Author of the new RSF book Epidemic City
James Colgrove, an associate professor at Columbia University, is the author of Epidemic City, published by the Russell Sage Foundation in 2011. His research examines the relationship between individual rights and the collective well-being and the social, political, and legal processes through which public health policies have been mediated in American history. Epidemic City analyzes the perspectives and efforts of the people responsible for New York City’s public health from the 1960s to the present—a time that brought new challenges, such as budget and staffing shortages, and new threats like bioterrorism. For more information, a reading list compiled by Professor Colgrove is available here.
Q: A central premise of your book is that public health is not purely of the scientific or empirical realm, as its practice inevitably involves political and ethical debates. To what extent is your view accepted in public health circles today? Was it widely held before?
Colgrove: The first public health reformers in the nineteenth century recognized their work as highly political. They addressed problems related to urbanization and industrialization, things like unsafe workplaces and overcrowded housing that raised issues of social justice and the state’s responsibility for the vulnerable. During the twentieth century, however, many public health professionals shrank from involvement in political battles. They didn’t take on powerful commercial interests like tobacco companies or manufacturers of hazardous chemicals. Today, I think there is widespread and growing recognition of the need to fight public health battles in the political arena. The problem is that public health as a field does not have a lot of financial or political power, and there is often hostility to the government’s role as a protector of health. Regulations for workplace safety or environmental protection provoke enormous resistance, for example. Efforts to encourage healthy diets and good nutrition are attacked as the "nanny state."
Q: In the period of time your book covers, you say there was a significant change in the common perception of public health. Initially, the field was largely accepted as the objective work of well-intentioned elites. But since the 1960s, different communities, from minorities to industry groups, have attacked it as biased and punitive. What accounts for this change? Do you think these criticisms have meaningfully reshaped public health?
Colgrove: One of the outgrowths of the civil rights struggles of the 1950s and 1960s was the rise of community mobilizations around health issues. For example, patient activism brought increased attention and funding for conditions such as breast cancer, AIDS, and mental illness. The involvement of communities in public health problems can be very beneficial, but communities often make conflicting demands on health officials. When the first cases of West Nile virus, a mosquito-borne illness, appeared in New York City, some residents wanted the city to be more aggressive in controlling mosquitoes with pesticides, while others were more afraid of the pesticides and demanded that the city stop straying completely.
Q: One the episodes you cover is the outbreak of tuberculosis in the late-1980s. Why did the disease resurface in New York City, and how did officials turn the tide?
Colgrove: TB is the classic disease of poverty and deprivation—it spreads where people lack housing, stable income and employment, and access to health care. Rates of homelessness skyrocketed in New York City in the 1980s and the shelters the city operated were a breeding ground for disease. This problem was exacerbated by the emergence of HIV/AIDS, since people with weakened immune systems are more vulnerable to TB.
The city’s control program had two prongs. First, all patients were placed on directly observed therapy, or DOT, where an outreach worker watches a patient take each dose of medication, at a clinic or in a community setting. Some civil liberties groups criticized DOT as intrusive or coercive, but the other way to look at DOT is that it’s a helpful service. This was certainly the view of the Health Department. They truly wanted to help people take their medications so they would get well and not infect others. TB treatment regimens involve multiple pills taken over many months, so most patients need help and support, which DOT provides.
The other component of the city’s approach was that the small number of patients who persistently failed to take their medications were placed under detention in a locked hospital ward until they were cured. This may sound draconian, but given that TB is spread through the air, even civil libertarians concede that detention may be warranted in extreme cases in order to protect the public. Only a tiny percentage of the city’s TB patients were ever detained. Most patients, when given the support of DOT, will take their medications. This two-pronged approach was remarkably successful in controlling the disease in New York. The World Health Organization now recommends directly observed therapy as the standard of care for tuberculosis.
Q: David Sencer, the former New York City health commissioner and a crucial figure in your book, died recently. His tenure coincided with the early rise of the HIV/AIDS epidemic in the city, and critics say Sencer did not do enough. What is your take on his legacy?
Colgrove: Sencer was working under extraordinarily difficult circumstances. When he assumed the leadership of the health department in 1982, it had been devastated by the city’s fiscal crisis of the 1970s. It had lost about a quarter of its staff and was a backwater in terms of technology and scientific capacity. He did a lot to rebuild the department, like recruiting new staff and getting the first computer systems in place, the benefits of which became evident only later on.
His handling of the emerging problem of AIDS was mixed. He was a strong advocate for protecting the privacy and civil rights of people with AIDS. On the other hand, the department under his leadership didn’t do a good job of developing educational materials for groups at heightened risk and for the general public. There was a lot of uncertainty about modes of transmission in the early years of the epidemic, and Sencer was very cautious about acting on limited scientific evidence.
Q: You write that "the greatest failure of the American public health profession in the 20th century" was its failure to deal with chronic diseases. Why did public health experts not make the transition away from infectious diseases?
Colgrove: It’s a lot harder to prevent heart disease, cancer, and stroke than it is to prevent most infectious diseases. These conditions have complex roots and typically develop over many years. There are no magic bullets here—no surefire preventive like a vaccine. Some of the causes of chronic diseases, like tobacco use or diets high in fat and cholesterol, are woven into the fabric of modern consumer society. These things can be sources of illness, but they can also be sources of pleasure.
Richard Coker. From Chaos to Coercion: Detention and the Control of Tuberculosis. New York: Palgrave Macmillan. 2000.
James Colgrove, Gerald Markowitz, David Rosner, eds. The Contested Boundaries of American Public Health. New Brunswick, NJ: Rutgers University Press. 2008.
Cutting-Edge Legal Preparedness for Chronic Disease Prevention. Webcast available at: http://www.publichealthgrandrounds.unc.edu/legal/webcast_hi.htm
Amy Fairchild, David Rosner, James Colgrove, Ronald Bayer, Linda P. Fried. “The Exodus of Public Health: What History Can Tell Us about Its Future.” American Journal of Public Health 100 (2010): 54-63. (Gated)
Constance Nathanson. Disease Prevention as Social Change: The State, Society, and Public Health in the United States, France, Great Britain, and Canada. New York: Russell Sage Foundation. 2007.