The European Journal of Public Health Advance Access originally published online on June 4, 2008
The European Journal of Public Health 2008 18(4):354-355; doi:10.1093/eurpub/ckn040
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Viewpoints |
Politics and health: a neglected area of research
Vincent Navarro1,21Pompeu Fabra University, Barcelona, Spain and 2The Johns Hopkins University, Baltimore, MD, USA
Correspondence: e-mail: vnavarro{at}jhsph.edu
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One of the more surprising features of the literature on public health and on health policy research in Europe and North America is the scarcity of references on the impact of political variables on health policy and on health outcomes. One can find in this literature a growing number of articles that focus on the social and cultural determinants of health, but very few indeed on the political determinants of health. This is remarkable, because one would have thought that in societies claiming to be democratic, public-health scholars and public-health analysts would study how the various instruments (such as political parties) through which people express their wants and needs shape public policies that affect the health of populations. There have been studies on the impact of health policy on health, but very few on the impact of politics on health policy and/or on health outcomes. This silence on the relationship between politics and health is particularly surprising for a profession in which one of its founders, Rudolf Virchow, wrote that ‘Medicine is a social science and politics nothing but medicine on a grand scale’.1 The awareness that health depends on political as well as social, economic and cultural forces is well-established in the public-health tradition. Thus it is paradoxical that the scholarly literature on public health has such a limited number of references on this subject.
Why is this so? The answer is a complex one. One explanation is that the public-health field is dominated by professionals trained in medicine and biology rather than in the social sciences. Epidemiologists and statisticians tend to dominate the field of public-health research. To them, politics seems to be very shaky and risky ground, something to be avoided. Political science is frequently seen as more politics than science. In my early years as a junior faculty member in one of the leading schools of public health in the United States, The Johns Hopkins University School of Public Health, politics was a forbidden subject, a ‘dirty area’, to be avoided by anyone with academic ambitions and hoping to climb the promotional ladder.
However, there is another reason for the deficit of studies on the impact of political variables on health. And it is related to how most public-health research is funded. In Europe, most of the funding agencies receive their money from public sources accountable to political forces. They are unlikely to fund any type of research that may please some political forces but displease others that have a voice in the funding of research institutions. A government of one political orientation, for example, may not like research revealing that parties of the opposite orientation are doing better in improving the health of their populations. Politics is related to power (class, race, gender, regional and national power) and its expression through representative institutions. Because of its content, politics is frequently controversial. Let us not forget that Rudolf Virchow was thrown out of his own country when he reported that the root of the public-health problem he had been asked to study was the distribution of political and economic power in the region. Asked by the establishment of Upper Silesia to investigate the typhus epidemic, he responded by stressing that the resolution of the problem required a whole set of measures that included land reform, housing reform, water regulation and other public interventions—all of which would have reduced the power of the property owners who held the land, the water, the real estate and other commodities. These groups were outraged by Virchow's proposals, and shouted: ‘This document is not a medical document. It is a political document’. To which the founder of public health replied with his famous statement (which should be carved in stone at the entrance of every school of public health): ‘Politics is nothing but medicine on a grand scale’. It is not surprising he was thrown out of the country.
At a more modest level, I experienced a similar situation, being awarded the special status of persona non grata by two political regimes: the Pinochet regime in Chile and the Brezhnev government in the Soviet Union. In both cases, I had reported that the root of the unhealthy state of their populations was the political nature of their regimes. Needless to say, being thrown out of a country or being declared persona non grata is an unpleasant event, but rare, and usually takes place under a dictatorship. In democratic societies, the establishments’ responses to such reports are more subtle. Discontinuation of one's research funding for political reasons is a much more common response. This is undoubtedly one of the reasons for the small number of researchers who dare to focus their analytical lenses on politics and health. Still, some have tried, and their numbers are increasing.2
The scarcity of references on politics and health is even more accentuated in the reports produced by international agencies such as the WHO. In these agencies, there is a demand for consensus that makes it very difficult to study the effects of political variables on health. Researchers are under pressure to reach a consensus that will satisfy the maximum number of governments and/or not antagonize the most powerful ones. We have seen this situation in many WHO Commissions and their reports, which, by definition, avoid a political analysis that would create tension in the international body. The recent Commission on Social Determinants of Health is an example. Political determinants are barely mentioned in the Commission report, even though the importance of those variables in shaping people's health and quality of life is enormous. The evidence on this relationship is robust.
