Recent moves by the US government to increase political control over federal research funding include having political appointees make decisions on what gets funded and withdrawn, and severe constraints on ability to fund international collaborations. They have rightly incurred condemnation and protest from across the medical community. The Editors of the 'New England Journal of Medicine' have likened the scale of the threat to the Soviet-era political promotion of Trofim Lysenko’s anti-Mendelian genetics, which had decades-long devastating consequences for agriculture and the development of biological sciences in the Soviet Union. Science, they argued, should not be politicized. Yet public health, as a research discipline as well as a practice, is inherently and inevitably political. The challenge is one of combining a political sensibility with a commitment to methodologically sound, open and critical science
The Lives Saved Tool (LiST) is a modeling software used to predict the impact of health interventions on maternal and child health and mortality in low-resource settings. LiST is more than a predictive software for maternal and child health. It is also a governance mechanism, organizing maternal and child health actors – including policy makers, program planners, NGOs, and researchers – to address maternal and child health according to donors’ preferences for cost-effective, standalone technical interventions. In this paper, I trace the history of LiST – from its early days as a series of spreadsheets created for a special issue in The Lancet by the Bellagio Group, a cohort of child survival researchers concerned about excess child mortality – to show how and why LiST data and frameworks narrow the scope of interventions considered appropriate for maternal and child health care in low-resource settings. LiST’s data and governance effects produce an imaginative captivity that sidelines other ways of knowing about maternal and child health in poor countries, circumscribing a fuller range of problem solving – such as listening to mothers, children, and local health care providers, and attending to the cultural, social and political economy factors of health – thereby limiting options for maternal and child health futures.
Constructing a genealogy of pathogen-responder relations, I reveal how pathogens register in complex ecosystems of human intervention. I illustrate how a grouping of pathogens orients the sensibilities of scientists toward calamity and dystopia through what I conceptualize as ‘crisis futurities’—doing so in ways that drive biopolitical impulses toward protecting life, mitigating human suffering, and experimentality. Crisis futurities spring from anticipatory temporalities scientists assign to pathogens: incubation and latency periods; speed and modality of spread; and causal risk factors. Intervention from this perspective is driven by an ethics of precision; a calculus of planning; and an experimental wrestling with ‘the hypothetical’ that anticipates the potential devastation and political consequences of pathogens.
In this paper, we examine the discursive dynamics of lifestyle within a Danish municipal lifestyle-changing program, focusing on how contemporary and sometimes conflicting understandings of lifestyle shape health-promoting practices. We identify two dominant discourses: lifestyle as living, which emphasizes well-being, pleasure, and quality of life; and lifestyle as health behavior, rooted in New Public Health approaches that frame lifestyle through notions of ‘right’ and ‘wrong’ behaviors aimed at preventing overweight and obesity. Drawing on ethnographic fieldwork and semi-structured interviews with participants and educators, our study reveals that while holistic lifestyle interventions aim to improve well-being, quality of life, and physical health, they remain discursively entangled with behavioral and responsibilizing approaches. We argue that expanding the concept of lifestyle to include broader aspects of living may intensify experiences of failure, not only in relation to ‘right’ health behaviors but also in pleasure, enjoyment, personal values, and self-acceptance. Efforts in a municipal program to emphasize lifestyle as living, in practice, extended rather than displaced behavioral logic, as well-being and quality of life became incorporated into the same framework of evaluation, responsibility, and potential failure. By critically reflecting on these entanglements, we call on health promoters to consider the unanticipated consequences and ethical implications of lifestyle interventions, particularly when expanding the concept of lifestyle while simultaneously responding to worldwide health challenges such as so-called lifestyle-related diseases.
It is widely acknowledged that place matters for health. Previous research has explored the ways in which the material and physical dimensions of place may shape the health-related behaviours of individuals. However, to date there has been much less focus on the importance of individuals’ ‘sense of place’ – the subjective and experiential aspects of place – in shaping health-related behaviours. This paper offers new insights into the importance of individuals’ sense of place in shaping attitudes towards, and consumption of, nicotine and tobacco products. Our qualitative study involved 42 interviews with residents and those working in a superdiverse UK neighbourhood, Handsworth, Birmingham. The study identified that attitudes towards, and consumption of, nicotine and tobacco products were variegated, and informed by issues such as neighbourhood identity and diversity, local infrastructures of nicotine and tobacco provision, the normalisation and regulation of nicotine and tobacco products and the extent to which place-based communities and social solidarity were evident or absent. Subsequently, the implications for place-based approaches to health are considered.
