In Healthy or Sick? Phillip Trein has taken up a topic that is excellent in two different ways. First, this book identifies and attacks a challenge that neither political scientists nor public health scholars have taken on: the comparative politics of public health. The scope of variation in public health systems, workforces, institutions, and priorities between even superficially similar countries is dramatic and largely unmapped, let alone explained. Insofar as it is mapped, the politics of public health is typically mapped by public health researchers. While some of their newest work is very illuminating (Rechel, Jakubowski, et al. 2018; Rechel, Maresso, et al. 2018), much of it has been part of efforts to improve compliance with some norm, be it the International Health Regulations, public health workforce competencies, or adherence to EU standards. As such, that research agenda is shaped more by the focus on the norms than by the demands of scholarly inquiry and causal analysis.
The main scholarly contenders in the field of finding and explaining public health variation are historians (Baldwin 2005a, 2005b; Bashford 2006; Fox and Fee 1988; Porter 1994; Porter 1999; Rosen 1993), with occasional input from sociologists (Dingwall, Hoffman, and Staniland 2013; Taylor 2013) and, incidentally to their main preoccupations, anthropologists. Most of the time, political scientists who compare anything related to health tend to compare health care systems, especially financing and coverage issues. When political scientists do write about public health, they tend to write about global public health issues. There are easily more political science publications about the World Health Organization than there are about comparative public health politics. Trein's book is therefore a welcome exploration of inexplicably uncharted territory.
Second, Trein focuses his inquiry in a welcome way. He sets out to map and explain policy divergence in an area that is of pressing policy relevance: the integration, or lack of integration, between public health and health care. Whether it is people in England working out the borders between the National Health Service (NHS) and local government in public health, Americans contemplating the role of public health departments after the passage of the Affordable Care Act (ACA) and Medicaid expansion, or any number of policy entrepreneurs promoting population health ideas, the interaction between that which is called health care and that which is called public health is a topic of interest. Trein, therefore, is onto something when he focuses on the relationship.
After considerable theoretical exposition, Trein maps this relationship into a four-cell diagram with two axes: responsiveness (the extent to which public health and health care systems respond to each other) and distinctiveness (the extent to which they are organizationally, legally, and otherwise separate from each other) (31). Into this four-cell typology he places his country cases, which are Australia, Germany, Switzerland, the UK, and the United States. The extent and kind of integration between public health and health care in different countries are shaped by two different factors, he argues. First, Trein posits that differences between countries will be explained by a two-stage interaction, in which “politicized” and “unpoliticized” professions have different effects in unitary and fragmented political systems. Politicization is a function of life in a pluralist society, effectively, and is seen in the propensity of the profession to mount public political campaigns (40–41, 51–52).
These effects, over time, are shaped by eras of technological change since public health today is just not the same as public health a century ago. Other things have changed too, but technology and disease profiles are the basis of the periodization.
Depoliticized professions produce “decoupled” or “noncoupled” systems in which public health and health care operate in parallel, with responsiveness. Politicized professions are where state structure comes in strongly, with institutions deciding whether politicized professions produce a loosely coupled, tightly coupled, or noncoupled system.
The nature of the health professions, therefore, is key to the book's argument. Professions are more or less politicized. German professions are unpoliticized, and German professionalism is weak (156), while UK and US professions are politicized and more professional.
This characterization of the professions, and for that matter corporatism and pluralism, will surprise students of both professionalism and comparative political economy. Normally we characterize social partners in neocorporatist systems as strong and politically important (Katzenstein 1985, 1987)—and part of the evidence is precisely that they do not always engage in noisy political campaigns. Those who are inside the room where decisions are made need not shout in the streets.
The result is that Trein rewrites fairly well-known facts—e.g., German organized medicine was not an advocate for wide-ranging public health—in theoretical framings that confuse the issues. For example, on p. 156 is the following summary of German findings:
Professionalism remained weak in Germany, in the sense that the medical and public health professions did not join forces against the state to advocate public health. The medical profession did not take the role of a politically powerful pressure group, but remained included in the health care governance system along with other interest groups of the health care sector. Doctors opposed public health professionals and their ideas for political reasons rather than trying to incorporate them into a national political agenda.
The definition of professionalism in the book is unusual and normatively charged, as is the characterization of German health politics, to say the least (why should we expect the medical profession to join forces with anybody against the state?).
Even if this characterization were unproblematic, deriving professional structures and politics from state structures, as he does, leads to a logical endogeneity problem that the process tracing in the case studies does not wholly overcome. If the politicization and strength of the medical profession (in his terms) is explained by overall pluralist or corporatist state structures, then aren't pluralism and corporatism rather than the specific professions the key independent variables?
The empirical quality of the chapters varies greatly, and some country case studies add little. Trein draws on interviews for contemporary reports on three of his countries (Australia, Germany, Switzerland). He explains that the empirical interviews were for a related project about comparative federalism, which may explain the presence in each country-chapter of case studies whose relevance to the topic is unclear (e.g., tobacco control). Trein conducted a semisystematic document review, searching databases with terms such as public health and health policy and then focusing his reading on “those that mention public health policy in general and/or with regard to the historical development of public health or health care policies” (80). The bibliography is, nonetheless, relatively thin.
The Switzerland chapter does adduce new information, and the Germany chapter relies on a wider range of published work and interviews than the other chapters—although half of the German interviews are professors or academic researchers. The discussion of the United Kingdom depends largely on secondary sources, and mostly a single one: Dorothy Porter's general history of public health (Porter 1994). Likewise, the discussion of the United States draws heavily on Porter also, although it is supplemented by the work of Elizabeth Fee (1994). He lists no interviews in those two countries, which shows, for example, in this gnomic interpretation of the Affordable Care Act: “Not until the establishment of the national health insurance legislation in 2011 did the institutional distinctiveness of health care and public health vanish and the United States fulfill (somewhat) the criteria of the institutional unification of health care and public health” (225).
Even granting his specific definition of institutional unification earlier in the book (81–82), this assertion is not well supported and is also an unusual interpretation of developments over the past decade in the United States.
In short, Trein earns our gratitude for identifying an important broad gap in scholarship—the lack of a comparative politics of public health—and for focusing on the politics as well as the organizational dynamics of integration between public health and health care. His ambitious book, covering five countries over more than a century and drawing from both institutions and the sociology of the professions, nonetheless is superficial. While this reviewer recognizes the scale of this task, Trein fails to engage precisely or usefully with the existing literature and evidence on a wide range of topics, from neocorporatism to public health history to the Affordable Care Act. Perhaps because of that, there are many poorly assembled arguments that also do not anticipate or engage in addressing coherent alternative hypotheses. Our debt to him is for showing what remains to be understood.