摘要：We trace the shifting definitions of the American public health profession's mission as a social reform and science-based endeavor. Its authority coalesced in the late nineteenth and early twentieth centuries as public health identified itself with housing, sanitation, and labor reform efforts. The field ceded that authority to medicine and other professions as it jettisoned its social mission in favor of a science-based identity. Understanding the potential for achieving progressive social change as it moves forward will require careful consideration of the industrial, structural, and intellectual forces that oppose radical reform and the identification of constituencies with which professionals can align to bring science to bear on the most pressing challenges of the day. NEARLY A CENTURY AGO, public health official Hibbert Hill wrote a provocative book, The New Public Health . In it he sought to capture the fundamental changes that had overtaken the field over the previous fifty years and to present a road map to the future. The “essential change” he characterized succinctly: “The old public health was concerned with the environment; the new is concerned with the individual. The old sought the sources of infectious disease in the surroundings of man; the new finds them in man himself. The old public health … failed because it sought them … in every place and in every thing where they were not .” 1 For Hill, to improve the health of the nation, one had to begin changing behavior a single person at a time. The field had to abandon universalist environmental solutions—introducing pure water, sewage systems, street cleaning—and begin focusing on training people how to live cleaner, more healthful lives. Bacteriology held out hope for “efficient” public health. The logic of the sanitarians' ideas ultimately led to radical reformation of the environment (e.g., tearing down filthy, air-deprived slums, improving the infrastructures of entire neighborhoods), whereas education and control of the actions of the infected individual merely required a focus on the renegade few. Treating a few thousand victims of disease was, in his analysis, far cheaper—he estimated “one seven-hundredth the magnitude”—than improving housing for millions. 2 Hill's analysis reflected one of two major strands of Progressive Era thought: efficiency as repudiation of reform through social, as opposed to individual, action. Hill sought a model for addressing disease that could limit the myriad responsibilities public health had accumulated in the nineteenth century. It also marked the beginning of a struggle to define the mandate of public health, a struggle that has consumed the field since the early years of the twentieth century. At the heart of the more than one hundred efforts to define the “new” public health that followed Hill's 1916 call for refocusing has been the question of the extent to which public health, as an agent of science, can also promote social, economic, and political reforms. 3 In the late nineteenth and early twentieth centuries, public health reformers recognized a common core to their work. It revolved not around clearly defined activities or even a delimited environmental sphere of influence but rather around a shared understanding of the causes of disease and the ambitious, sweeping action that would be required to promote the public's health. During the first two decades of the twentieth century, science and technology emerged as major forces in American life and helped to reshape public health and medicine. With this change and the decline of infectious diseases, the old core of beliefs and actions began to collapse. History poses a challenge to go “back to the future”: to understand how the field attempted to balance what it came to view as a tension between reform and science after the Progressive Era. We do not promote yet another vision of the “new” public health. Nor do we attempt to define this dynamic and ever-changing field that has responded, over the course of more than a century, to pandemics of infectious disease, housing crises, obesity, violence, drugs and alcohol, and even nuclear war, with an expanding panoply of players drawn from the professions, civil society, academics, and social activists. These conditions and the activities meant to allay them defy easy description. 4 Indeed, history tells us that attempting to define the field in terms of activities will make our current initiative just one more in the series of efforts. We argue that the death of progressivism and the advent of the conservative political and social environment of the 1920s pushed public health into the laboratory and the university and away from the traditions that had once been central to its identity. Although the Depression created new opportunities for public health, allowing for alliances with the labor movement in support of a national health plan and local initiatives to set up community health centers for the vast number of unemployed, the growing power of medical science and narrowly defined “efficiency” continued to push public health away from its reformist roots. In the years after World War II, the end of the New Deal, the rise of consensus politics of the affluent consumer society, and the invention of new medical and therapeutic technologies once again led public health to shift its focus away from social reform in favor of “magic bullets” as the preferred means for addressing disease. Since the 1960s, public health practitioners have struggled with their identities as scientists and activists. Although issues of socioeconomic disparities and inequality have become a part of the public health agenda, we remain uneasy with forming political alliances even as our initiatives have been challenged by a host of activists. Although public health cannot be easily characterized, we can see in the history of the field a broader unifying mission and a new political and economic context for articulating it. Understanding the potential for setting forth an ambitious charge as the field moves into the twenty-first century will require careful consideration of the current social backdrop, particularly as it relates to how we define the relationship between science and action.
