Keywords

1 Introduction

The continuing importance of public health is not hard to see. Even before the COVID-19 pandemic, the continuing challenge of the Ebola virus in sub-Saharan Africa, measles outbreaks around the world, divisive debates about the role of vaping as an alternative to combustible tobacco products, the looming crisis of bacteria resistant to existing antibiotics; these and other issues point to the fact that public health is a critical policy challenge for governments around the world. The pandemic has served to magnify many times over the critical importance of public health, However, precisely because the response to a pandemic and other public health challenges require action by governments and the closely associated reality that citizens often disagree on whether and what to do, public health is inherently political. This is well understood by actors within public health and has been for a long time. Thus, it is both appropriate and indeed essential that the tools and insights of political science be applied to public health. In fact, over the past decade there has been a slow and steady increase in the amount of interaction between disciplines. Political scientists have begun to pay close attention to public health and, in parallel, public health scholars and actors have slowly begun to appreciate the contribution of political science.

The result, alas, has been a less than ideal partnership and something of stalemate. If nothing else, the public health enterprise (Tilson & Berkowitz, 2006) continues to be unduly concerned with the ways in which “politics,” understood as a largely negative influence, interferes with or otherwise distorts the making of scientifically based public health policy. For political scientists, by contrast, politics and political conflict are endemic and the task at hand is not how to eliminate or contain political influence but rather to understand it. Conversely, all too often the political science of public health does not fully engage with the ongoing public health research that offers rich insights into a myriad of policy and political questions, even if this is not done in ways familiar to political scientists and, by extension, readily accessible to a political science audience. To explore and hopefully get past this stalemate, in this exploratory essay, we propose a typology of the possible interactions between political science and public health. In addition to the common pattern of public health without political science, we suggest there are three broad patterns to describe the intersection between the two disciplines. Drawing on earlier work in sociology (Mykhalovskiy et al., 2018), we suggest that what some have called health political science (de Leeuw et al., 2014; Kickbusch, 2015) can be divided into four broad categories: political science without public health political science in public health, political science of public health, and political science with public health. Each has different implications for what role political science can play in better understanding the public health enterprise and, by extension, what role scientific evidence does and does not play in the making of public health policy. The essay is divided into three parts. The first briefly sketches the original typology drawn from sociology. The second part offers an application of this model to political science and public health. The third section explores the implications of this typology for the place of scientific evidence in the making of public health policy. A short conclusion ends the essay.

2 From a Sociology of Medicine to a Sociology of Public Health

As well described in a recent paper by Mykhalovskiy and colleagues (Mykhalovskiy et al., 2018), in 1957 the American sociologist Robert Straus introduced the distinction between sociology in medicine and a sociology of medicine (Straus, 1957). He distinguished between an applied sociology in medicine where scholars with a background in sociology worked with health professionals in a health sciences setting. This is in marked contrast with a sociology of medicine, a more basic and much less applied exercise which was, and presumably still is, the preoccupation of scholars working largely outside of medicine. For this latter group medicine is an institution and as he put it, “a behaviour system” that is an object of inquiry, something to be understood from without. In this same era, sociologists in other countries, including Canada, began to pay closer attention to public health (Badgley et al., 1963).

In their highly original (if somewhat overstated)Footnote 1 paper, Mykhalovskiy and his colleagues build on this approach in medical sociology to develop a framework for understanding the relationship between sociology and public health.Footnote 2 They extend the original distinction and offer an account of a sociology that is neither in or of, but rather is a sociology with public health. In their view, a critical sociology with public health is a set of research practices that recognizes the epistemological and other differences between sociology and public health but seeks to turn these differences into productive opportunities.