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The need to undertake studies on politics and health |
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All scientists are human beings and, as such, are carriers—consciously or unconsciously—of all types of values (political, social, cultural and others). This is so in the basic and the applied sciences. Women and men may look at reality differently. Blacks and whites may see things differently. And an upper-middle-class physician most likely looks at reality differently from his or her working-class patient. These different ways of seeing the world also exist in the social sciences. It is unavoidable that researchers, consciously or not, include their own values in their research studies. Ideally, scientific commitment and methodology can diminish and even eliminate these biases, and this is particularly important in areas that are, by their very nature, highly controversial, such as research on politics and health. The risk of being perceived as ‘propagandist’ is too great to be ignored. But that risk can be diminished through rigor, clarity and transparency, exposing one's own work to debate and scrutiny. With these conditions, there is an enormous need to study a critical question in any democratic society: Do politics matter? We should realize that if the answer to this important question is no, then we—those living in democratic societies—are in deep trouble. Democracy does not work and we live under technocratic regimes. Fortunately, the evidence shows that the answer is yes, politics do indeed matter. Political parties, for example, do shape health outcomes, although not always in the direction one expects.
Actually, this question of whether politics matter, while new in public-health research, is not new in the social and political sciences. The literature in these fields contains a relatively long list of useful references. In Europe, the founders of this type of study are Walter Korpi and his collaborators. Korpi's classic study, The Democratic Class Struggle,3 initiated an extremely productive scholarship. Korpi looked at how political traditions and the power relations they represented (class, but also gender) had affected the nature of the welfare state and the well-being of the populations.
In the health field, I followed that tradition of inquiry and initiated work in this area in 1989, with the article ‘Why Some Countries Have National Health Insurance, Others Have National Health Services, and the U.S. Has Neither’.4 Extensive research has been developed since then, and very valuable work has been done on how political traditions affect health policy. But, until recently, no such work has been done relating political traditions to health outcomes. And here, the evidence that political variables have an impact on health outcomes is robust. For example, in Europe, political parties committed to redistributive policies (through a range of social policies) have been more successful in improving the health of their populations than those without such commitment.5 Less clear evidence exists, however, on the impact of these political forces on reducing health inequalities. A political force can be very successful in reducing social inequalities, but not so successful in reducing health inequalities. At least, this is what some scholars claim, although others report different outcomes and conclusions (see the inequalities series in the International Journal of Health Services). Thus a fruitful debate is underway that, no doubt, will continue for some time. This debate is also raising important issues about the methodologies used in these studies and their conceptualization.6 For example, many studies have used the size of public social expenditures as an indicator of the size of the welfare state—an indicator that may be insufficient because, among other reasons, the size may depend more on demographic factors than political variables. A rich debate is taking place on many fronts, and especially in the pages of the International Journal of Health Services. These studies are breaking new ground and they need to be done. As Virchow wrote, ‘It is the duty of society through the state to protect and promote the lives and health of its citizens’. We, public-health professionals, therefore, should also study the state and its governance in democratic societies to see how it does what it is supposed to do.
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References |
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1 Taylor R, Rieger A. Medicine is a social science: Rudolf Virchow on the typhus epidemic in Upper Silesia. Int J Health Serv (1985) 15:547–60.[Web of Science][Medline]
2 Navarro V, Muntaner C, eds. Political and economic determinants of population health and well-being: controversies and developments. (2004) Amityville, NY: Baywood.
3 Korpi W. The democratic class struggle. (1983) Boston: Routledge and Kegan Paul.
4 Navarro V. Why some countries have national health insurance, others have national health services, and the U.S. has neither. Int J Health Serv (1989) 19:383–404.[Web of Science]
5 Navarro V, ed. The political and social contexts of health. (2005) Amityville, NY: Baywood.
6 Clasen J, Siegel N. Investigating welfare state change. (2007) Cheltenham: Edward Elgar.
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