Public Health and a Healthy Public

In this blog entry, John D. Fairfield, author of The Public and Its Possibilities addresses the topical issue of public heath care.

    In the forty years after the legislative triumphs of the civil rights movement and President Lyndon Johnson’s Great Society, Americans lost faith in public initiatives.  In what has been called the second Gilded Age, we viewed government as, by nature, wasteful, corrupt, and dangerous. Trusting only to private self-interest, we shunned civic obligations and social responsibilities. The market presumably answered to all difficulties — voucher systems to supplant public education, private retirement accounts instead of social security, and for-profit hospitals rather than national health insurance.

      But in the last decade, market fundamentalism has begun to wane. Polls show that since 1999 the percentage of Americans who acknowledged a broad range of necessary functions for government topped sixty percent and continues to rise. During the 2008 presidential campaign, the blind faith in laissez-faire began to yield to a renewed interest in public initiative. The election of President Barack Obama suggested that leaders willing to ask Americans to participate in something larger than themselves might produce a political realignment on the basis of civic renewal.

      As if on cue, President Barack Obama appealed to the American people during his inaugural address in just such terms. “Our challenges may be new,” but the civic virtues which have served as the “quiet force of progress throughout our history,” the president explained, “these things are old.” “What is required of us now,” Obama concluded, “is a new era of responsibility —  a recognition, on the part of every American, that we have duties to ourselves, our nation, and the world, duties that we do not grudgingly accept but rather seize gladly.

     Following a host of presidents before him, Obama seized upon health care as a crucial arena for expanding public responsibilities. Succeeding where past administrations have failed, the Obama administration successfully guided health care reform through Congress. “It is a monumental accomplishment,” Michael Tomasky writes, “but at its heart the story is about the tension in American society between the individual and the community – whether we are just a loose confederation of individuals who should be left alone to pursue self interest, or something more than that, a community of citizens with mutual ties and obligations.”

   As I argue in The Public and Its Possibilities, this tension between the individual and the community is central to American history, played out in the competing claims of private and public. But previous generations have managed a better balance than we have. Inheriting a legacy of public schools, parks, and libraries, transit, water, and sewer systems, facilities for public health and safety, as well as roads, tunnels, and bridges, we have failed to preserve this legacy, much less add to it. It may surprise Americans to learn that at the turn of the twentieth century our cities enjoyed an array of public services unsurpassed anywhere in the world, state-of-the-art facilities and services that enriched the daily lives of millions.

      The celebrated American standard of living owed as much to these public initiatives as to private interests. So did our longer life expectancies, which are almost wholly the result of the public health investments at the turn of the twentieth century. This is what makes the recent health care bill the most important public initiative since the 1960s, something which can enhance the security and quality of millions of American lives. Yet, for all its virtues, the new law still treats health as a market commodity, rather than a public good that is a product of our common environment. While we spend billions to extend the lives of the terminally ill, public health expenditures that save both lives and dollars continue to decline in both absolute terms and as a proportion of total spending on health care (one percent in 1992 and declining ever since).

     So while we celebrate the expansion of private health care to millions of Americans, we might pause to consider the balance between the vast expense of the private health care system and our neglected public health facilities. Both civic responsibility and common sense demand that we launch new initiatives for monitoring the purity of air, water, and food, controlling infectious diseases, regulating the chemicals and pharmaceuticals that enter our bodies, and preventing bio-terrorism. On such initiatives, millions of lives depend.

     Public initiatives can also be the occasion for revitalizing our democracy. But they will require a political movement that is both democratic and participatory, for they will have to take on both concentrated economic power and popular habits and attitudes. Public health initiatives, such as the federal legislation that arose from Upton Sinclair’s 1906 expose of the meat-packing industry, The Jungle, have always arisen from the grassroots and challenged entrenched interests. Public health must go hand-in-hand with a healthy public as we create the economy and the culture our democratic aspirations demand.

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