Keywords

Early in the study of public health, most students come across the famous quote from the nineteenth-century German pathologist and social reformer Ruddolf Virchow: ‘Medicine is a social science and politics is nothing else but medicine on a large scale’ (Aston, 2006). The phrase has been used and abused many times since but is usually invoked to draw a link between medicine and public health on the one hand and politics on the other hand. The coronavirus 2019 (COVID-19) pandemic that ravaged the world and the efforts to address it have made the link between public health and politics very visible to all. Specifically, the pandemic has demonstrated that the choices that governments make to address infectious disease threats are necessarily and inherently informed by both scientific evidence and a host of other economic, social, and ethical considerations. Reconciling these sometimes-conflicting imperatives is the stuff of politics.

But Virchow’s understanding of politics was very particular, as revealed in the second and less well-known part of his statement. After characterizing politics as medicine on a larger scale, Virchow went on to write, ‘Medicine as a social science, as the science of human beings, has the obligation to point out problems and to attempt their theoretical solution; the politician, the practical anthropologist, must find the means for their actual solution’ (Aston, 2006). For Virchow, indeed for many in public health, politics is a practical matter, something that is done by politicians, and something that can and should be informed by the insights of medicine and, by extension, public health sciences such as epidemiology. Unfortunately, translating scientific evidence into public policy is a messy business indeed. Moreover, medicine and public health have few effective tools for systematically understanding the choices governments make, much less the broader complexities of politics.

It is for this reason that, over the last 25 years or so, there has been a growing interest among public health scholars and practitioners in what political science—the systematic study of politics and government—can offer. Simply put, if public health is political, it only makes sense to draw on the insights of efforts to systematically understand how politics and government work. This has led to the proliferation of research that draws on concepts and theories from political science to better understand the public health policy and programme choices that governments make at all levels—global, national, regional, and local. However, a nascent ‘public health political science’ is both an analytical and a normative project. It is analytical insofar as scholars deploy theories and concepts from political science to better understand not only what governments choose to do, but why and how they do it. It is normative insofar as scholars also draw on political science to explain how the public health enterprise (Tilson & Berkowitz, 2006) can more effectively make claims about what governments should do and investigate the normative underpinnings of disagreements, often quite profound, about what constitutes good public health policy.

Public health political science is, however, a relatively underdeveloped cross-disciplinary effort. It arises as a response to the realization from researchers in both disciplines that despite the political nature of public health, work in political science and public health research typically unfolds within ‘disciplinary silos’ (Fafard & Cassola, 2020, p. 108). For example, the inherently political nature of public health has been much discussed in the public health literature including, for example, by Nancy Milio (Cohen et al., 2000; Milio, 1981, 1986, 1987), Amy Fairchild (Fairchild et al., 2007, 2010), and Nancy Krieger (Beckfield & Krieger, 2009; Krieger & Birn, 1998). Similarly, but much more rarely (at least before the COVID-19 pandemic), political science occasionally took note of public health (Alley, 2012; Asare et al., 2009; Axelrod, 2008; Fox et al., 2012; Givel, 2006; Marmor & Weale, 2012; Studlar, 2002). However, these literatures do not tend to overlap. Political science engagement with public health published in political science journals is most often written for a political science audience and is a political science of public health (see Chapter 2, Fafard et al., 2022).

Certain structural barriers have, to date, hindered productive partnerships between the two disciplines. Some of these barriers involve engrained differences in disciplinary identities, methodologies, and knowledge processes, including an enduring professional distinction between politics and science in public health, which leads many to see their mandate as chiefly technical; the divergence between clinical and policy-related needs and processes when it comes to integrating scientific evidence; and a gap in the traditional level of analysis, with political science typically focused on macro-level processes and public health often focused on micro-level interventions (reflecting the field’s biomedical origins) (Bernier & Clavier, 2011; Breton & de Leeuw, 2011; Golden & Wendel, 2020; Greer et al., 2017). In addition, the system of incentives in the respective disciplinary research communities—particularly as they relate to funding and publishing—also creates key structural barriers to effective partnerships.

To bring these two bodies of research and thought together, an intellectual conversation has begun that is designed to bridge the gap between public health and political science. The volume and intensity of the conversation has grown over the past decade or so, and many of the editors and contributors to this volume have been at the centre of it (Bernier & Clavier, 2011; Breton & de Leeuw, 2011; Cairney & Oliver, 2017; de Leeuw et al., 2014; Fafard, 2015; Greer et al., 2017; Hawkins & Parkhurst, 2016; Smith, 2013).

