Blockchain Papers

Aimee Petrosky, Omonyêlé L. Adjognon-Bancolé, Michelle K. Surdyk, Rachael Cain · 5 authors

CONTEXT: The Massachusetts (MA) local public health system is highly decentralized. All 351 municipalities autonomously manage local public health infrastructure and budget, resulting in service delivery disparities. The MA Department of Public Health (MDPH) recognizes that achieving equitable access to public health services requires systems change, and successful systems change demands active participation and input from partners at all levels. OBJECTIVES: To collaboratively establish the first Performance Standards (PS) with and for MA local public health to reduce inequities in public health system delivery. DESIGN: Partner engagement and the Framework for Applying Qualitative Methods in Health Policy and Systems Research guided PS establishment. Relevant standards from MA laws were compiled and organized using document and thematic content analyses. Partner elicitations guided edits for finalizing PS. SETTING: In 2021-2023, MDPH facilitated statewide partner collaboration to establish PS. PARTICIPANTS: Six key MA public health organizations, representatives from 4 state agencies, and widespread MA local public health. INTERVENTION: Targeted engagement with internal partners enabled drafting PS. Widespread engagement with external partners elicited open comments to improve and finalize PS. MAIN OUTCOME MEASURES: MDPH and partners collaboratively formalized PS after analyzing 283 comments and 66 edits. RESULTS: Through active collaboration with partners, MA formalized the first official PS for local public health, released in October 2023. PS comprise 5 subjects, including 87 standards written into MA legislation across 4 subjects (environmental health, tobacco control, disease control and prevention, administration), plus recommended workforce standards. PS set minimum expectations for local public health credentialing and support consistent public health service delivery. CONCLUSIONS: PS are a steppingstone toward MA public health systems change. Collaboration is critical for partner buy-in, to establish and implement PS using shared resources structures. Effective PS implementation, synergistic with other efforts, will reduce disparities in local public health services and delivery and provide MA residents with more equitable access to public health services.

Ilaria Tocco Tussardi, Marcello Di Pumpo, Stefano Tardivo, Luca Gino Sbrogiò

Background: In Italy, Departments of Prevention (Dipartimenti di Prevenzione, DPs) are primary organizational units for disease prevention, health promotion, and environmental health. Constitutional decentralization (2001) generated significant regional variability. While national data exist, in-depth regional analyses are lacking. Objectives: To provide a systematic descriptive analysis of organizational structure, governance mechanisms, and workforce composition of DPs in the Triveneto area (Veneto, Friuli Venezia Giulia, Autonomous Provinces of Trento and Bolzano), contextualized within national and international frameworks. Methods: Cross-sectional descriptive study using 2022 Italian Prevention Observatory national survey data. A structured 87-item questionnaire assessed organizational structure, governance, staffing, and quality systems. Results: A total of 10 of 14 DPs participated (71.4% coverage; 5.2 million inhabitants, 87% of Triveneto population). All maintained three mandated core services (Public Health and Hygiene, Veterinary Public Health, and Occupational Health and Safety), employing medians of 35%, 23%, and 14% of staff, respectively. Management Committees were active in 80% of DPs (vs. 77.6% nationally). Quality certification (30%) and institutional accreditation (50%, Veneto only) showed inconsistent implementation. The workforce was predominantly non-executive (65% vs. 67% nationally), reflecting progressive task reallocation. Median staff density: 3235 inhabitants/staff member (vs. 2608 nationally). Conclusions: Participating DPs—predominantly from the Veneto Region—demonstrate comprehensive service coverage and established governance structures, yet face standardization challenges. Findings should be interpreted in light of Veneto overrepresentation (8/10 participating DPs). Alignment with territorial care reforms (Ministerial Decree 77/2022) and National Recovery Plan investments could enhance integration, digital infrastructure, and preparedness capacity.

Nabil Georges Badr

Public health systems face mounting challenges from pandemics, environmental disruptions, and persistent health inequities, exposing the limitations of static, siloed infrastructures. This paper introduces a conceptual model for Learning Public Health Systems as a Service (LPHSaaS), integrating principles from service science, resilience theory, and decision systems architecture. The novelty lies in reimagining public health as a continuously adaptive, stakeholder-informed service ecosystem, enabled by emerging technologies such as AI, IoT, cloud computing, and distributed ledger technologies. Methodologically, the paper presents a cyclical workflowevent monitoring, validation, decision-making, feedback, and knowledge translation, illustrated through a use case that demonstrates how real-time analytics and participatory design enhance responsiveness and trust. Findings suggest that LPHSaaS can improve situational awareness, resource allocation, and intervention precision while fostering resilience and continuity during crises. The proposed model offers a blueprint for transforming public health infrastructures into dynamic, learning ecosystems, with implications for both theoretical advancement and practical implementation across diverse health contexts.

