Book Review

The Health of Nations: Public Opinion and the Making of American and British Health Policy

N Engl J Med 1994; 330:872-873March 24, 1994

Article

The Health of Nations: Public Opinion and the Making of American and British Health Policy
By Lawrence R. Jacobs. 259 pp. Ithaca, N.Y., Cornell University Press, 1993. $34.50. ISBN: 0-8014-2761-4

Public opinion, systematically sampled in polls, mattered a great deal to makers of health policy in Britain in the 1940s and in the United States in the 1960s, according to Lawrence R. Jacobs. “Political struggles,” caused mainly by doctors, he writes, “heightened state actors' sensitivity to public opinion and their willingness to make authoritative choices among alternative principles and administrative arrangements.”

Jacobs has three purposes in writing this book. The first is to describe and compare how officials made decisions about policy on the basis of data from systematic polling in Britain and the United States. Although he acknowledges the difficulty of studying “fundamentally different contexts” two decades apart, he claims success in his search for uniformities in different cultural contexts and different periods. Other political scientists and sociologists have made similar claims, despite the reservations of most professional historians, who have become skeptical about generalizations that ignore chronology.

Jacobs's second purpose is to participate in a debate among political scientists, whom he divides into Weberians and culturalists. The former have argued that elites make policy in response, mainly, to judgments about what Jacobs calls “objective administrative capacity.” Culturalists, among whom Jacobs includes me, insist that “public preferences and understandings” have the most important influences on policy.

Jacobs's third purpose appears to be to publish as much of his doctoral dissertation as possible. As a result, he extends information and analysis that would fit in one or two papers to more than 200 pages.

Jacobs ignores evidence that contradicts his claim that public opinion was the major cause of decisions about policy. Most important, he does not assess sufficiently data about the agendas, constituencies, and influence of interest groups. In his discussion of Britain, for example, he entirely ignores the influence of consultants' (specialists') organizations on the design of the National Health Service. Consultants were delighted to accept salaries from quasi-public sources and wanted hospitals to be nationalized rather than run by local governments. Politicians in the Labour party made effective use of support from consultants to challenge the official line of the British Medical Association.

In his zeal to prove his thesis about the importance of opinion polls, Jacobs ignores the congruence of public, medical, and official interests that made both the National Health Service and Medicare popular as soon as they were implemented. In both countries, intense disputes preceded the enactment of reform as groups representing doctors, hospitals, labor, and management (and within government, politicians and civil servants) contended for advantage. But these disputes occurred within the context of a consensus about the priorities of health care.

As a result of this consensus, both the National Health Service and Medicare gave priority to hospital and specialists' services: the National Health Service in its expenditures, and Medicare in its declared goals. In both countries, everybody whose opinion mattered agreed that the chief goal of health policy was to treat the acute manifestations of disease with the best available technology. In both, the convergence of increased access to services for the public and higher incomes for doctors created a broad agreement that the new health policy was successful.

What is most striking, in retrospect, is the lack of attention to alternative priorities for health care in Britain in the 1940s and the United States in the 1960s. Neither prevention nor management of the disabling consequences of chronic disease, for instance, had vigorous champions in either country, although each of these strategies had contemporary advocates and support in the scientific literature.

Jacobs properly insists that public opinion mattered a great deal. But the public accepted uncritically the promise of medical science to cure disease that had been promoted by most leaders of medicine and repeated in the media for more than half a century.

Daniel M. Fox
Milbank Memorial Fund, New York, NY 10021