Last April, JHPPL published a themed issue titled Prevention Politics and Public Health Governance. The articles in that issue examine underlying questions and debates about the nature of public health politics. One such basic question is whether public health enjoys a stable, expansionary politics or suffers from a residual retrenchment politics? Although public health is often portrayed — at least in the US context, though increasingly in many other contexts across the globe — as a government-spending laggard and therefore residual, there may be more investment and expansion than the rhetoric implies.
Donley Studlar picks up the threads of this debate in “Cancer Prevention through Stealth: Science, Policy Advocacy, and Multilevel Governance in the Establishment of a ‘National Tobacco Control Regime’ in the United States,” the first article of this themed issue on the politics of tobacco policy. While it is clear that public health has made substantial gains in the area of tobacco control policy, Studlar looks within the policy process to better understand how such strides were achieved. He challenges the portrayal of US tobacco control policy as defined by “outsider politics” where only outside, community-based organizations developing a cohesive social movement can stand successfully against the strong interest group politics of the tobacco lobby and their hold on Congress. He looks anew at the development of tobacco control programs in the United States and finds more happening at the federal level — through a particular type of agency activism — than others have realized. In particular, he finds that experts in federal agencies relied on the power of scientific persuasion to develop policy initiatives and were able to sustain such initiatives by hiding programs through intergovernmental arrangements and by collaborating and contracting with large nonprofit antitobacco organizations at the local level.
While Studlar describes a process of “cancer prevention through stealth,” the next article, by Elizabeth Laposata, Allison Kennedy, and Stanton Glantz, introduces an altogether different picture of stealth. “When Tobacco Targets Direct Democracy” is an account of how the tobacco industry gradually focused on changing the rules of direct democracy as it realized that the outcome of citizen initiatives were going against industry interests. This is an interesting discussion of how interest groups influence the ballot initiative process, not only through the obvious mechanisms of media campaigns or by submitting their own initiatives, but by gradually focusing on changing the democratic rules of the game. This article highlights an understudied aspect of the role of interest groups under forms of direct democracy, one that should be taken into account when considering the legitimacy of such democratic endeavors.
The next article, “Public Health and Agenda Setting: Determinants of State Attention to Tobacco and Vaccines,” helps us understand why some states devote a lot of attention to tobacco and vaccine regulation, while others devote relatively little. Given prior work on tobacco politics, one might surmise that the composition of interest groups and political influence of those groups would go a long way in explaining this variation. Though authors Julianna Pacheco and Graeme Boushey acknowledge that their interest group measures are lacking (there is a real need for better state-level interest group data to more fully understand the role of interest groups on state health policy), they find no evidence that interest groups influence the attention states pay to tobacco or vaccine policy. Interestingly, the role of the federal government and whether it pays attention to tobacco or vaccine policy seems to matter less than the significant impact of gubernatorial attention and whether neighboring states pay attention. Thus, when thinking about policy diffusion, gaining gubernatorial attention and support might be a linchpin for securing public health regulatory policies across the fifty states.
Shifting from the US context to the global, we have two articles that focus on the landmark Framework Convention on Tobacco Control (FCTC), developed under the auspices of the World Health Organization. “Evolving Norms at the Intersection of Health and Trade,” by Jeffrey Drope and Raphael Lencucha, analyzes changes in international discourse within the context of over twenty-five years of major tobacco-related trade disputes. Although tobacco control discourse has evolved enough for the FCTC to pass, Drope and Lencucha document tobacco trade policy discourse as well and ask what happens over time when these two policy domains collide under disputes? They point to an increasingly broad network, which includes many new actors and, as a result, has generated a new discourse. In particular, they find that, with time, economic actors have been forced to grapple with public health frameworks and are more likely to adopt “health” in their messaging and activities.
Because the FCTC is intended to be an internationally binding convention regarding global best practices on tobacco control, Drope and Lencucha's findings of a shift in discourse in light of this landmark convention is perhaps not that surprising. However, the next article by Jiyong Jin looks beyond discourse and focuses on what is happening on the ground in one specific country — China. In “Why FCTC Policies Have Not Been Implemented in China: Domestic Dynamics and Tobacco Governance,” Jin finds that despite Drope and Lencucha's observation of an evolved discourse and despite the expectation that countries voluntarily signing the FCTC would willingly follow its prescription for tobacco control, China has failed to pursue FCTC politics. Jin documents a number of social and political dynamics that make it particularly difficult for China to follow through with FCTC policies.
In this issue we also have three special sections. The first two are quite complementary. In the Report on Health Reform Implementation, the article “Supporting the Needs of State Health Policy Makers through University Partnerships,” by David Heller, Catherine Hoffman, and Andrew Bindman, documents the development of state-university partnerships. There are fourteen such partnerships across the country, which provide important support for answering pressing policy questions. This article explains how such arrangements tend to form, discusses what their structure looks like, and provides examples of the content of their projects. The projects most often affect Medicaid policy, which, given the program's growing influence under the ACA, makes these partnerships worthy of further consideration.
The Report from the States section features an article by Elizabeth Kilbreth that discusses recent health reform efforts in Maine. In “As the Nation Goes, So Goes Maine?,” Kilbreth reviews Maine's track record of health reform under Democratic leadership with the support of moderate Republicans prior to 2010. She then contrasts these past efforts with recent initiatives led by conservative Republicans. Maine is strongly resistant to the Affordable Care Act (ACA), with a reduced Medicaid program, no Medicaid expansion, a defunded state access initiative, and no state exchange. Kilbreth discusses some of the factors that contributed to this dramatic change.
The Report from Europe concludes this issue. Written by Caroline Rudisill, Sotiris Vandoros, and Joseph George Antoun, this article examines the approach used in Russia to reform pharmaceutical policy. The authors take into account the policy priorities specified by the Russian government and recommend value-based pricing. They suggest that we view this recommendation “as a jumping off point for further discussion.” Don Light provides an introduction to this essay.