1 Introducing This Book

The book you are currently reading is a continuation and a consolidation of this conversation about the interconnections of political science and public health. It began with an international invitation-only workshop at York University in Toronto in June 2019 (Fafard & Cassola, 2020). Since then, the importance of building a robust public health political science has become more salient. High-profile scholarly outlets like The Lancet and Nature have started to recognize the political nature of public health and as an issue of both scholarly and practical interest (Editor, 2020; Horton, 2020).

With this context in mind, the book has three ambitious goals. First, it provides direct examples of how political science perspectives (broadly defined) can inform public health research and practice with a view to, ultimately, improving the overall health of the population. In doing so, it aims to address and ameliorate the current underutilization of political science tools, theories, and knowledge within the public health field, particularly as they relate to the policymaking process and the role of science and evidence within it.

Second, this book is designed to demonstrate that there is also much that political science can gain from a deeper engagement with public health (Fafard & Cassola, 2020; Lynch, 2019). In particular, there is a need for political science to consider the full scope of the public health enterprise and pursue truly interdisciplinary work that goes beyond positioning public health simply as a case subject or a target for critique (Fafard & Cassola, 2020). Amid calls for scientific advice and modelling to become more transparent, it is critical for political scientists to learn from and engage with public health researchers’ understanding of evidence generation and use.

Third, this book is intended to advance the interconnection of public health and political science as scholarly disciplines. Here, we tackle a long-standing intellectual stalemate arising from different conceptions of the relationship between evidence and policy. The premise that policy decisions should be ‘evidence-based’ or at the very least, evidence-informed is commonplace in the field of public health, and efforts to achieve a better relationship between science and public health policy are ubiquitous. Perspectives from political science do not discount the value of scientific knowledge, but highlight the political nature of evidence and emphasize that policy choice is a negotiated reality (Fafard & Cassola, 2020; see Chapter 13, Cassola et al., 2022). A central focus of this book is to bridge these two perspectives, towards a more fulsome understanding of the relationship among evidence, policy, and institutions of representative democracy.

2 Conceptual Ground Clearing

Before moving on, it is important to specify what we mean by ‘public health’ and ‘political science’. First, we are using these terms to describe academic disciplines. In most high-income countries,Footnote 1 this is straightforward at least insofar as in most universities, the study and teaching of each are done in separate places. Public health is typically the purview of a faculty of medicine or a faculty of applied health sciences or is a stand-alone faculty. Political science, by contrast, is usually a department or school in a faculty of social sciences or arts and humanities. In some places, schools of public policy or international relations also are home to large numbers of political scientists. However, unlike political science, public health is an inherently interdisciplinary academic exercise, and some ‘atypical’ formats for the institutional presence of research, development, teaching, and learning have been identified (de Leeuw, 1995). Typically, a school of public health will have experts in disciplines closely identified with or unique to public health (such as epidemiology and biostatistics), faculty with expertise in other medical and health disciplines, and faculty trained in bodies of knowledge that inform public health practice, such as economics and psychology. It is much less common for schools and departments of public health to have faculty who self-identify as political scientists and bring to bear political science theory and concepts.

Second, unlike political science, the term ‘public health’ is used to describe not only an academic discipline but also an area of applied practice and institutional grounding. Public health is routinely characterized as an ‘applied’ discipline designed to train students to take jobs in public health, usually but not always in government (be it local, state/provincial, national, or global) or the not-for-profit sector (e.g. health charities that seek to influence public policy).Footnote 2 The chapters in this book are meant to be of interest to both public health scholars and public health practitioners. In fact, it is the latter who, absent formal training in political science and government, may find themselves having to ‘learn on the job’ and work hard to better understand how government works and how policy choices are made. Over time they often develop a keen understanding of politics and the policy process but may lack the conceptual language needed to articulate this understanding. Public health practitioners are thus arguably the largest part of the public health enterprise who could benefit from the insights of political science or, at least, particular forms of applied political science (Cairney, 2015).

Third, it is important to clarify that only particular dimensions of political science and public health, of necessity, emphasized in this book. In the case of political science, we focus those parts of the discipline focused on policy making and, by extension, the role of scientific evidence in the making of public policy. There is some discussion of the closely linked political science sub-discipline of public administration or public management. This emphasis reflects the book’s goal of reconciling public health and political science conceptions of evidence and policy as well as the disciplinary background of the editors and authors, which is disproportionately in political science or social policy. As a result, this volume does not engage explicitly with sub-disciplines such as international relations, various forms of political economy, and political theory, despite the relevance of these fields to public health governance and practice more broadly. In addition, this book is primarily about public health policy not public health politics. Consequently, partisan politics, political culture, social movements, interest group lobbying, and other expressly political questions that are the central preoccupation of much research and teaching in political science come up obliquely in the chapters of this book insofar as they are part of the story of the making of public health policy. Others have pursued this linkage more directly (Greer et al., 2017). In the case of public health, this book does not directly address a host of contemporary challenges in public health such as the health impact of climate change; the securitization of public health; global health equity; and various aspect of chronic disease prevention and health promotion. Finally, the book draws on the expertise of the authors and editors with public health policy in high-income countries with only passing references to the challenges in low- and middle-income countries.