Vishnu Subrahmanyam

Photo by Evgeni Tcherkasski on Unsplash
 ABSTRACT
 Public health ethics has been contingent on a political landscape leading to several operational hurdles, especially during global health emergencies. Several scholars have pointed out that liberal decision-making has prevented public health institutions from achieving their goals. Thus, the need for a substantive outlook on public health has never been stronger. First, this article highlights the ethical tension and limitations of a presumptive approach to public health that a vaccination policy might produce in a liberal political landscape. Second, influenced by the works of Angus Dawson, this article emphasizes the importance of a substantive approach to public health, especially in a post-COVID era. Last, it looks at how TM Scanlon’s theory of contractualism aids in framing a substantive approach to health policy design and the added advantages of the theory.
 INTRODUCTION
 A public health intervention like a vaccination program for COVID-19, let alone a mandatory one, faces difficulties in implementation as it presents a clash between the role of the government and liberty of its citizens.[1] The clash stems from public health operating in a liberal political landscape that accords great regard for individual liberty. The government, in good conscience, is right in feeling morally obligated to act in ways that serve to prevent the pandemic from escalating. To represent the citizens, governments and policymakers prioritize achieving and maintaining herd immunity. The tension of the state versus individual liberty questions the extent to which governments can go to implement a vaccination policy.
 In trying to balance the considerations of individual liberty and the scope of the state to impose an intervention, the Nuffield Council on Bioethics came up with a design known as the ‘intervention ladder.’[2] The takeaway from the intervention ladder is that the state has the burden of proof in justifying reasons for implementing a particular policy.[3] Such justified trade-offs envisioned from the intervention ladder have guided policymakers in their attempt to design and shape interventions. However, public health ethics and even the intervention ladder view public health through a presumptive or a moderate liberal lens.[4] In a presumptive approach or a moderate-liberal approach to public health, policymakers regard values like liberty or autonomy as more prominent when weighed against values like creation of public goods and their maintenance.[5] A libertarian approach favors liberty and autonomy even more strongly.
 The substantive view of public health holds that values, such as liberty and autonomy, do not automatically hold precedence over community-oriented values such as public goods creation.[6] Some have critiqued the intervention ladder endorsed by the Nuffield Council of Bioethics. Angus Dawson remarks that the intervention ladder as a metaphor prevents the act of climbing. He claims the ladder assumes that liberty is the only guiding principle in policymaking. Such a view neglects any responsibility the citizens have in achieving public goods and maintaining them.[7]
 The emphasis on the drawbacks of a presumptive approach, especially in a situation like the COVID-19 pandemic, leads us to question should public health undergo a redefinition? The approach in public health focusing on non-interference stems from traditional clinical bioethics.[8] However, I argue that public health ethics in a pandemic should accord less emphasis to individual liberty and evaluate every ethical value on a level playing field. Individual liberty provides less platform for action in situations where the community has not established herd immunity. Accountability for the harm principle and maintenance of public goods override concerns surrounding liberty.[9] Angus Dawson argues that with more participation in a vaccination program, protection of public goods from disease can be created faster.[10]
 Characterizing public health as an antagonist to individual liberty undermines the confidence in public health institutions and interventions for which public trust is vital. Although the government may propose a mandatory vaccination policy when voluntary measures fail to meet public health requirements, clear scientific evidence and accountability for public welfare should be the guiding principle. Thus, resetting the parameters gauging a public health intervention is the starting point to prepare for future pandemics.
 In Resetting the Parameters, Angus Dawson suggests that utilitarianism or contractualism could serve as philosophical frameworks that may aid in framing a substantive approach to public health.[11] Evaluating utilitarianism and contractualism according to the COVID-19 facts would help clarify which is better suited to framing a substantive public health approach.
 l. Is Utilitarianism Substantive?
 Under utilitarianism, the morbid circumstances of the COVID-19 pandemic urge us to act in ways that translate to maximizing the overall good. Utilitarianism is a philosophical theory that prides itself on maximizing the best of outcomes for the maximum number of people. In an ideal utilitarian framework, a morally right act does good for all. Utilitarians consider utility the single determining variable that should guide actions.[12] The actionable aspect of a utilitarian framework is its ability to quantify thresholds or markers that mostly dwell in the abstract.
 In Utilitarianism and the Pandemic, Savulescu et al. outline certain determinants as aids in applying utilitarianism.[13] Looking at the aids in the context of a mandatory vaccination policy in light of COVID-19, shows some pitfalls of utilitarianism. 
 The first utilitarian aid is to save the maximum number of lives.[14] Rightly so, an intuitive starting point in a pandemic with striking mortality rates is attempting to save the most lives. However, implementing and justifying a policy with the aim of saving the highest number of lives is complex. While a high number of deaths is a concern, it is reductionist to concentrate only on the end goal and not the means through which such a goal is attained.
 The second utilitarian aid is the length of life.[15] The length of benefit gained from an outcome is crucial for utilitarians. The duration of a benefit determines the quantity of good produced. As an extension, younger people should then, theoretically, count for more than older individuals in prioritizing benefits. Such prioritization has been a matter of concern during the COVID-19 pandemic. While it is true that younger people might tend to benefit more, the pathology of COVID-19 goes against such logic. Elderly populations have experienced disproportionately more severe cases. Therefore, prioritizing youth when the elderly are suffering more of the harm would be ethically contentious.[16]
 The third utilitarian aid is the quality-of-life post-intervention.[17] Through measures such as QALYs and DALYs,[18] utilitarians have attempted to quantify each individual's quality after an intervention. This quantification can result in connecting an individual’s quality of life to their social worth. From a utilitarian viewpoint, a person's ability to produce relevance in society becomes a key determinant in shaping public policy. By extension, people born with disabilities such as mental illness or late-stage dementia can be overlooked merely because they lack "social value.”[19] And yet, “taboo trade-offs occur when we are forced to put a finite monetary value on these sacred values [life, health, ability], when we acknowledge that there is a maximum ‘price’ that we want to pay to uphold values that should be of ‘infinite’ value.” [20]. As such, it is unethical to place a value on someone's life based on the duration or quality of life they may have after an intervention.
 Besides creating difficulty in assessing the quality of life, measures such as QALYs do not address the nuances in providing healthcare. In Economic Evaluation of Mental Health Interventions, Luyten et al. discuss several operational changes that account for these nuances.[21]
 Utilitarians believe in a moral indifference between actions and omissions as the fourth aid.[22] It does not matter how a result is achieved as long as it benefits the common good. Putting forward a bad policy is the same as not putting forward a policy. In the ever-changing and unpredictable dynamics of the COVID-19 pandemic, actions and omissions have different moral implications. Equating them often places an unfair burden on lawmakers, leaving them emotionally and morally exhausted as they weigh the advantages and risks of various outcomes.
 Actively avoiding social biases, feelings, intuitions, and heuristics is the fifth aid.[23] The pandemic elicits strong feelings and aggressively tests beliefs. During the pandemic, some profoundly troubling ethical dilemmas stemmed from bias. In a utilitarian system, a mandatory vaccination policy aimed at crossing the threshold for herd immunity may overlook groups of people who are vulnerable due to a lack of access to the social determinants of health. Attempting to avoid feelings and intuitions all the time does not always result in the creation of a fair policy. Anti-vaccination activists use emotion to further their cause, hence it is critical that politicians consider the feelings at stake for the general public when enacting a mandatory vaccination policy.
 While utilitarianism has benefits such as developing simple operationalizable concepts, providing a quantitative check, and a balance sheet of risks and benefits, it is based on an ethical dystopia. Utilitarian policies can treat people as a means to an end by focusing solely on outcomes. Utilitarianism rests on a presumptive outlook toward public h