On this account, a sociology in public health is one where scholars trained in sociology find themselves working closely with public health scholars and especially practitioners. The task at hand is to use the tools and insights of sociology to address public health challenges and problems. The downside risk is that sociologists lose their unique status qua sociologists and focus almost exclusively on the preoccupations and concerns, not of sociology, but of public health. Pushed to an extreme, this becomes a “service relation” where sociological “theories, concepts and methods are used to support public health aims” (Mykhalovskiy et al., 2018, p. 3). In this situation, the scholarly autonomy of the social sciences is weakened in support of “applied public health reasoning and objectives” (Mykhalovskiy et al., 2018, p. 3). Using the example of population health intervention research (PHIR) (Bärnighausen, 2017; Hawe & Potvin, 2009) they suggest that sociology might become nothing more than “a kind of conceptual handmaiden – a reservoir of concepts that might fix a public health research problem” (Mykhalovskiy et al., 2018, p. 4).

In contrast, a sociology of public health retains far more critical distance from the public health enterprise. Mykhalovskiy and colleagues cite the work of Levinson (2005), for example, who sought to understand why there is often a tendency in public health (or at least applied public health policy making) to emphasize individual risk behaviors as opposed to the more structural causes of the health of populations. In this same vein, they go on to cite the examples of applications of the work of Bourdieu, Foucault, and Science and Technology Studies to a variety of public health issues where the emphasis is increasingly on offering a rather fundamental critique of some of the basic foundations of the public health enterprise (Mykhalovskiy et al., 2018, pp. 4–5). They raise concerns that, when pushed too far, the critique can become “a tendency to take pleasure in pointing out the failings of public health, while remaining relatively unencumbered by an obligation to help produce something that might work differently” (Mykhalovskiy et al., 2018, p. 5).

As an alternative to sociology in service of public health or a sociology that is hypercritical of public health, they then sketch a sociology with public health that draws on similar efforts to develop a sociology with medicine. They emphasize that this requires recognizing and addressing epistemological and ideational sources of difference and tension between public health and sociology. To oversimplify a complex argument, they draw simultaneously on Chantal Mouffe’s work on agonism (Mouffe, 2000) and the applied case of tobacco control, Mykhalovskiy and colleagues explore the possibilities of a sociology with public health.

In summary, a sociology in public health puts the former in a service relationship with the latter and theories, concepts, and research methods of sociology are used instrumentally to address public health challenges. A sociology of public health, in contrast, is far more focused on public health as an object of study and, quite often, offering rather fundamental critiques of the failings of the public enterprise. A sociology with public health seeks to strike a new path that respects and engages with the epistemological foundations of each partner. In what follows, we will argue that much the same situation exists with respect to the relationship between political science and public health. Our goal is to situate the growing body of political science research on public health issues before moving on to consider the implications of this typology for debates about the role of scientific evidence in the making of public health policy.

3 A Typology of the Interaction of Public Health and Political Science

Despite the inherently political nature of public health and the fact that government action of all kinds (e.g., regulation, taxation, exhortation) is critical to addressing public health challenges, there are relatively few examples that suggest that public health scholars have a good understanding of how the insights of political science can shed light on the perennial challenges of public health. Similarly, even though they often develop a deep practical understanding of the realities of politics, most public health practitioners (or what has been described as the “government arm” of public health [Contandriopoulos, 2021]) have little or no formal training that is rooted in political science. Thus, the dominant trend is public health without political science (even as the public health workforce often seems to have an insatiable appetite for in-service learning opportunities on how government and politics work (Cairney, 2015)).

To make sense of the various possible relationships between political science and public health, Table 1 offers a preliminary overview of a political science in, of, and with public health as well as the status quo where public health is understood with little or no reference to political science.

