Editorials

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Editorial: Why History?

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Nov

1997, V61.'97 No. I!

1997 is the 125th birthday of the

American Public Health Association. Major
anniversaries, like this one, provide occasions for celebration and have traditionally
been times for historical reflection. The
Journal marked the centennial of the Association, 25 years ago, by inaugurating a new
section dedicated to historical essays: Public Health Then and Now. Although the
Journal had always published historical
papers, the centennial provided the occasion to give them a new prominence. The
Bicentennial of the country in 1976 was
marked by an increase in the number of historical papers published in the new section,
coinciding with the high tide of national
interest in history. In 1985, the Journal celebrated its Diamond Jubilee with a historical
article in every issue and historical reproductions on all of the covers. Now we
commemorate the Association's 125th year
with a special issue devoted to the history
of public health.
Why the turn to history on these
occasions? Anniversaries provide a natural opportunity to acknowledge milestones,
celebrate achievements, remember turning
points, and honor individuals of courage
and vision who have made significant
contributions. They give us a chance to
recognize enduring values and commitments and, by doing so, to rededicate
ourselves to these principles. There may
be a touch of romanticism as we recollect
what, with the distance of time, seem to
be more colorful personalities and less
complicated circumstances.
At another level, anniversaries can be
occasions for deeper reflection. Even those
most optimistic and upbeat would
acknowledge that the progress of public
health has not always been smooth and
that its forward direction has sometimes
been difficult to discern. Historical inquiry
may be helpful in discovering positive
trends amid the confusions of the present.
A broad historical perspective can help us
shrink specific disappointments to size and

show them in context as only temporary

setbacks. Historical case studies may be
able to teach us useful lessons about successful strategies used by public health
reformers in the past. They may assist us
in identifying patterns and deeper continuities beneath the surface shifts.
At yet another level, history may provide new insights into the difficulties of
change, whether of social and political
realities, attitudes, or behaviors. It allows
us to perceive deep structural impediments, identify blind spots, and analyze
social forces and cultural trends over
which we have little control. At the same
time, historical study shows us that despite
the difficulties, change is possible, given
dedication, organization, and persistence.
Twenty-five years ago, George Rosen
was simultaneously public health educator
and advocate, the nation's premier public
health historian, editor of the Journal, and
author of at least half of the articles published in Public Health Then and Now.
Today, none of us can do it all. To explore
most effectively the implications of the
history of public health requires the collaboration of trained historians and public
health professionals. But this collaboration
is not automatic; indeed, the professional
cultures of academic history and public
health practice make it difficult.
Public health practitioners are necessarily committed to change: they believe
they can make a difference, that with their
activities and energy, they can, ultimately,
reshape present and future reality. Historians are trained to be more skeptical, to
perceive the difficulties of creating social
change, the inertia of economic and political structures, and the interests served by
maintaining the status quo. By the same
token, historians, taking a longer time perspective, believe that change of some kind
is inevitable and that any specific current
reality represents merely a transitory
moment, a cross-sectional slice across the
currents of historical motion.
American Journal of Public Health 1763

Editorials and Annotations

Another reason for difficulty in communication and collaboration is the

scientific culture of public health education. Public health scientists and researchers
are passionately devoted to a scientific
methodology that values empirical rigor,
quantitative precision, and objectivity.
That objectivity is understood to be independent of cultural influences or historical
specificity. Public health researchers are
dubious about the validity of nonquantitative forms of analysis, which are generally
regarded as being imprecise, open to bias,
and dangerously subjective. Public health
academics are highly interested in analytical methods and statistical refinements,
and those of more philosophical persuasion are inclined to be concerned about
the conceptual issues of positivism: the
problematic relationship between fact and
theory and the troubled nature of causation.
Historians, on the other hand, consider
quantitative data to have no special validity
independent of their historical context; they
consider the primacy of numerical forms of
analysis and the positivistic mind-set to be
themselves outcomes of historical processes.
For the historian, historical time is not
homogeneous, and truth is not eternal.
Actors perceive their realities through historically and culturally specific prisms;
notions of scientific objectivity are but
aspects of a particular paradigm. Historians
are relatively casual about methodology,
resistant to claims of a timeless truth, and
highly sensitive to context-dependent
meanings. They tend to varieties of philosophical relativism.
These differences in professional subcultures, although wide, can also be
creative. Public health professionals can
help direct historians to certain critical
problems, themes, and periods in the
shared quest for the meaning of the past.
But historians can apply their own assumptions, methods, and standards of proof to
the process of retrieving those meanings. A
negotiation of sorts can take place. And
just as in good science, there must be a balance between immersion in the intricacies
of a particular field and the critical distance
that allows for innovative insight. Public
health professionals, faced with the
urgency of practical problems, may have
neither the time nor the training to devote
to historical analysis. Yet the timeconsuming and finely honed craft of the
professional historian can produce results
that illuminate the problems of public
health. The conventional understandings of
history and the quick and easy lessons from
the past that people sometimes desire are
not always useful or abiding. Consensus
1764 American Journal of Public Health

sometimes needs to be redrawn and common sense to be reeducated.