Jacob Steere‐Williams

Previous articleNext article FreeA “Menace” or a Martyr to the Public’s Health?Jacob Steere-WilliamsJacob Steere-WilliamsCollege of Charleston Search for more articles by this author PDFPDF PLUSFull Text Add to favoritesDownload CitationTrack CitationsPermissionsReprints Share onFacebookTwitterLinked InRedditEmailQR Code SectionsMoreAs a historian of public health, it strikes me that the concept of uncertainty is key to understanding pandemics. Much like past pandemics, our current public health crisis, COVID-19, is surrounded by uncertainty. Transmission rates, reinfection probabilities, testing modalities, and—perhaps topping the list right now—the role played by asymptomatic carriers are all shifting scientific questions. And as in the past, scientific uncertainty has led to the questioning of scientific expertise by the broader science-consuming public.It is no surprise, then, that in our own pandemic moment of uncertainty we have turned to past pandemics to help us navigate the present. I have been most interested in seeing the expression “Typhoid Mary” reappear in news headlines, the hashtag #TyphoidMary trend on Twitter. Given that the causative organism for the novel coronavirus can spread through asymptomatic carriers, even if we do not quite yet know the extent, a renewed interest in Typhoid Mary makes sense. The name still provokes stirring images about an inherent dichotomy in modern public health: how governments are at once charged with preserving individual civil liberties and with stopping the spread of infectious disease in the community. Not knowing who is healthy and who is sick is worrying enough; knowing that seemingly healthy individuals can unknowingly spread an infectious disease is quite another matter and has produced palpable anxiety.Judith Walzer Leavitt’s 1996 Typhoid Mary: Captive to the Public’s Health was a milestone scholarly exploration of the most notorious asymptomatic carrier in the past, Mary Mallon.1 The basic details of Mallon’s life are well known. Born in County Tyrone, Ireland, she immigrated to America in 1883 and became a cook for several prominent New York families. At some point around 1900 Mallon contracted typhoid fever, a food- and water-borne bacterial infection and one of the leading causes of death at the time. A civil engineer, George Soper, independently investigating the cause of a violent outbreak of typhoid in 1907, traced the epidemic back to the cook, Mary Mallon. He implored New York City’s health officer, Hermann Biggs, to apprehend Mallon, obtain stool, urine, and blood samples, and—if they were found positive for typhoid—isolate her. Although Mallon showed no symptoms of the disease, bacteriological tests for Salmonella typhi were positive and Mary was quarantined on North Brother Island for two years. Despite signing a legal affidavit that she would not handle food upon her release, she was discovered—again by Soper—to be the cause of a subsequent outbreak of typhoid at Sloane Maternity Hospital in 1915. Mallon was thereafter demonized by health officials and the media, constructed as a “menace to the public’s health” (p. 69) and “the most dangerous woman in America” (p. 132). She was sent back to North Brother Island, where she died in 1938.The brilliance of Leavitt’s Typhoid Mary is what today we would call its intersectional approach. Mary Mallon’s fate was shaped, Leavitt argues, at the intersections of gender, class, race, and ethnicity. In Leavitt’s hands the story twists around like a Rubik’s Cube, each chapter turning, complicating, and nuancing. The journey takes us into the perspectives of bacteriologists, public policy makers, lawyers, the media, the broader public, and Mary herself.Rereading Leavitt’s book in the time of COVID-19 reinforces the power of studying epidemics using an intersectional approach. In our own moment of uncertainty about transmission and reinfection, long-standing structures of systemic racism and health inequalities have exposed racial and ethnic minorities to much higher rates of infection and death from COVID-19. The same forces worked on Mary Mallon in the early twentieth century, first in exposing her to typhoid fever and later in American public health officials designating her—a single, female, Irish, immigrant cook—a threat to the nation’s health.Origin Stories: Why Mary? and Why Bacteriology?Uncertainty is at the heart of Leavitt’s Typhoid Mary, which seeks to understand why Mary Mallon was singled out and quarantined for over twenty years while thousands of healthy typhoid carriers roamed American streets. In the first three decades of the twentieth century, the healthy carrier presented a serious public health risk. It was the newest fad in public health, a kind of canary in the coal mine. Deaths from typhoid fever were decreasing as a result of the implementation of municipal water and sewerage projects and the safeguarding of milk supplies, but sporadic outbreaks continued. With the discovery of the healthy carrier, and the highly publicized case of Mary Mallon, public health authorities had a new way to explain ongoing outbreaks and to teach domestic sanitation and personal hygiene—what Nancy Tomes has called “the gospel of germs”—to everyday Americans, particularly immigrants.2But in practice public health officials were unsure how to solve the healthy carrier problem. What rights could be infringed upon, and what powers did local authorities have? Seeing hundreds of heavily armed protesters recently storm the capitol building in Lansing, Michigan, demanding an end to quarantine and stay-at-home orders, reminds us that government authorities are still unsure. In early twentieth-century America, health officers across the country identified and surveilled lists of healthy typhoid carriers. Some of these individuals were isolated for a short period, but most fell through the cracks and escaped oversight. Virtually none were treated like Mary Mallon. Her ethnicity, her work, and her gender served to single her out, marking her as an important case, but Leavitt argues that another reason for the attention she received is that she was the “first” healthy carrier identified in America. Recent scholarship, particularly by Christoph Gradmann and Richard McKay, has underscored how such origin stories can turn toxic and serve class-based and race-based agendas.3To address the uncertainty of the healthy carrier—for typhoid in the early twentieth century and for COVID-19 today—we have turned to laboratory testing. And here too Leavitt’s account can help us understand our current pandemic: how conflicts of scientific expertise shape pandemic responses and how laboratory practices reveal deeper social structures. Take just one example from the book: the 1909 court decision that kept Mary medically imprisoned on North Brother Island. From March 1907 to June 1909, the New York City health department collected and analyzed 163 fecal specimens from her—more than one per week. But their bacteriological results were inconclusive. So often were the tests for Salmonella typhi negative, and so bent was Mallon on disproving the expertise of the city laboratory, that she sought out an independent laboratory, Ferguson Laboratories, to analyze her urine and feces. In all of his bacteriological tests George Ferguson found no positive typhoid cultures. Despite the conflicting evidence, in 1909 the judge ruled in favor of the city health officials, responding to what I have termed a “conflict of analysis”: in a moment when scientific experts disagree on methodology or results, factors of race, class, and gender shape how courts decide routine cases. Given Christopher Hamlin’s recent work on fin-de-siècle bacteriology, I am left wanting more on the differing bacteriological analyses and wondering how representative Mary’s case was within bacteriological circles at the time.4 In my own research on debates over late nineteenth-century legal cases pertaining to typhoid and food adulteration, such conflicts in scientific practice were the norm, not the exception. In the time of COVID-19, conflicts over testing, and reports of inaccurate tests, are shaping how we experience the pandemic and how our