Health Policies - Health Politics, The British and American Experience 1911-1965 by Daniel L. Fox, Princeton University Press, Princeton, N.J., 1986
by Del Meyer, MD
In his introduction, Fox summarizes three assumptions that became the basis of health policy in Britain, the USA, and most industrialized countries in the twentieth century. 1) The causes of cures for most diseases are usually discovered in the laboratories of teaching hospitals and medical schools. 2) These discoveries are then disseminated down hierarchies of investigators, institutions, and practitioners that serve particular geographic areas. 3) Health policy should stimulate the creation of hierarchies in regions that lack them and make existing ones operate more efficiently.
Most authors feel
that health policy should encourage people to seek medical care by providing an
adequate and efficiently organized supply of services – doctors, health
workers, and hospital – and removing or reducing the burden on individuals to
pay for them. Most
American students of health policy have assumed that their central task is to
explain the failure to achieve compulsory national health insurance.
Fox feels that’s an
invalid assumption and writes the history of health policy from a different
point of view. He tries to remain
neutral about the worth of particular policies and of the people who advocated
or attacked them. He is critical of
the concept that history teaches. Instead,
he tries to explain why particular policies were adopted in American and
Britain. Unlike other historians of
health policy, Fox does not believe that the progress of medicine has made a
particular policy inevitable or desirable.
In his view, medicine changes and advances technologically; but it does
not progress. Neither medicine nor
the human condition progresses – changes for the best – over time.
The purpose, content, and social valuation of medicine are, he believes,
in constant flux. A century ago,
many people in America and Britain began to believe that, for the first time in
history, scientists were discovering wholly new kinds of truths about nature
that would, eventually, make it possible for doctors to reduce the suffering and
death caused by the most threatening diseases. By the 1920s, medical
care and health policy had become synonymous for most people.
For the next half-century, health
policy was usually made on the assumption that increasing the supply of medical
services and helping people to pay for them was the best way to reduce morbidity
and mortality and help individuals lead more satisfying lives.
The priority of public health policy in each nation changed from
regulating or improving the environment to providing direct services to
individuals. Doctors’ decisions
about what to order for their patients distributed most of the resources
allocated by health policy. Moreover,
priority within health policy was accorded to the services provided by
specialized doctors in hospitals.
Fox takes us on a fascinating journey that I believe provides insight as to how the US may do something significant in health care and in public health. As he states in his final paragraph, both in a practical and philosophical sense, there is no past – no correct description of any earlier time. There is only evidence, which historians must reinterpret continuously. Neither is there a future – no way to predict what will happen. There is only a succession of presents, each with enormous possibilities for thought and action. The study of history is a source of experience, not of justifications for policy. . . . My four grandparents left Europe just before the government intrusions of the 1880s occurred to go to a country of freedom from those restrictions of individual initiative. This book may give us the rationale why their reasoning was valid then and may still be logical. The real question may be, “Can we preserve their vision for another generation, our children and grandchildren?”