The papers selected for this issue
reflect these several themes. The first three
take up large issues in American public
health history. Martin Pemick casts a critical
eye on the professional culture and selfimage of public health, its deeply embedded
values and assumptions, and its self-deception
of political neutrality and scientific purity.
He does this by showing that the assumed
opposition between eugenics and public
health is only one superficial part of a larger
story; the overlap between institutions and
goals, the transit of ideas back and forth
between the two, and the commonalities and
contradictions between them are all parts of
a richer, more nuanced understanding.
Vanessa Gamble takes on another major
theme in American medical and public
health history: racism. She criticizes the
widely held belief that the suspicion in
African-American communities toward
medical and public health interventions
derives mainly from revelations of the
Tuskegee Syphilis Study and shows that the
history of distrust has much deeper roots
and wider ramifications. Leslie Reagan
examines a third central theme in American
public health history: gender conventions.
She analyzes the ways in which public
health educational materials about cancer
have carried culturally embedded messages
about men, women, and sex. She shows
how women have been systematically and

successfully-if unintentionally-taught,
through a century of public health campaigns, that risk is gendered and that it is
their special duty and responsibility to
worry about cancer, the "dread disease."
One result is American women's tendency
to overestimate their risk of breast cancer
and underestimate their risk of heart disease.
The subsequent eight papers present
specific historical case studies. Jessica
Warner demonstrates the need for cultural
and period specificity and sensitivity in
speaking about the social harms of alcohol
use in the premodem period. Bert Hansen
examines the imagery of public health controversy reproduced in late-l9th-century
newspaper and magazine editorial cartoons
and the ways in which these cartoons identified villains and distributed moral and social
responsibility for preventable health problems. Emily Abel illuminates the conflict
between professional culture and immigrant
experience in New York City's Progressive
Era tuberculosis control program and
explores the roots of popular resistance to
public health measures. John Hutchinson
explores the health educational books and
plays produced by the Junior Red Cross in

the 1920s and the ways in which they were

adapted to the conservative mood of postwar America. Through an examination of
Wilhelm Hueper's contributions, Christopher Sellers argues that the development
and dominance of risk factor epidemiology
after World War II effectively displaced an
earlier, more clinically grounded epidemiology centered on occupational exposures.
Alan Derickson analyzes the impact of the
Cold War on the national health insurance
movement of the 1940s and focuses in particular on conservatives' demonization of its
leading representative, I. S. Falk, and the
vulnerability of such technocrats to isolation
and political assault. David Rosner and Gerald Markowitz describe the racially
bifurcated system of foster care in New
York City, the ways in which public agencies essentially abdicated responsibility for
the well-being of children by farming them
out to private sectarian organizations, and
the perverse public health outcomes of this
long-term social policy of segregation. Preston Reynolds looks at the ways in which
Medicare hospital certification policy was
used in the mid- 1 960s to accelerate the
racial integration of hospitals in the United
States by holding out the inducement of federal funding.
Finally, two historical examples, both
from the Progressive Era, represent bicoastal
bookends to the scope and diversity of public
health in the United States. In the Voices of
the Past selection of Isaac M. Rubinow,
submitted by Walter Lear, we see the
theoretically sophisticated and selfconscious socialist, a Russian Jewish East
Coast immigrant fully conversant with the
latest developments in European social policy and economic theory, who approaches
public health problems in a deeply analytical
and politically challenging style. And, from
the West Coast, Thomas Keller introduces us
to William F. Snow, the young, pragmatic,
and enthusiastic Stanford professor and
health educator who brought an innovative
public health program to Californians in the
optimistic and perhaps naive belief that a
railroad car, outfitted with sanitary displays
and charts, could have a major impact in promoting health and preventing disease. Each
in his own way contributed to the advancement of American public health, and therein,
ultimately, may lie the glory of a tradition so
wide in what it encompasses. D
Elizabeth Fee
Theodore M. Brown
Special Issue Editors

November 1997, Vol. 87, No. 11