We noticed that there was a coding mistake in our Stata do-file. This affected 298 participants, who had taken part in sweep 6. For these participants, the possible imputed time range should have started in year 2000, which was the year of data collection for sweep 6, but instead it started in 1986 (age 16), although this value should have only been used for those who skipped wave 6. We corrected the mistake and ran the analyses again. The corrected analyses did not change the main conclusions of the published paper. However, the results are somewhat different for the 30-33 age group, which was the most affected by the coding mistake. Thus, below we show the corrected tables and figures.
The national rollout of the COVID-19 vaccine in the United Statues failed to produce equitable vaccine uptake across racial and class lines, repeating well-known patterns of health disparities. In mid-2021, community leaders in St. Louis identified the need for improved vaccine access in underserved areas. Washington University in St. Louis responded by launching the ‘Our Community Our Health St. Louis’ program, targeting fifteen zip codes with high COVID-19 hospitalization rates and low vaccine uptake. ‘Our Community Our Health’ formed partnerships with trusted community organizations to deliver vaccines through flexible, neighborhood-based pop-up clinics and used a design framework to interrogate vaccine ‘hesitancy’. Over two years, the program administered 1,354 COVID-19 and influenza vaccines to 874 individuals through 89 events. A design framework was employed to learn from vaccine recipients directly what vaccine availability and acceptability looked like to them. The program’s community-driven approach revealed critical insights for designing and scaling a hyperlocal vaccine distribution system that meets people where they are to deliver equity.
Progress on health inequalities in England following the New Labour era has been undone by austerity policies, COVID-19, and the cost-of-living crisis. Meanwhile, New Labour’s devolution agenda, which led to the creation of Scottish, Welsh and Northern Irish legislatures, has been followed by a longer-term focus on city-regional devolution. These devolutionary processes have provided opportunities for political actors to compare newly empowered places in various ways. By analysing policy texts and policymaker interview data from Greater Manchester Combined Authority (GMCA) and the Scottish Government (SG), this paper explores the intersection between place-based health inequalities and the place-making processes of devolution. In GMCA, health inequalities were used to emphasise difference with the nation, to ‘justify devolution’ and to make the case for further powers. Similar ‘poor us’ comparisons were prominent in Scottish policy texts shortly after devolution, but are now almost entirely absent. Instead, Scottish policy texts focus on within-Scotland inequalities: the ‘poor among us’. GMCA also appears to be moving towards this focus, suggesting a pattern of health inequality policy framings closely related to broader devolutionary aims. By highlighting political incentives for attention to particular axes of health inequality, this paper provides new ways to consider policy approaches to inequality in the context of increasing devolution.
North American mental health organisations often struggle to diversify community perspectives informing their programs. A lack of representation compromises advocates’ ability to serve members of equity-seeking communities. I conducted semi-structured interviews with nine youth who volunteered with a North American charity, ‘Catalyst,’ and who self-identified as Black, Indigenous, low-income, or male. I used thematic analysis to identify common motivations for participation and ways to close gaps in engagement. Catalyst-involved youth undertook advocacy to: 1) combat social injustice; 2) find like-minded peers; and 3) strengthen personal skillsets. These compelling motivations provide opportunities and strategies for recruiting under-represented youth. Adult-led organisations may wish to improve their organisations’ visibility in public spaces, host networking events, and offer professional development opportunities.
The medical-scientific enterprise has benefited from implementation science’s (IS) fundamental insight: that contextual factors contribute to the success or failure of evidence-based interventions. Yet, IS often fails to account for the institutional commitments of research as an essential element of ‘context.’ In doing so, it may fail to acknowledge that its own institutional commitments to scientific research are themselves key power dynamics affecting how social change is thought of or how interventions are designed. This paper leverages two long-term ethnographic projects studying behavioral interventions to examine how structural conditions shape service delivery. We draw from two intervention projects: e-mental health research in Australia, and an overdose prevention clinical trial in the US. We demonstrate how the prioritization of funders’ interests, the political economy of evidence-based interventions, and the epistemic commitments of intervention research dictate what seems feasible or possible, conflicting with the moral and ethical values of intervention researchers themselves. This paper contributes to critical public health scholarship by demonstrating how IS risks legitimizing structural inequities by absorbing institutional logics rather than challenging them. The disconnect between researchers’ private critiques and the field’s focus on intervention adoption merits ongoing research that examines how IS knowledge production itself reinforces systemic injustice.
