Abstract
This book gives a thoughtful account of the various public health issues and controversies dealt with by the New York City Department of Health from 1965 to 2005. The author refers to his method of approach as a narrative history a story, or collection of stories that seeks to convey the texture and detail of what it was like to address public health issues in a particular place and time and to understand why specific actors made the choices they did (p. 16).
This was an appropriate way to approach the subject matter because it enabled the author to present a finely nuanced picture of what was happening as the events unfolded. In other words, it helped to ensure that the developments analysed were always situated within their proper social and political context. Further, the approach made for a ‘readable’ and easy to follow book.
The introduction gives a brief but useful history of the Department and helps to set the stage for the discussion of more recent events. Covering the early 1960s, the first chapter tells the story of how the departmental activities were influenced by the forced adoption of a policing approach that audited the practices of city physicians. Particular focus was on identifying instances of unnecessary medical procedures, duplicate billing and overcharging. Also during this period, Colgrove discusses how concerns over health care provisions for the poor were shrewdly secured by the Department. Specifically, to deflect charges of ‘socialised health care’, the Department acquired funding for what was called ‘ghetto medicine’ by framing their concerns in terms of a poverty reduction programme. Funding for this programme was to be directed to the Health Department’s neighbourhood centres, but in the end, the funds were diverted to hospitals. The way that the funding of health and clinical services was allotted was a contentious issue with considerable political and social resonance. Essentially, the conflict was between who should receive the funding and associated services—community neighbourhood centres or city hospitals. In fact, this conflict led to an enduring tension between the advocates of each approach and would come up again and again in different forms, thus influencing the nature of the city’s public health programmes and strategies more generally and leading to a climate of mutual distrust and hostility within the Department.
The late 1960s are covered next. This was an era in which health issues were very much defined by the civil rights movement and identity-based activism. Developments such as the Vietnam War, urban poverty, the decline in deference to professionals and the emphasis on the rights of those marginalised began to exert an influence on the way public health was conceptualised and managed. Influences from these developments served as the impetus for initiatives designed to integrate community members into service delivery—as evidenced by the hiring of community outreach workers to help those in poorer neighbourhoods. It was during this period that The Health Department sought to implement programs freighted with symbolic meanings around power, inequity, and social disorder: lead paint poisoning, heroin addiction and abortion (p. 46).
Notably, the way these specific issues were dealt with gives the reader an idea about the extent to which the Health Department had to contend with external political pressures, which in turn would shape the possible responses that could be taken. Further complications arose with the introduction of a business management approach—one which emphasised inputs, outputs and optimal results. This led to the hiring of ‘programme analysts’ who had no background in public health or medicine but were given the task of designing and implementing public health programmes. As one could imagine, this would introduce a whole set of additional problems and Colgrove deftly reviews these.
The third chapter discusses how the Health Department continued to deal with issues beyond their traditional purview into the 1970s. This time, the crucial difference was the fiscal crisis now faced by the city. Facing insolvency, the city was forced to find ways to save money. The most common method was of course to slash budgets and lay off city personnel. At the same time, however, efforts were made by the new head—Lowell Bellin—to ‘reprofessionalise’ the Department by recruiting staff with substantive experience in public health. It was quite remarkable how Bellin and his new staff were able to take creative measures to ensure and protect public health functions despite the significant economic threats faced by their department. In light of the current economic conditions, this chapter is well worth a detailed read as a primer on how public health agencies can effectively maintain their functions under challenging circumstances.
Focusing on the 1980s and 1990s, the next chapters discuss the HIV/AIDS epidemic, homelessness, crack cocaine use and the rise of tuberculosis. A highly politicised atmosphere in which stigmatised and disenfranchised victims were fighting for the right to fair treatment sets the stage here. Again, Colgrove gives a detailed account of how the Department was able to rise to the challenges. Although the Department was somewhat successful in curbing the HIV/AIDS epidemic and very successful in relation to tuberculosis control, Colgrove nevertheless poignantly observes that The department’s approach had left untouched the deeply entrenched social conditions that gave rise to the epidemic. The program of directly observed therapy worked within structures of poverty and deprivation—welfare hotels, homeless encampments, crack dens, jails, neighbourhoods devastated by the war on drugs—rather than attempting to reform them (p. 212).
The remainder of the book analyses more recent issues: the debates around the use of pesticides to deal with the West Nile virus, the implications that the World Trade Center attacks of 11 September 2001 had on the Department and the anthrax scare. A notable recent development—one that significantly bolstered the ability of the Department to fulfill its mandate—was the election of Michael Bloomberg in 2001. Unlike other New York City mayors, Bloomberg had a deep appreciation and respect for public health and what it could accomplish. Bloomberg promptly recruited Thomas Frieden as the new public health commissioner and, with his hiring, the emphasis of the Department changed quite drastically. Attention now came to focus on those ailments facing an increasing number of New Yorkers. Namely, the so-called lifestyle illnesses such as: cardiovascular disease, obesity, diabetes and cancer. To pursue preventive strategies in relation to these types of illnesses meant a more interventionist approach, one which attempted to alter matters often conceived of as private and personal (and therefore outside the purview of the state). This included targeting behaviours related to smoking, diet, alcohol consumption and level of physical activity pursued. Colgrove outlines how public health interventions related to these behaviours led to conflicts and a public relations war with various corporate interests and lobby groups such as the restaurant, hospitality and tobacco industries. In the end, many of the newly introduced public health initiatives were quite successful; a success Colgrove attributes to the ability of Mayor Bloomberg to ensure the priority of public health goals over competing ones.
The concluding chapter gives an excellent discussion of the larger social and political implications of the content covered in the book. Much insight can be gained here about how the functioning of public health bureaucracy is influenced by the interactions and relationships between various groups within a city.
This book goes beyond merely historical description to give some valid social and political commentary about the unfolding developments covered. Thus, I would strongly recommend this book to anyone with any sort of interest in public health. Public health scholars, practitioners, as well as those interested in the relationship between urban politics and the operation of local state bureaucracies more generally, will definitely gain some useful insights.