governments respond to it. Both for Mary Mallon’s time and now, the material culture of surveillance through testing is critical and deserves closer scrutiny.In important ways, though, scholarship on the germ theory and laboratory bacteriology has shifted since Leavitt wrote Typhoid Mary. Baked into Leavitt’s account is the idea that the bacteriological revolution represented a sharp epistemological break from older theories of disease causation and public health practice.5 A new faith in the laboratory fueled a “new” public health bent on identifying and isolating individuals, not cleansing environments. Leavitt writes that “bacteriological laboratories with their microbe-identifying capabilities became the single most crucial tool in identifying the people and the problems to which health departments should attend” (p. 26).Scholarship that followed Leavitt’s book, such as the work of Michael Worboys, has shown that debates about germs raged into the early twentieth century.6 Skepticism about the authority and expertise of laboratory bacteriology continued, we now know, well after the German hygienist Max von Pettenkofer, in the ultimate act of defiance of Robert Koch’s laboratory discovery of Vibrio cholerae, swallowed a cholera broth in 1892. Decentering the power of the bacteriological laboratory opens up at least two important ways to rethink the story of Typhoid Mary in the time of COVID-19. The first is to see conflicts in laboratory testing as key sites of knowledge production and powerful tools to politicize the science of pandemics. Today, for example, decentering the COVID-19 laboratory might help us better see preexisting health-care disparities as a driver of differential morbidity and mortality and encourage us to redouble public health efforts focused on preventable deaths that result from social determinants of health. The second is to see the field-based practices of epidemiology as deeply related to the laboratory-based practices of bacteriology.Recent research suggests that we might view the story of Typhoid Mary and the asymptomatic carrier not solely through the lens of laboratory bacteriology but also through the lens of epidemiology. In my own work, I have found that epidemiological approaches dominated thinking about typhoid through the first two decades of the twentieth century. Epidemiological practices were spatial, statistical, and environmental, but epidemiologists also were philosophically committed to the idea that typhoid was a specific disease spread via media such as food, water, and people. Experiences with healthy carriers like Mary Mallon were part of a longer gestation of epidemiological practice. Often epidemiologists claimed that they did not need the expertise of the laboratory to provide proof or to shoulder the burden of identifying an index case, and laboratory evidence was often seen instead as back-end scientific proof. We might, for example, see George Soper’s identification of Mary Mallon as the cause of two typhoid outbreaks within the longer history of epidemiological practice. Soper self-identified as a “thoroughly trained and experienced epidemic fighter who had seen service in the laboratory and the field” (p. 103). Leavitt calls him an “engineer epidemiologist” (p. 109), but I wonder how that label stacked up against contemporary Anglo-American actor categories. While Soper may have practiced epidemiological methods, did he identify as an epidemiologist? Was he part of what Thomas Gieryn calls disciplinary “boundary-work”? In other words, how representative was Soper’s brand of epidemiological practice? My book The Filth Disease, on epidemiological practice related to typhoid in Britain, sheds some important light on this question, but we still don’t have a comparable American work.7 Such a reframing of the story forces us to ask different questions about the history of epidemiology and bacteriology and reminds us today, in the middle of a pandemic, to think through the reliability of COVID-19 tests alongside the reliability of epidemiological maps and statistics.One criticism I have of Leavitt’s book that helps us think about COVID-19 today is how stable typhoid itself appears throughout Typhoid Mary. I have long struggled to make sense of the epistemological problem that what we today call typhoid fever does not neatly map onto the way late nineteenth- and early twentieth-century observers used the word “typhoid.” Anne Hardy’s 2015 Salmonella Infections, Networks of Power, and Public Health in Britain, 1880–1975, goes some way in clarifying how, in the early twentieth century, what had long been called typhoid was split into a number of distinct subcategories. “Typhoid” came to mean a single disease caused by Salmonella typhi, but bacteriologists also learned that there were subcategories of similar diseases in the Salmonella family, such as paratyphoid A and B.8 Typhoid was a disease in motion, in other words, not a stable target. There is a kind of epistemological certainty in Typhoid Mary about the stability of disease categories that looms particularly large as we confront COVID-19. Early in the pandemic there were reports of ongoing mutations, and the novel coronavirus that causes COVID-19 is—maybe not unlike typhoid in the early twentieth century—a disease in motion.I have been teaching the story of Mary Mallon for over a decade, largely through the lens of Leavitt’s multiple frameworks and intersectional approach. Students often comment in their course evaluations that this was the topic that resonated with them the most all semester. I suspect that, going forward, because of COVID-19 Typhoid Mary will become even more important in our classroom discussions about the complexities of public health, about naming and blaming as part of the fabric of epidemics, and, above all, about how science functions in moments of uncertainty.NotesJacob Steere-Williams is Associate Professor of History at the College of Charleston. His research focuses on the history of infectious disease, public health, and biomedicine. He is the author of The Filth Disease: Typhoid Fever and the Practices of Epidemiology in Victorian England (Rochester, 2020). College of Charleston, 66 George Street, Charleston, South Carolina 29424, USA; [email protected].Acknowledgments. I would like to thank Nathan Crowe for reading a draft of this essay.1 Judith Walzer Leavitt, Typhoid Mary: Captive to the Public’s Health (Boston: Beacon, 1996). Subsequent references to this work are indicated in the text by page number.2 Nancy Tomes, The Gospel of Germs: Men, Women, and the Microbe in American Life (Cambridge, Mass.: Harvard Univ. Press, 1998).3 Christoph Gradmann, Laboratory Disease: Robert Koch’s Medical Bacteriology (Baltimore: Johns Hopkins Univ. Press, 2009); and Richard McKay, Patient Zero and the Making of the AIDS Epidemic (Chicago: Univ. Chicago Press, 2017).4 Jacob Steere-Williams, “A Conflict of Analysis: Analytical Chemistry and Milk Adulteration in Victorian Britain,” Ambix, 2014, 61:279–298; and Christopher Hamlin, “Bacteriology as Cultural System: Analysis and Its Discontents,” History of Science, 2011, 49:269–298.5 She explored the topic in a 1992 Isis article: Judith Walzer Leavitt, “‘Typhoid Mary’ Strikes Back: Bacteriological Theory and Practice in Early Twentieth-Century Public Health,” Isis, 1992, 83:608–629.6 Michael Worboys, Spreading Germs: Disease Theories and Medical Practice in Britain, 1865–1900 (New York: Cambridge Univ. Press, 2000).7 Thomas F. Gieryn, Cultural Boundaries of Science: Credibility on the Line (Chicago: Univ. Chicago Press, 1999); and Jacob Steere-Williams, The Filth Disease: Typhoid Fever and the Practices of Epidemiology in Victorian England (Rochester, N.Y.: Univ. Rochester Press, 2020).8 Anne Hardy, Salmonella Infections, Networks of Knowledge, and Public Health in Britain, 1880–1975 (Oxford: Oxford Univ. Press, 2015). Previous articleNext article DetailsFiguresReferencesCited by Isis Volume 111, Number 4December 2020 Publication of the History of Science Society Article DOIhttps://doi.org/10.1086/712254 Views: 1660 © 2020 by The History of Science Society. All rights reserved.PDF download Crossref reports no articles citing this article.