Table 1 Political science for, of, and with public health
Full size table

The first point of comparison is the extent to which theory and concepts from political science are used instrumentally (see Chapter 11 [Cairney et al., 2022]) to better understand public health, or to borrow from Mykhalovskiy et al., political science is nothing more than a “conceptual handmaiden” to public health. The second point of comparison is whether and to what extent the research accepts the inherent legitimacy and autonomy of politics. The third point of comparison is one of breadth: Following Greer and colleagues (S. L. Greer et al., 2017), does the relationship consider the depth and breadth of theorizing and empirical research in political science? The fourth comparator is whether and to what extent public health and issues arising in public health are the raw material for a case study of a broader theoretical, conceptual, or empirical concern of political science. The fifth comparator is the extent of the shared commitment to the core principles that inform the public health enterprise. Public health scholarship and practice are built on the foundation of science, the primacy of health, and social justice. The first of these refers to a deep commitment to the primacy of science and scientific evidence. The second refers to the pattern of asserting that population health is the most important goal of a society, a form of health essentialism, or what Coggon refers to as “health theocracy” (Coggon, 2012, pp. 193–200) that is to say the deep-rooted conviction that the most important goal of a good society is and must be the protection and promotion of health. On this view when, inevitably, there is a conflict between health and other societal goals (e.g., freedom, economic growth, national security), health should prevail. The third core principle refers to the oft-repeated commitment of public health to some overarching vision of social justice which, more recently, has become a deep-rooted commitment to health equity. The final point of comparison is a more pragmatic one that is about the intended audience for scholarly work produced in each category, as described by the forum where the research from each perspective is likely to appear.

3.1 Public Health Without Political Science

It is critical to emphasize that much theoretical, conceptual, and practical work in public health is done with no reference to political science in general or its various sub-disciplines and approaches. While there is a widespread acceptance that there is a political dimension to public health (this is where Virchow is usually quoted (see Chapter 1 in this volume [Fafard et al., 2022])), there is typically little perceived need to draw on the systematic study of politics (and by extension, no need to try and draw on the full range of tools and insights of political science). This may be because the dominant view of politics in public health (or at least in academic public health) does not accept the inherent legitimacy and autonomy of politics. Typically, in public health scholarship “politics” and “ideology” or a “lack of political will” (see Chapter 3 [S. Greer, 2022]) are the enemies of the public health enterprise. Politics thus becomes a problem to be solved. While this is a common view among public health practitioners and scholars alike, the latter, as they gain experience and seniority, often develop an appreciation of the necessity and utility of politics and how to advance public health goals in ways that accept if not embrace political realities (see Chapter 13 [Cassola et al., 2022]).

For public health researchers, on the other hand, it is quite common to continue to see politics as nothing more than something that gets in the way of evidence-based or at least evidence-informed decision making. On this account, the making of public policy is like other forms of decision making and the knowledge translation or knowledge transfer tools that are useful in medicine and public health practice can easily be repurposed for making public policy (for a contrasting view see Fafard & Hoffman, 2018). In this space the commitment to the broader public health project is very high as is the embrace of the core themes of public health: scientific primacy, health essentialism, and social justice. Of necessity, the only possible venue for scholarly research in this tradition is public health journals.

3.2 Political Science in Public Health

To the extent that there is within academic public health a recognition of political science, often the relationship is one of a political science in public health. As with a sociology in public health, the goal of studies in this tradition is to shed light on the challenges facing public health per se. They do not seek to advance political science as a discipline or, more precisely, test or at least refine political science theories. While this is not, in of itself, a problem, it also means that political science concepts and theories are used in a rather naïve, instrumental manner. They are invoked almost tactically to try and explain how and why politics and ideology get in the way of a proper, evidence-based policy process. Moreover, the use of political science is often quite “loose”—concepts and theories are referred to almost metaphorically. So, for example, while Kingdon’s multiple streams theory is very popular in the public health literature, researchers often pay little or no attention to the role of policy entrepreneurs, and few studies examine the evolution of the theory over time. Yet for others, Kingdon is popular because, as Greer and colleagues have noted, the multiple streams approach is one of the few that allows for agency and allows analysts to position public health actors to imagine themselves as skilled policy entrepreneurs (S. L. Greer et al., 2017). In their words, “Despite the empirical power of multiple streams analysis, excessive use of it risks reinforcing the focus on heroism and voluntarism in the public health literature by suggesting that sheer will, sufficiently adept framing or policy entrepreneurship leads to the adoption of policies” (S. L. Greer et al., 2017, p. 42). Kingdon is also commonly used in public health to try and understand why “politics” is getting in the way of evidence-based policy and program change. The politics stream is identified but is perceived as an impediment as opposed to a necessary part of representative democracy.