Concerns exist that mortality remains elevated after COVID-19 peaks. This study examined whether mortality in England and Scotland in 2022 exceeded predictions from austerity-era (2012–2019) and pre-austerity (2001–2010) trends. Time trend analysis was conducted using data from 2001–2022. The outcomes were observed and expected age- and sex-standardised mortality rates (ASMRs). Expected 2022 ASMRs were calculated from austerity-era and pre-austerity trends. Excess deaths were estimated by comparing observed and expected ASMRs. Observed ASMRs were higher than austerity-era predictions and substantially higher than pre-austerity predictions. In England, excesses for females were 4.4% (4.0–4.8) and 38.2% (95% CI: 37.7–38.7), and 7.2% (6.8–7.6) and 57.0% (56.4–57.6) for males. In Scotland, excesses for females were 3.4% (2.2–4.5) and 26.6% (25.2–28.0), and 2.6% (1.5–3.8) and 45.2% (43.6–46.9) for males. COVID-19 accounted for 5.3–6.5% of deaths in 2022 and explained much of the excess compared to austerity-era trends. ASMRs were 1.68–1.94 times higher in the most versus least deprived areas. Deaths attributable to COVID-19 explain much of the excess compared to austerity-era trends. However, 879,430 excess deaths relative to pre-austerity trends, even excluding COVID-19 deaths, highlights the devastating impacts of austerity on public health.
In this editorial, I would like to reflect on the phenomenon I am calling here ‘bait and switches’ in academic publishing. Rather than representing an anomaly, I want to suggest that it’s simply business as usual for corporate publishers. While few are in the position to be able to substitute a lower-tiered open access journal for a higher ranked subscription one, they have realised – or, at the very least, assumed – that branding is all that matters to academics.
The National Institute for Health and Care Excellence (NICE) recommends rivaroxaban for stroke prevention in patients with non-valvular atrial fibrillation in England. While not a directive to practitioners, that advice is widely regarded as authoritative and intended to guide practice. Yet a medical device, INRatio2-PT for monitoring coagulation/blood-clotting and producing crucial data on rivaroxaban in its key clinical trial, was defective. Following discovery of the defective device, a medical controversy about the therapeutic value of rivaroxaban ensued. Drawing on social science theories of medical controversies, such as ‘chronic contestation’, ‘closure’, ‘corporate bias’, and ‘countervailing powers’, this article describes the unfolding of the INRatio2-PT/rivaroxaban controversy and seeks to explain it. We explore the role of key protagonists based on documentary and interview data. Our findings about the media partly support ‘countervailing powers’ theory, while those regarding industry and regulators support ‘corporate bias’ theory. We found little evidence of chronic contestation of medical knowledge-claims. Rather, we contend that a sociological process of closure through synthetic certainization of knowledge-claims that rivaroxaban is efficacious and cost-effective evolved via the combined political power and interests of the medical-industrial complex, capitalist industry, and the regulatory state. Synthetic certainization, together with a regulatory ideological commitment to innovation, curtailed contestation and discouraged the medical profession from facing troubling uncertainties.
The concept of ‘health systems’ is pervasive in contemporary public health policy and scholarship. Health systems are invoked as objects that can be strengthened, made resilient or reformed through better design, improved governance arrangements or more rational use of evidence. Yet, as much work in critical public health has shown, health systems are not neutral, coherent or stable entities. They are made and remade through the actions of situated actors, drawing on particular historical trajectories, ideas and interests, and they routinely reproduce social and health inequalities. This Special Issue of Journal of Critical Public Health brings interpretive and decentred approaches on public governance to bear on a set of empirical cases that span European economic governance, European Union (EU) meta-regulation, multistakeholder food policy partnerships, housing policy, place-based public health, integrated care reforms and healthcare within prisons. Collectively, the papers ask: what happens when we stop treating health systems as unitary structures or technocratic projects and instead treat them as contingent, contested practices? In doing so, they invite us to rethink how we conceptualise ‘systems’, and what it might mean to pursue more just and inclusive forms of public health.
Prison health is intricately connected to public health given the significant burden of poor health which the majority of people in prison experience. Prison healthcare suffers from chronic understaffing, mostly due to macroeconomic austerity. The COVID-19 pandemic inflicted extensive damage on this already fragile milieu. We employ decentred theory as a sensitising concept to articulate competing narratives about prison healthcare decision-making during the pandemic. We predominantly draw upon 44 interviews conducted in 2021. We found that non-urgent healthcare provision almost collapsed with exhausted healthcare staff trying to deliver a reduced service to patients who felt abandoned. Consequently, our analysis portrayed narratives of suffering, trauma and injustice that were experienced in markedly different ways. Many participants compared a muddled and un(der)funded prison healthcare COVID-19 strategy against that of well financed community healthcare. Decision makers implicitly competed with each other over lines of accountability and responsibility. The research process itself was distorted and resisted by various actors in both overt and covert ways. We argue that prison healthcare is emblematic of a devalued and underfunded public healthcare agenda where actors have been physically and emotionally harmed by habiting space within a struggling institution during the largest public health crisis of the past century.