Chrissa McFarlane, Marquesa Finch, Tiffany Gray, Jonathan M. Fuchs · 6 authors

There are growing initiatives and calls for focusing greater attention to social determinants of health and their impact on population health [1]. Several emerging strategies are being used to begin to address social determinants, such as the use of health impact assessments and applying health in all policies (HiAP). These strategies and tools are being implemented in an effort to review existing and needed policies, as well as propose new policies to lessen health disparities [2]. Efforts to further integrate social determinants of health through the use of health information technology and other emerging technologies, such as distributed ledger technology both in and outside of existing health care systems are also increasing [2]. Understanding and addressing the social determinants of health through both traditional and non-traditional sectors is key to further reducing health disparities [1, 3-4]. Through exploration of the current state of social determinants of health in the healthcare industry, an analysis of blockchain technology will render the acceleration and adoption of social determinants of health to effectively provide improved health outcomes.

Colleen M. Flood, Vanessa MacDonnell, Bryan Thomas, Kumanan Wilson

The COVID-19 pandemic has highlighted the challenges governments face in balancing civil liberties against the exigencies of public health amid the chaos of a public health emergency. Current and emerging pandemic response strategies may engage diverse rights grounded in civil liberties, including mobility rights, freedom of assembly, freedom of religion, and the right to liberty and security of the person. As traditionally conceived, the discourses of civil rights and public health rest on opposite assumptions about the burden of proof. In the discourse of civil and political rights of the sort guaranteed under the Canadian Charter of Rights and Freedoms, the onus rests on government to show that any limitation on rights is justified. By contrast, public health discourse centers on the precautionary principle, which holds that intrusive measures may be taken—lockdowns, for example—even in the absence of complete evidence of the benefits of the intervention or of the nature of the risk. In this article, we argue that the two principles are not so oppositional in practice. In testing for proportionality, courts recognize the need to defer to governments on complex policy matters, especially where the interests of vulnerable populations are at stake. For their part, public health experts have incorporated ideas of proportionality in their evolving understanding of the precautionary principle. Synthesizing these perspectives, we emphasize the importance of policy agility in the COVID-19 response, ensuring that measures taken are continually supported by the best evidence and continually recalibrated to avoid unnecessary interference with civil liberties.