However, even when there is selected reference to political science theory, too little attention is paid to more basic but powerfully important features of policymaking at all levels. Again, see Greer and colleagues for a discussion of the need to consider the powerful shaping roles of federalism and other basic features of how power is shared (e.g., Westminster vs. congressional systems) (S. L. Greer et al., 2017). Thus, as with sociology, in a political science in public health, political science as a discipline risks being not much more than a source of concepts (e.g., policy cycle, policy window, securitization) or theories (e.g., multiple streams; policy transfer) that are deployed instrumentally to, again, fix a public health research problem (Mykhalovskiy et al., 2018).

3.3 Political Science of Public Health

Of course, the salience and importance of many of the core issues facing the public health enterprise—think COVID-19, Ebola, tobacco control—means that there is an independent body of scholarship and analysis that is rooted, not in public health per se, but in political science. The most common form of this is public health as case study. In this case, to advance research on a concern of political science there is a case study drawn from public health. The primary focus of the research is not necessarily public health per se, it is advancing our collective political science understanding of politics and government. This includes, for example, electoral studies (Mattila et al., 2013; Zeitoun et al., 2019), the policymaking process (see, e.g., Givel, 2006; Pacheco, 2017), the changing nature of international relations, or the capability approach to social justice (see Chapter 12; Holt & Frohlich, 2022; Prah Ruger & Mitra, 2015; Saith, 2011). Of course, this perspective rarely exists in its pure form—in many cases there is some degree of concern with advancing public health scholarship if not public health goals. This approach to a public health political science has dramatically increased since 2020 as political science seeks to make sense of the politics and governance of the COVID-19 pandemic.

3.4 Political Science with Public Health

The final approach, a political science with public health, is, we would submit, the dominant one among political science scholars who do research on public health subjects (at least before the COVID-19 pandemic). Political science theories, concepts, and tools are not simply used instrumentally to inform some broader public health goals. It is taken as axiomatic that there is an inherent legitimacy to politics and political institutions. Politics is much more than something that gets in the way of doing good (public health) policy. However, unlike a simple political science critique of public health, a political science with public health tries to find ways to reconcile the realities of politics with the goals of public health.

What perhaps distinguishes a political science with from a political science simply of public health is the commitment to the broader public health project. Research that is meant to be political science with public health must, necessarily, have some minimal degree of interest in, if not commitment to, the broad goals of the public health enterprise. A political science with public health will also be interested in the core themes of public health—use of scientific evidence, social justice, health essentialism—but will take a variable and often critical perspective. For example, one can be sympathetic to the desire to ensure that public health policy is informed by the best available scientific evidence but for this to happen a sophisticated conception of the nature and role of evidence in representative democracies is required (see the chapters in Part II of this volume). Similarly, while it is likely that a political science with public health will be based in a broad agreement on the importance of health as an overriding societal goal, the approach will be critical and self-aware. In this case, a critical contribution of political science might be to emphasize and explain what health essentialism entails, why it is a matter of considerable philosophical debate, and critically consider the many practical implications for what governments do and do not do when it comes to making policy and program choices. To take one concrete example, a political science with public health will seek to draw attention to the fact that much of the academic public health critique of how governments have responded to the COVID-19 pandemic assumes shared agreement that maximizing population health is the most important goal for governments when, in fact, inside government and in civil society more generally, this is a matter for debate and discussion.