3 This Book in Detail

The central theme of this volume concerns how the different perspectives on scientific evidence and policymaking from public health and political science can be reconciled towards more effective public health policy and practice. The chapters approach this theme from different angles, use a variety of methodologies, and address diverse areas of public health policy.

The three remaining chapters in Part I are designed to set the stage and investigate the relationship between public health and political science and consider how the two fields can work productively in partnership. In Chapter 2, Fafard, Cassola, and Weldon propose a framework for understanding the different forms of interaction between public health and political science and address their implications for the way questions of evidence and policy are tackled. This is then followed in Chapter 3 by a consideration by Greer of key areas of tension and misunderstanding between public health and political science and associated research pathways to address them. Of note is his effort to rescue the oft-used concept of ‘political will’. In Chapter 4, Kothari and Smith introduce the interrelationships among evidence, policymaking, and politics from a public health perspective, elucidate how these conceptions tie in with the field’s community orientation, and consider potential areas of engagement between public health and political science.

In Part II, a set of empirical chapters use a public health political science approach to focus specifically on the evidence-policy stalemate and examine processes of knowledge production, evidence circulation, and policy learning. In Chapter 5, Oliver analyses the reciprocal relationship between processes of evidence production, mobilization, and use on the one hand, and the types of knowledge that are valued and sought out by policymakers on the other. Chapter 6 by Clavier, Gagnon, and Poland examines the ways in which local public health actors in the Canadian cities of Toronto and Montréal engage with the policymaking process and use evidence strategically within it and investigates what this engagement reveals about these actors’ conception of the role of evidence in policy. In Chapter 7, Smith uses the case of health inequalities in England and Scotland to provide an in-depth look at the potential for one such mechanism—deliberative citizens’ juries—to overcome the ‘stalemate’ between science and politics. In Chapter 8, de Leeuw describes the ever-evolving research journey of local health policymaking and analysis associated with the global network of ‘Healthy Cities’. She argues that for both the study of health policy processes and policy impact, ‘local is better’. Finally, using the e-cigarette debate as a launching point, in Chapter 9 Hawkins and Oliver examine the role of Parliamentary Select Committees in the United Kingdom as producers and synthesizers of evidence for policy and highlight the implications of the governance of these committees for the influence of corporate actors on regulatory debates.

In Part III, a series of chapters analyse different aspects of public health evidentiary systems or policymaking processes more broadly and the politics and intersectoral complexities of public health policymaking. Fierlbeck, McNamara, and MacDonald take an in-depth look in Chapter 10 at the political dynamics of pandemic decision-making about vaccines and antivirals in the context of the H1N1 crisis in the Canadian province of Nova Scotia. In Chapter 11, Cairney, St. Denny, and Mitchell draw on public policy theories to explain the gap between public health commitment, policy, and policy outcomes. They examine these themes in the context of a qualitative systematic review of ‘Health in All Policies’ (HiAP) research. HiAP is also the focus of Chapter 12, where Holt and Frohlich argue that these approaches have been ineffective at reducing social inequities in tobacco use and make the case for a distinct policy framework based on the capabilities approach to address social inequities in health. Finally, in Chapter 13, Cassola and her co-authors describe and categorize mechanisms that aim to reconcile scientific considerations and democratic politics in evidence-informed policymaking and develop an analytical typology that identifies salient dimensions of variation in their selection and design. In their concluding chapter, the editors review the stated ambitions of this volume and provide an overview of the chapters to make the case that political science perspectives do, in fact, add value to the public health enterprise but that many challenges remain.

Closing the gap and breaking the stalemate, between public health and political science, is not only a lofty intellectual pursuit. It is a necessary endeavour. With this book, we intend to offer strong, evidence-informed views on policy processes to enhance population health. Although the public health realm, at least rhetorically, has embraced the need for good policy processes since the writings of Villermé and Virchow, the COVID-19 pandemic more than anything else has demonstrated the urgency of embracing the complex nature of policymaking and its drivers. It is time to leave naïve allusions of the impenetrable nature and yet necessity of good policymaking behind us and argue health to policy and policy for health.