Margitta Mätzke

In many countries, health systems have developed impressive levels of medical care and organizational complexity, providing treatment of a broad range of conditions for the vast majority of citizens and arresting the attention of academic observers, politicians, and the general public. But the health care system has an older step-sister that is much less in the public eye, much poorer both in resources and reputation, and more often concerned with lackluster tasks such as hygiene, immunization, or telling people to clean their teeth or cut back on drinking and smoking. It is to Philipp Trein’s credit that he calls our attention to public health, the older step-sister of clinical medicine and presents this study of the development and relationship between the two, pointing out the significant difference between individualistic, curative health care and collectivist, population-oriented public health. In times of new threats by infectious diseases such as Ebola or the Measles, increasing incidence of multiple drug resistance, and growing prevalence of chronic disease, this is a timely and laudable contribution. Trein’s book is also commendable for its emphasis on the interdependence—coevolution, as Trein calls it—of the two sectors. The book considers this coevolution in an internationally comparative perspective, combining the detailed substantive focus of public policy analysis with the broader generalizations of Historical Institutionalist comparative politics scholarship. Trein is also right in highlighting the great diversity in institutional design of the two health sectors and their relationship across countries—this last point being not so surprising, as this usually emanates from such internationally comparative undertakings. Public health and health care systems, Trein argues, are two policy sectors that evolve in partially interdependent and partially autonomous ways; they coevolve. The form of this coevolution is interesting, because it is consequential for the extent to which activist public health policies are feasible. Coevolution of the two sectors, Trein argues, takes the form of four different institutional and policy-related types, which he calls types of sectoral coupling. The types reflect different kinds of institutionalization of the two sectors, their interaction, and the extent to which there is cooperation and policy integration (i.e., shared policy agendas and jointly developed policies) between the two. Two institutional and behavioral dimensions define the types. First, institutional distinctiveness of the two sectors pertains to the question of whether they are organizationally autonomous or integrated; second, responsiveness pertains to the behavior of professionals in the two sectors and the question of whether they talk to each other and coordinate their work. Tight coupling refers to a situation in which the two sectors are highly responsive and organizationally highly integrated. Under conditions of loose coupling, the two sectors are institutionally distinct but their actors are still responsive and work together. Noncoupling describes organizationally integrated policy sectors in which professionals concerned with the tasks of public health or curative medicine do not work together, and a decoupled setting is one in which we find neither organizational integration nor responsiveness (complete separation). The four types are consequential because only the responsive types are able to produce integrated policies, combining the agendas and resources of both sectors. The book’s explanation of the four types of coevolution draws on the two dimensions of the typology, with sectoral distinctiveness and autonomy being a facet of power sharing in the political system at large, such that integration of the two public health sectors is to be found in countries with unified government. Mutual responsiveness of professions working in the two sectors is a function of the institutionalization and, as the author claims, the strength of those professions. Where professions are strong and politically active and position themselves in competitive, pluralist systems of interest group institutionalization, Trein expects to find responsiveness, whereas “weak” professions in corporatist systems of interest mediation produce situations with little responsiveness between policy sectors. Since unification of government structures and professional interest organization are both institutional variables and, as such, better suited as intervening factors than as independent variables, the author introduces contextual factors such as problem pressure, fiscal strain, and the notion of political environments that are generally amenable to policy integration and responsiveness to account for institutional change and policy development. The case studies examined in the book exemplify the four types, with the three Anglo-Saxon countries (Australia, the United Kingdom, and the United States) representing the responsive types while Switzerland and Germany are constellations with little responsiveness and interaction between professionals of the public health and the health care systems. The book’s empirical chapters present evidence from the histories of health policy over the course of the past 150 years. The case studies trace institutional integration or differentiation as well as responsiveness and cooperation of the professions working in the two policy sectors in four time periods. Trein puts much effort into presenting the historical material very systematically, in each chapter highlighting how it relates to the conceptual framework and in the concluding chapter summarizing the different pathways of coevolution very clearly (cf. p. 240). He is also very explicit about points in which theoretical expectations were not met by the historical record. This analysis demonstrates the author’s strong commitment to reconciling the detailed historiographic work of public policy analysis and policy history with the explanatory and generalizing ambitions of comparative politics scholarship. The reader is never lost in the complexity of historical detail; there is no ambiguity, and the author succeeds in lucidly and transparently identifying distinct cross-national patterns of coevolution as well as explanations for those patterns. It is this very clarity that also exposes limitations of the conceptual framework and some weak spots in the explanation and the historical analysis, however. Here, I would first make some remarks about the conceptualization of the dependent variable, coevolution, and then comment on the explanation of the patterns of coevolution both with regard to its theoretical underpinnings and the historical evidence presented in support of this explanation. The book’s central theoretical claim is that public health and curative medicine coevolve, that is, they are interdependent yet potentially distinct. Coevolution occurs at the intersection of two dimensions, organizational distinctiveness of the two sectors and responsiveness of the professional staff working in the two sectors. This results in the four types of coupling of health care and public health described above. The first of the two dimensions, organizational distinctiveness, is systematically underdeveloped, however. This holds with regard to the empirical case studies, where the author often reports that his findings about the organizational dimension were not in line with his theoretical expectations. It also holds with regard to theoretical underpinnings, where the meaning of “unified government,” conceptually the main explanation of institutional integration of the two policy sectors, remains unclear. Chapter 3 of the book, which discusses the institutionalist underpinnings of the two central hypotheses about responsiveness and distinctiveness, presents a whole bundle of theorizing on government unification or fragmentation, ranging from arguments from the comparative federalism literature to veto player analysis. These arguments are mobilized to motivate the author’s expectation that distinctive and autonomous sectors are to be found in polities with dispersed political power. This is conceptually imprecise, as it does not specify where and in what way political power is dispersed (in legislation, in state structures, in administrative resources, in patterns of political mobilization and interest organization, etc.), and why and how this should have an impact on administrative structures in policy fields. It is not fruitful theoretically, for instance, to use a blanket characterization of German government as “relatively unified” (p. 169) if the intention is to explain details in authority patterns and administrative structures of public health and health care. The German polity may be politically relatively centralized and unified, but public administration is not unified but decentralized. In terms of political power, German corporatism and German federalism are among the core institutions that have been explicitly designed to render the German state “semi-sovereign.” Therefore, while conceiving of sectoral distinctiveness as a facet of power sharing in the political system at large is an interesting approach, it would require more theoretical work specifying precisely how we can establish a connection between dispersed or concentrated executive authority and the organization of tasks in policy sectors. In addition to the fact that the explanation of the distinctiveness dimension is not fully developed, the overall status and significance of that dimension are not entirely clear. It seems of lesser interest than responsiveness, as responsive types of coevolution, whether loosely or tightly coupled, are the constellations in which policy integration, cooperation in public health campaigns, and overall reform activism on public health are more likely. Throughout the book there is an underlying notion of “successful public health activism,” capturing the evolution of public health out of its subordinate status and the “creation of a global public health strategy” (p. 250). This is an interesting and important prospect, and asking when and under what conditions it may occur is certainly a valid and highly significant question. But this question remains implicit and is never accurately formulated as a research question; it is never properly theorized, and it is an entirely different question than what identifying types of coevolution between two policy sectors can answer. Therefore, if successful institutionalization of activist public health is the core commitment, and if cooperation and responsiveness of professionals working in public health and the health care systems is the principal explanation, then the core conceptual tool should reflect this. A typology is probably not the most suitable approach for studying stages of development toward an integrated and activist public health policy because we would then not be talking about a typological distinction but, instead, about an ordinal scale of more or less successful public health efforts. If the underlying core commitment is explaining the success of the public health effort, an outcome of professions’ responsiveness, and responsiveness, in turn, is a function of the “strength” of professionalism, then a few words about that causal connection are in order. In the kind of semantic shorthand-fashion that sometimes makes reading this book more cumbersome than necessary, Trein often refers to the “responsiveness of the two sectors.” As only actors and not sectors can respond or cooperate, he means the extent to which professionals working in the two sectors are willing or able to cooperate across sectoral boundaries or within settings in which sectoral boundaries have become unimportant or nonexistent. Responsiveness, according to Trein, is a function of the political strength of professions. In the case of public health and health care, this includes primarily the strength of the medical profession and its interest organizations. In pluralist systems of interest organization in which interest groups and professions compete based on their political appeals, professional organizations mobilize on a broader substantive agenda; they are willing to respond to the commitments and agendas of adjacent policy fields, such as public health. In corporatist social insurance systems, by contrast, there is no need for broader political mobilization; professional representation accords public status to organized interests, and professions focus on their narrow material interests. Therefore, weak professionalism renders policy sectors nonresponsive and, as a result, less able to produce integrated policy solutions. The first difficulty of this argument is that we learn a lot about the political strength or weakness of the medical profession, but the image of the public health profession (or professions?) remains pale. So, it is a one-legged cooperation, responsiveness to an unknown interlocutor. The argument’s main problem, though, is rooted in the theoretical underpinnings of the notion of “weak professionalism” as core building block of the explanation of coevolution types. As in the case of organizational distinctiveness and unified government, this notion is based on a somewhat selective and skewed reading of large theoretical literatures on systems of interest mediation. In the central point, namely the assessment of a profession’s (or an interest group’s—Trein never decides which) strength, it runs flatly against core findings of these relevant literatures, especially when it comes to assessments of corporatism. While there is no divine verdict against disagreement with core claims of a literature, some discussion would have been required. This is what is often lacking here—there is no recognition and discussion of Mancur Olson’s seminal argument that interest groups under pluralist conditions may be more prone to defending narrow interests and more powerful in doing so but are especially ill-suited for taking on more encompassing views, which are more likely in corporatist systems of interest organization with their broad peak organizations (Olson 1982: 47–50). The book includes no acknowledgement of Peter Katzenstein’s groundbreaking argument about a state (Germany’s state), rendered semisovereign, precisely because of this political system’s entrenched corporatist structures in which a strong and centralized civil society organizes policy sectors such as health with some degree of autonomy, thus constraining the central government’s interventionist prowess (Katzenstein 1987, especially pp. 23–34). This idea may explain sectoral distinctiveness, but Trein does not use this opportunity and instead sets out to contend that organized medicine is politically weak in corporatism. There is no appreciation of scores of writings about veto-group politics in health policy making, in which the strength of organized medicine may have made cost-containment a cumbersome task in many health systems but has not per se undermined the activist policy making or quality of health services in either the health care or the public health domain. Finally, not much actual evidence is provided for the claim that lesser amounts of actual interaction, cooperation, and responsiveness amount to lesser efforts and success in sanitation, vaccination campaigns, health surveillance, health education, or however one might circumscribe the substantive scope of activist public health policy. The conceptual weakness, again, spills over into the cogency of the empirical narratives. For instance, it is a bold assertion (to put it mildly) to call organized medicine in Germany politically weak. This profession has been able to determine prices for medical services (i.e., their income) practically unilaterally for decades, which is not much of a sign of political weakness. To write a 30-page policy history of public health in Germany, a narrative that amounts to an image of institutional underdevelopment of that sector because of the putative political weakness of health professions, without ever mentioning the names of Robert Koch, Emil Bering, Paul Ehrlich, Rudolf Virchow, all of whom are towering figures in the history of public health, amounts to a bold assertion, to say the least. It is also testimony to the difficulties of a style of argument as predominantly institutional and structural as this one. Organizational distinctiveness is a function of government fragmentation, an institutional variable. Responsiveness is a function of professions’ political strength and status, likewise primarily a function of the professions’ institutionalization. Schematically applied, this leaves little room for understanding the actual policy histories, and that, in turn, leaves us wondering how much explanatory power this account of coevolution has at the end of the day. This book is full of interesting ideas and observations. The way in which they are put together into a conceptual argument, however, is not fully convincing. There are (too many) weak spots on the conceptual and theoretical level, and readings of underlying theoretical literatures are somewhat thin and skewed at times. As a result, some of the empirical narratives—likewise often lacking the historical and policy field-related depth and detail that would be necessary to sustain this argument—do not capture key developments in the countries and in the time periods under review. As such, the five-way comparison does not successfully substantiate this book’s explanation of coevolving policy sectors. It is the very commitment to clear-cut hypotheses and systematic inquiry that has brought forth the limitations of the argument. But then, social science is a collective undertaking, one might say, and much can be said in favor of putting an interesting and novel set of observations and possible relationships on the table, leaving much room for improvement. We read our colleagues’ work as much in search of inspiration and creative disagreement as we look for instruction and conclusive results. In that spirit I can say, do read this book! But do not believe what you read.