From a critical public health perspective, public health serves as an instrument of biopolitics in modern societies. Through public health measures, citizens’ bodies are regularised to exhibit desirable characteristics. However, what is considered desirable differs between epochs and political configurations. In this article we aimed to discern what kinds of subjects were envisioned as ideal and what configurations of public health were consequently produced in the late Soviet Union and post-Soviet Russia. Through the analysis of legislative documents that have regulated Russian public health since their first codification in 1971 until now, we traced transformations of the state’s biopolitical agenda. We demonstrate how the Soviet paternalistic state aimed to provide health(care) for all while coercing those who did not share its ideals of health. We show how the liberalisation and marketisation of the 1990s attempted to transform citizens into responsible patient-consumers, and how, nowadays, public health regulation balances neoliberal ideas of health and Soviet notions of control. ‘Reading off’ legislative documents highlights how public health is transformed in line with biopolitical agendas, which exist in continuity and are deeply rooted both in the agendas of the past and imaginaries of the future.
In this introduction to the Special Issue, we reflect on why a critical approach to the concept of vulnerability is particularly important for reproduction. We explain how each article in the special issue draws out key insights from critical theories of vulnerability, including: (1) The importance of conceptualising vulnerability as created by social structures rather than as inhering, biologically or otherwise, in ‘the vulnerable population’; (2) How the violent application of reproductive norms, within and beyond the state, creates vulnerability; and (3) Reflections on how vulnerability is defined in the realm of reproduction, who shapes the category of vulnerable’, and what consequences this may have.
Concluding this Special Issue are some thoughts on vulnerability, and how health practices and policies engage with vulnerability, via a detour through some reflection upon Bernadine Evaristo’s novel ‘Girl, Woman, Other’.
The rise of ‘multistakeholderism’ in global governance over the past few decades has led to the increasing involvement of corporations as key ‘stakeholders’ in decision-making. As a norm, multistakeholderism invokes deliberative democratic ideals of dialogue and consensus as a procedural solution to complex societal problems. Through an examination of a food policy partnership, this article explores processes of political marginalisation that occur within multistakeholder governance, contrasting formal structures of inclusion with informal exclusion. The article draws on the notion of ‘post-politics’ in developing a decentred analysis of a multistakeholder setting, arguing that the informalisation of decision-making constitutes a key means through which unequal power relations are rendered invisible. While presented as inclusive and participatory, multistakeholder partnerships often reflect a form of post-political regulation in which contestation and conflict are intentionally displaced to informal spheres of decision-making. This article unpacks how pressures to maintain the vision of multistakeholder partnership as deliberative and inclusive can paradoxically result in processes of marginalisation and exclusion, which enhance the power and influence of corporations over policy making. In doing so, the article contributes to understandings of power in a world increasingly characterised by multistakeholder governance, illustrating the tensions that surface between the ‘post-political’ vision of partnerships and informalisation and exclusion in practice.
Reproduction is tied to gendered social, economic, and political systems. Interrogating these connections is crucial for health policies and programmes that seek transformative change. Public health’s focus on biomedical vulnerabilities – how the body is susceptible to harm – is unable to capture the full and complex factors that contribute to reproductive inequities and injustices. Operationalising an understanding of vulnerability as a social process, this article examines how men conceptualise their own reproductive vulnerabilities and the implications this may have. This article draws on qualitative interviews with men, from a multi-method project on masculinities and sexual and reproductive health and rights in Accra, Ghana. Analysing men’s expressions of queerphobia through the lens of vulnerability, this article highlights the significant link between masculinities and reproduction. Masculinities are embedded in precarious, gendered economic systems and social and cultural institutions. Men’s experiences of the vulnerability of their masculinities in this context manifest as queerphobia and a (re)entrenchment of gendered norms around reproduction, which can perpetuate and exacerbate inequities and injustices. This article argues that using a more critical understanding of vulnerabilities makes visible the gendered systems and precarity that create key obstacles to reproductive health, rights, and justice.
