A Tale of Two Polities

By Scott Burris

Last week, Northeastern University’s effort to convene a much-needed conference on the future of health policy was a casualty of the successful manhunt for the Boston Marathon bombers.  One hardly wants to make too much of a stymied conference given all the human damage of the bombing and its aftermath, but all of us who had gathered for the meeting regretted that we would not hear from the panelists, and sympathized with organizers who had put so much into planning it.  In recognition of that, I am summarizing here what I planned to say there.  It is a tale of two polities that seem to compete for existence in our perceptions of the politics of public health.

One public health is incredibly popular with citizens and lawmakers alike – demonstrated by polling and passage of legislation.  I’ve recently blogged on this here.  The other public health is the despised nanny state, big government, the sequestered and slashed-to-the bone struggling provider of essential services that don’t get no respect and don’t deserve the meager tax dollars we still pay in. We see this in budget cuts, in hyperbolic allegations of “corruption,” and in disingenuous advocacy for a radical caveat emptor regime for all legal products.

What do we make of these two radically different views of where public health now stands in the public’s regard? My claim is that the former is largely the truth – public health is popular, not despised – but the latter view is what is driving budgets and a lot of policy. The action points follow: a sustained fight to mobilize public support and win more battles over budgets and laws. I see three main strands of work:

1)    Fending off those who are attacking public health for narrow ideological or economic reasons.  Top of the list is what we might call the “legal products” movement,” selling the canard that somehow the fact that a product is legal means that we can’t discourage its excessive or dangerous use through soft education and tax measures.  The idea appears in court decisions, appropriations riders, and propaganda, and it is all the more galling because its proponents are the same people who contest any sort of serious regulation that goes beyond education.

We also have to take on the related notion (which seems to reflect a bipartisan legislative view) that it is somehow improper or illegitimate for health agencies to investigate, develop or support policy interventions.  Though I am hard-pressed to imagine public health practice without public health law and policy, I for one seem to see too many health people, politicians and reporters seeming to take as given that policy is out-of-bounds for health agencies. We can’t let this idea go unchallenged – see below. (BTW, Tom Frieden had a good piece along these lines in NEJM last week.)

2)    Building the backbone of our “friends” in politics and practice who act unpopular.  The data suggest that people want their government to take sensible action to protect and promote public health. They don’t want to live in a state of nature as tiny individual mammals dodging predatory corporate dinosaurs. They appreciate efficient air traffic control systems, safe food and water, good schools, clean air, and even efforts to help us make healthier choices from healthier options. But every time a budget is passed or a policy is launched, too many of our representatives flinch, quail and stand abashed, allowing canards about the nanny state and big government to go unanswered or – worse – enacted into law.  Too many legislators seem to misunderstand the public’s values and beliefs.

3)    Normative work, especially for law professors.  We just have to stop acting as if being right is all it takes, and put more sustained effort into making the case for collective action, a proper tax base, and optimistic investment in our future as a society. The anti-government/anti-action side has, at bottom, some pretty unattractive ideas: you’re on your own, we can’t work together, there’s no money, “Pay no attention to that inequality behind the curtain.”  But they a couple of things we seem to lack: the persistence and resources to keep saying the same thing over and over everywhere until their ideology of scarcity and collective paralysis becomes a social reality.  We have some heroic philanthropies that put their funds into important research and action, but where are the Koch brothers willing to invest year after year in building the underlying social attitudes and political “realities” we need to put our ideas into practice?

There is definitely a crying need for work to counter legal strategies aimed at collective action.  These include the expansion of First Amendment doctrines limiting the ability of government to use informational strategies to inform or protect the public; the increasing effort to suppress pro-health speech by health agencies and those who receive government funding, and to cut funds for research that might reveal inconvenient truths;  evidentiary standards that set impracticable burdens of proof to justify health actions; and judicial contentions that public health work must be confined to preventing communicable diseases (see the NYC soda ban decision).  These developments are the product of coordinated litigation and lobbying strategies, and they need to be countered in the same coordinated fashion.

Finally, I think there is work to be done towards mapping a new ideology of collective action and shared responsibility.  If it is true that most people support cooperation and good government generally, and sensible regulations in particular, why does policy turn out as it does? Why doesn’t this silent majority start screaming – and voting, and organizing.  Of course, to some degree they do – our system is just getting more and more anti-majoritarian through super-majorities and gerrymandering. But I also think we – this mass of us who may be registered R or D, or dispositionally C or L – don’t have a set of ideas – an ideology – that helps us see our commonalities and coordinate our actions towards sensible and effective policies.  The “latent ideology” constituted by the substantial agreement on concrete issues in this country is an opportunity it is time to seriously explore.

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