead-eyed ghouls. Vitriol aside, what I really mean to say is that what public health professionals think the institutions that employ them do and what they think they do in their own actions as employees of those institutions, that’s all very opaque to me. I mostly just have assumptions to go on. I suspect many of them share a view Tony Smith talks about in his superb Beyond Liberal Egalitarianism, namely that with sufficient state action capitalism’s harmful tendencies can be arrested, but again this is speculation. Maybe they’re just trying to do a little good that feels meaningful and are fully aware of the ultimately low ceiling on those efforts (relative to the demands and just deserts of human dignity). At a minimum I feel confident in saying there doesn’t seem to be any evidence that public health in any of its respectable, legitimized, state-supported forms is remotely anticapitalist, but that hardly seems like an insight.
This thread seems to be coming to its end and I’m unsure what it was worth, though I suppose one has to unspool the thought sometimes to see how long it actually was. (Okay sure, the thoughts are bad, but so are the metaphors!) Two final thoughts for now. One, as I talked about a while back, Simon Clarke has described capitalist social relations in their concrete existence in the world at any given time as existing in the form of specific organized or institutionalized practices. (https://buttondown.com/nateholdren/archive/thinking-out-loud-about-simon-clarke-and-public/) There are, in his terms, institutional forms of class domination and class collaboration that exist, that facilitate some forms of struggle and inhibit others, and which change over time due to the combined effects of class struggle and capitalism’s tendencies like competition and crisis. It seems clear that public health as set of institutions and professions is very much a set of such forms of class domination and class collaboration. Hamlin’s account of the history of public health in Victorian Britain supports this, since the field and its institutions largely develop as responses to industrialization, which was an important transformation in multiple aspects of capitalism - that transformation scrambled a lot things, and out of that scramble emerged new institutions, professions, outlooks, as well as transformations of old ones. I’m unsure how to do that here but I think what I’ve said above could maybe be generatively connected more fully to Clarke’s account.
Two, I think what I talked about the other day (https://buttondown.com/nateholdren/archive/a-four-cornered-impasse-politics-of-4-kinds/) re: assumptions like ‘if people only knew!’ and related practices like my own efforts to tell people more about the pandemic, as if the facts alone are motivating, is nontrivially connected to the assumptions I mentioned earlier, that there is or was a normative consensus, and specifically an action-motivating one, animating public health. In that post I said something to the effect that the idea of speaking truth to power assumes an efficacy to truth, when the hard-to-sit-with reality is that truth’s power in the world is context-dependent: truth has efficacy conditions, meaning its social power, its capacity to motivate action, simply can’t be taken for granted. And we are in a situation where the truths about covid are to an important extent not truths for which the efficacy conditions currently exist. The assumption that such conditions do exist seems to me to be related to (or just another name for? I’m unsure) what I’ve called in this post the assumption of an action-motivating normative consensus within public health as set of professions and institutions.
The steam’s run out. Quoth a poet, “it's not a lot, but it's what I got.” (https://www.youtube.com/watch?v=CUxLnk87VGo.) So on that note, friends, I’m out. Don’t let the bastards grind you down.