Discuss the two philosophies of public health, one based on the free market and the other on state intervention that were prevalent in the 19th century. With which countries were these two philosophies identified? (there are more than two countries). How can this information help us understand the debate over health care today?
Porter, The Greatest Benefit of Mankind, pages 397-492
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In the 19th Century, advances in industrialization, economic understanding, as well as intellectual insight helped to develop different paradigms regarding health care. For example, in England of the 19th Century, health care for all was being championed by social reformers. As industrialization took hold in England, it developed a stark reality of those who had wealth and those who did not. During this time, wealthy individuals possessed the means to have health care and those who were not economically empowered did not. An outbreak of cholera on national proportions helped to spur a call for change. Social reformers demanded to generate a government approach or publicly funded platform for health care. They argued that for the poor, the exorbitant costs of health care perpetuated poverty and a lack of economic empowerment. Initiatives such as the first Public Health Act caused the setting up of a Board of Health that gave towns the right to appoint a Medical Officer of Health represented one aspect of the health care debate in the 19th Century. England embodied the idea that the government can play a direct role in providing health care. It absorbed the philosophy that it is in the public welfare to ensure that health care is a right and not a privilege of the few.
In America of the 19th Century, the same dynamics were evident. However, the philosophical approach was entirely different. Industrialization came later in the 19th Century to America, and as a result, the understanding of the government's role in providing health care was not recognized with the same force as it was in England. Social reformers like Dorothea Dix advocated that government should play a role in health care provisions and that the concept of health care should be something that falls under the control of the state. However, federal leadership in America disagreed. President Franklin Pierce made the argument that health care should be a local issue, which was interpreted to mean that health care should be an issue for the free market and not for state or governmental regulation. Once industrialization took place on a massive scale after the Civil War, entrenched economic interests ensured that a laissez faire approach to economic matters denied government regulation of health care. The opportunity ideology that took a hold of American society at the time was one in which everyone believed in their own "duty to get rich." This desire precluded a belief that governmental intervention in health care should be mandated. When the pendulum of political and social awareness moved towards suggesting in external control of health care, entrenched business interests advocated free market beliefs and suggested that capitalism works best when intervention is minimal. This paradigm helped to construct a free market approach to everything, including health care. Providing it was seen as a service where profit motives could be present. The philosophy of the free market and an "invisible hand" solving all problems within the marketplace prevented governmental intervention in health care issues.
The paradigms offered in England and America in the 19th Century still linger in the health care debate today. There are equal numbers who believe in either the free market approach or the governmental intervention approach. The zeal featured in both sides usually reduces what should be a complex dialogue into a screaming dual monologues. One side labels the other. "Socialist" and "Communist" is offset with "Capitalist" and "Parasite." In understanding the debate today, both sides present valid points. Individual choice via the marketplace is as compelling as seeing a family struggle under the crushing weight of health care costs. While there is a majority that believes that the health care issue has to be addressed, the means through which to do so is as varied as the paradigms in 19th Century England and America.
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