Paul Kuehnert, Herminia Palacio

For decades, governmental public health in the united States has been relegated to operating at the margins of the country's massive healthcare system that drives nearly 20% of the uS economy.1 Further buffeted in recent years by a variety of external forces (including the 2008 economic recession, shifting demographics, a high and complex population burden of chronic disease, and a rapidly changing health care delivery system), public health leaders and policymakers increasingly recognize that the existing practice models are no longer adequate for the task of protecting and promoting the public's health.2 put simply, uS public health risks moving from being marginalized to becoming irrelevant if public health practice is not transformed.the challenges embedded in changing public health practice are multiple, and are made more complex by the decentralized structure of public health in the united States. public health here is a federated enterprise that includes national entities such as the Center for Disease Control and prevention, the Food and Drug Administration, and others; state and local governmental health departments; non-governmental organizations at the national, state, and community levels that are organized around single or multiple health-related issues; and public and private colleges and universities that provide education and training to the multiple disciplines making up the public health workforce. National study committees convened by the National Academy of Science's institute of Medicine over the past 30 years3-5 have consistently found the uS public health system to be in a state of disarray: misunderstood by elected policymakers and the general public; under-resourced in financial, technological, and workforce spheres; and highly variable in practice and services provided by over 2500 state and local governmental public health departments.For more than 20 years, the robert Wood Johnson Foundation (rWJF) has made significant investments in advancing public health in the united States. this includes multi-million dollar, flagship investments in public health accreditation and in public health systems and services research, with both efforts broadly directed toward improving the quality and impact of public health practice. it also includes more recent, and more narrowly concentrated, investments in engaging public health leaders in focused dialogues on critical operational issues as well as on more aspirational strategic thinking about how to catalyze and support transformational change in public health practice. three current examples of these strategic investments include:1. Building consensus around a set of core and foundational public health capabilities and services;2. developing an aspirational vision for uS public health in 2030; and3. identifying leadership and educational preparation needed to prepare the public health workforce of the future.Foundational Capabilitiesrecognition of the significant variability in the type, amount and financing of public health services led the institute of Medicine in 2012 to call for a '... minimum package of public health services, which includes the foundational capabilities and an array of basic programs no health department can be without...'.5 through funding a public Health Leadership Forum (pHLF), rWJF convened a diverse group of federal, state, and local public health leaders and stakeholders in April 2013 to review this recommendation and operationalize it. over the course of the next nine months, the group developed consensus around a foundational capabilities and services framework6 (see Figure 1) and operationalized them with enough specificity that a costing model is now being developed. the framework is being systematically vetted with the broader uS public health community by way of presentations at multiple conferences, webinars, and social media. once vetted, it is hoped that the foundational capabilities and services framework will be utilized by state, local, and federal policymakers and result in increased resources for public health while decreasing variability in practice and, ultimately, improve population health outcomes. …

Justeen Hyde, Stephen M. Shortell

No abstract is available for this record.

Joan R. Villalbí, Joan Guix

Este trabajo analiza la estructura de los servicios de salud pública en Estados Unidos. Pretende aportar la perspectiva de una organización federal de la salud pública con más de 200 años de historia, que puede ser de utilidad en el actual contexto español. La información se ha obtenido a partir de la realización de entrevistas con personas clave de los tres niveles de la administración pública (federal, estatal y local), así como con académicos (muchos de los cuales han sido directives del sistema de salud pública). Se presta especial atención a la organización, financiación y actividades de los departamentos de salud pública locales y de los estados, así como a los esquemas de relación entre ambos. Se comentan las implicaciones para un país como España, que ha pasado en poco tiempo de una estructura muy centralizada a una estructura descentralizada en 17 comunidades autónomas. The present article analyzes the structure of public health services in the USA. It aims to describe the perspective of 200 years of a federal organization of public health services, which could be useful in the current context in Spain. Information was obtained by interviews with key informants from the three levels of government (federal, state, and local) and with academics (many of whom had previous experience as public health officers). Special attention is paid to the organization, financing and activities of local and state health departments, as well as to the relationships between these departments. The implications for a country like Spain, which has evolved in a short period from a highly centralized system to a decentralized system based on 17 Autonomous Communities, is discussed.

Milton Terris

No abstract is available for this record.