History

This concluding chapter explores how the bigger historical picture opened up by the volume might be pursued further in the context of modern Britain. It does so by asking how we should explain the multiple and always problematic forms assumed by ‘the public’ within public health since its inception as a discrete field of government during the first half of the nineteenth century. The answer the chapter offers accords only a limited role to differing cultures of governance and the succession of liberal, social-democratic and neoliberal forms of statecraft. Of more importance, it suggests, has been the enduring interplay of a set of more basic, fundamental factors. The chapter highlights three in particular: democracy, by which is meant, loosely, considerations of citizenship and political subjectivity and inclusion; strategy, by which is meant considerations of organisational logistics and costs; and finally, epidemiology, by which is meant shifting distributions of morbidity and mortality. The chapter deals with each factor separately, but the argument is that they need to be grasped together if we are to understand why, and how, the public has proved such a problematic, yet central actor in the management of modern public health.

Immigrants have been deemed a ‘problem public’ because they are branded as ‘other’, as threats to public health and as potential burdens on health systems. In addition, immigrants and migrants usually lack the rights conferred on citizens, including the right to receive government-funded medical services. This chapter examines how international human rights treaties on the right to health have included or excluded people who move across national borders. The 1990 United Nations' International Convention on the Rights of Migrant Workers codified only weak health rights for migrants and has only been ratified by a few countries. However, an international human rights framework has been and can be used to fight for better health conditions and access to care for migrants and immigrants. Since 1990, human rights advocates and immigrant rights activists in the US and Spain have invoked international agreements to argue for the inclusion of immigrants and migrants in definitions of ‘the public’.

By the mid-twentieth century, public health services and the health of the American population had been repeatedly surveyed as part of normative and prescriptive efforts to standardise public health administration. In the focus of many such assessments on institutional relationships and aggregate health activities, however, the ‘public’ was homogenised and structural inequalities within the public health system obscured. This chapter examines three local surveys conducted in rural Minnesota in the 1930s–1940s. The struggle to provide even limited public health services in rural areas made visible critical problems of public health administration in general. These surveys reveal fundamental inadequacies in the imagined comprehensive approach to public health, not least the construction and exclusion of the target publics. The ‘public’ alternately appeared as categorical population groups, consumers of specific services, residents of different places, clients of certain health authorities or voluntary organisations, racialised and excluded populations and idealised citizens demanding efficient public health service at all levels of government. While the local community was the logical site for coordinating various federal, state and local government programmes, from disease prevention to clean water to school health, in fact, the community level was where integrated intergovernmental public health provision was most lacking. From the local level up, the effective collection and application of data to establish a uniform public health system were undermined by failures to acknowledge the diverse publics in public health.

Conservative Prime Minister Harold Macmillan’s declaration in 1957 that ‘most of our people have never had it so good’ has come to encapsulate the idea of post-war consensus and the ‘golden age’ of affluence. Yet this consensus served to exclude and marginalise those not considered ‘our people’. Those deemed unsatisfactory and unable to improve themselves through the new benefits afforded in national prosperity and ‘social citizenship’ were outcasts. These ‘problem families’ were failed social units given that nuclear families constituted the building blocks of post-war society and social policy assumptions. Nowhere are these more visible than in public health policies which sought to contain and confine these ‘problem populations’. Through the operation of the local welfare state, public health professionals and practitioners created what Zygmunt Bauman terms ‘dumping grounds for … human waste’. However, there is a discrepancy between the discursive construction of actions on ‘problem families’ through reports and policy pronouncements, and their materialisation through the everyday operation of the welfare state apparatus. Drawing on the case files of those identified as a ‘problem family’ and subject to intervention, this chapter provides five mechanisms whereby public health practice in post-war Britain delineated, marginalised and confined ‘problem families’ from the public in order to safeguard ‘our people’. Together, practices concerning homeless families, housing hierarchies, intermediate welfare accommodation, slum clearance and peripheralisation materially constructed ‘dumping grounds for human waste’.