A political science with public health is most clearly prominent in international relations where there is an important and growing body of research on global health governance and global health security (see, e.g., Hindmarch, 2016; Lee & Kamradt-Scott, 2014; McInnes, 2020; Parker & García, 2018; Rushton & Youde, 2014). One can also find examples of a political science with public health for selected public health issues including tobacco control (Breton et al., 2006; Cairney, 2007; Studlar & Cairney, 2014), health promotion, (Clavier & de Leeuw, 2013), so-called health in all or joined up policies (Baum et al., 2013; see Chapter 11 [Cairney et al., 2022]; Carey, 2016; Chapter 12 [Holt & Frohlich, 2022]) and collaboration more generally (Fierlbeck, 2010). More recently, there are studies of pandemic response that are broadly consistent with a political science with public health (S. Greer et al., 2021).

4 Implications for Thinking About the Role of Evidence in the Making of Public Health Policy

In a public health without political science, there is a tendency emphasize the baseline proposition that public health policy should be evidence-based or, at least, evidence-informed. Of course, senior public health officials learn from experience the limits of what can be accomplished by relying too heavily on the “best available evidence” as the sole or at least the primary tool to make the case for policy and program change. However, this can often give rise to conflict within public health organizations as highly trained staff at the lower levels becomes frustrated that senior executives or the minister does not pay sufficient heed to what the evidence says the government should do. Moreover, in a public health without political science, the lack of evidence-based public policy is often explained by invoking a rather pejorative view of politics or making more and less sophisticated references to “political will,” “ideology,” or neoliberalism (Bell & Green, 2016; Fishbeyn, 2015; Fox et al., 2017). For example, Brownson et al. refer to politics, a lack of political will, and special interests as barriers to evidence-based policymaking (Brownson et al., 2009). Similarly, in a study on the taxation of sugary beverages in the USA asked “why is this policy not supported by several States even though it is underpinned by evidence?” (Roberto et al., 2015). A public health without political science is also likely to preoccupy with conventional approaches to knowledge translation that emphasize process (e.g., plain-language summaries, knowledge brokers, bringing public health scientific expertise inside government, etc.). However, the premise often remains one of a knowledge deficit, that governments would act differently and make different choices if they were fully aware of the best available scientific evidence.

In marked contrast, in a political science in public health, while there will be more critical perspective on the role that scientific evidence does and does not play in the making of public health policy, it may be restricted to pointing out how evidence is but one factor among many that influences public health policy. This is one of the core messages of the papers in Part II of this volume. Note, however, there is a risk is that the role of political science, or at least a political science perspective, is reduced to explaining how to be ever more sophisticated in giving the best available science some influence on policymaking or in how governments and international organizations can organize science advice (Gluckman & Wilsdon, 2016; Wilsdon, 2014). Alternatively, when we are talking about non-state actors who wish to influence public policy, the role of political science is reduced to an offering an instrumental guide to how politics and government work. At worst, this becomes political science as lobbying advice.

A political science with public health is arguably one that joins a strong commitment to the broader public health project with a sophisticated account of the role that scientific evidence does and does not play in the making of public health policy. This is by far the dominant perspective in the public policy literature on public health particularly that which deals with the role of evidence in the making of public health policy.

5 Conclusion

In the necessary and inevitable post-mortem on the government response to the COVID-19 pandemic, there are calls to get “politics” out of evidence-based public health policy. From the perspective of political science, this is both impossible and undesirable. While the senior public health leaders in government understand this by virtue of experience, public health scholars are slower to accept this as demonstrated by both what is so often taught in schools of public health and their interventions in the public square. There is thus something of a stalemate between competing views about the role that politics and evidence in the making of public health policy. To foster a rapprochement between the two disciplines this essay proposes a typology of the possible interactions between political science and public health: political science without, in, of, and ideally with public health. Each interaction has often distinct assumptions about the goal of studying public health policy, the legitimacy of politics, the commitment to the core themes of public health that focus on science, the primacy of health, and the importance of health equity if not social justice. We make the case for a political science with public health that, as others have argued for sociology, recognizes the epistemological and ideational sources of difference and tension between public health and political science. Rather than asking public health leaders to learn about politics on the job, the goal is to foster a new, more integrated account of public health policy that can be shared with students who will be the public health leaders of tomorrow.