Over the past four decades, three processes took place that reflect the emergence of violence as a public health problem in Latin America. First, these decades witnessed an increase in the volume of scientific literature related to violence, as well as in a range of publications by national and international organisations. Second, institutions focused on monitoring violence-related situations were designed. Lastly, violence appeared as a mainstream topic on the public agenda, in media debates and as a key structuring component in the representations of the population. This chapter analyses the emergence of violence as a public health problem in Argentina, from a constructivist approach. Tensions between the different explanations of this phenomenon are considered. Is the establishment of this topic in the public sphere explained by the rise of violence indicators? To what extent do statistical fluctuations explain the rise of public problems? A document analysis was conducted, reviewing papers, international organisation publications, reports and newspaper articles. This chapter typifies two mainstream approaches which explain the emergence of violence as a public health problem. Objectivist perspectives are described, characterised by interpreting public problems as a mechanical consequence of patterns in society. Perspectives which relativise the relation between the existence of a problem and its manifestations are studied. Both discourses illustrate transformations in the public health field, such as the incorporation of youth as a key actor in the understanding of violence, the conceptualisation of violence as a health issue and a shift from top-down to bottom-up policies to address this phenomenon.

This chapter uses the launch of low-fat milk as a case study to argue for the role the food industry played in reconceptualising the public as health consumers. It explores how diets, particularly low-fat diets, became reworked to create a popular understanding that preventive health can be bought on the high street. It demonstrates how government–industry cooperation enabled health education messages to be more effectively transmitted within a consumerist context, part of a rise in voluntary efforts the food industry was making to maintain their influential role within governmental policy-making. It examines what it means to buy health in the 1980s and 1990s and seeks to better understand how this corresponds (or not) to governmental priorities around heart disease prevention. It emphasises how the public was identified as gendered consumers and assesses what this focus means for historical understandings of public health more broadly during this time period.

This chapter introduces the collection by exploring the changing meaning of ‘the public’ and ‘public health’. It suggests that there was no single unitary ‘public’, and ‘public health’ also has multiple meanings. This diversity is echoed in the framing of certain groups, individuals and behaviours as ‘problem publics’. The essays in this collection unpack a range of examples of ‘problem publics’. This introduction summarises the contents of the chapters in the collection, but also highlights a series of key cross-cutting themes. These include the overlapping of ‘problem publics’ with identity categories and certain kinds of behaviour, as well as the geographical location of groups and individuals. The introduction places this in the context of the recent COVID-19 pandemic, which has brought fresh interest in how to deal with ‘problem publics’, but with many old tropes rising to the fore.

As the HIV/AIDS epidemic emerged as a global crisis in the 1980s, both East and West Germany responded with an array of educational and prevention initiatives, including some that involved collaboration across the ‘Iron Curtain’. Histories of AIDS in divided Germany have tended to focus on the deficiencies of the East German response. This, however, has obscured not only the efforts and agency of East German AIDS activists, but also the complex and wide-ranging conversations about HIV/AIDS that took place in the socialist East. Due to the centrality of self-organised advocacy groups in response to the epidemic that emerged in many Western contexts, East German health officials faced difficult questions about the role of civil society in a highly centralised socialist health system. This chapter reconstructs the debates surrounding efforts to combat HIV/AIDS by East German activists, health workers and health officials, arguing that talking about AIDS in East Germany often meant talking about the nature and meaning of socialist health care writ large.

This chapter focuses on two distinguishing features of HIV/AIDS in Italy, and their intersection: the prevalence of HIV transmission via intravenous drug use in Italy, and the interventions of the Catholic Church. It uses as a case study the controversial founding by Caritas of an AIDS care centre in Rome in 1988, to serve young current or former heroin users who lacked a stable home. There is also an important international context in that the controversy that delayed the opening of the centre coincided with the passing of stricter drug legislation in the USA and the visit of Italian Socialist Party Secretary Bettino Craxi to New York and Washington to discuss related matters. Craxi soon introduced similar legislation into Italian parliament. The confluence of these events and their conflation in government and media discourse alike, this chapter argues, affected attitudes towards the care centre, and led to the effective criminalisation of HIV/AIDS in Italy.

The sources cited and analysed to reconstruct this history include print and audio-visual media from both Italy and the USA. These sources highlight Italy’s concern for its image on the international stage; the ‘activism’ of Caritas and the counter-activism of neighbourhood residents; the fears of these residents of social contagion and drug use in their wealthy area; and how all of these factors contributed to the construction of an aetiology that posited intravenous drug users as the ur-sources of HIV, outside the bounds of ‘normal’ society and the traditional Italian family.