Interchange (2019) 50:129–136

https://doi.org/10.1007/s10780-019-09367-z

Public Health is Politics

Jan Sundin1

Published online: 10 May 2019

© The Author(s) 2019

Abstract
‘Public health’ investigates the determinants of health, born during the Enlight-
enment in the seventeenth/eighteenth century. But ‘public health’ is also policies,
aiming at the improvement of a population’s health. There is a mutual interchange
between public health as science and as politics. A brief historical background is
followed by an analysis of the impacts of political changes during the first two dec-
ades of the twenty first century in Sweden. In 2005, a policy document accepted by
all political parties except for the Moderate Party highlighted socio-economic fac-
tors and structural reforms to decrease the health gaps in the population. The gen-
eral election in September 2006 resulted in a new majority in the parliament and
a center-right coalition government, including the Moderates and three parties that
had approved of the 2005 document. In 2007 a “new public health policy” was intro-
duced. Its priority lists stressed individual behavior and the new policy should be
incentives to work instead of “allowances”. The Public Health Institute got instruc-
tions in accordance with the new policy. The ten years following this policy change
has seen public health policies and attitudes to research shifting almost year by
year. The new policy met a counter-stream from the very beginning. Influenced
by Michael Marmot’s WHO Commission on health inequalities, regional commis-
sions started in Sweden, Recommendations how to decrease social health gaps was
adopted with almost no opposition by regional health boards in 2012–2013. But new
problems were now occupying politicians and media—how to finance the growth of
the old, multi-sick part of the population and increasing costs for new medical tech-
nologies and drugs. Public health as an academic discipline was in the middle of this
fluctuating political landscape with direct effects on what has been considered worth
listening to or support by public money.

Keywords  Public health · Policy making · Contemporary history

* Jan Sundin
[email protected]
1
Emeritusakademin, HusEtt, Linköping University, 581 83 Linköping, Sweden

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Enlightenment and Public Health

Public health as science and politics in Sweden dates to the eighteenth century.1 For
Confucius, 2500 years ago, a bad king could bring all kinds of misfortunes, includ-
ing disease and death, upon his people. This idea was also part of European think-
ing, at last until the seventeenth century. It was also in the Early Modern period that
the Prince/State began to fight the plague by isolation, quarantine and other attempts
to keep the epidemic outside the borders. To a certain degree, the state had then
accepted a responsibility, if limited, for the public health. But public health as a con-
cept, a target of study and collective action is for several reasons said to be born and
developed during the eighteenth century. It was an offspring of the Enlightenment,
empirical with a trust that the expansion of knowledge could be used to further the
good and hamper the evil. Making life better for individuals was of course one rea-
son to take positive action. However, the prime goal for the State was often to breed
a large, healthy population who could pay taxes and produce soldiers.
As policy and a target of research, public health was met with enthusiasm by the
Swedish State and its academics. The botanist Carl Linnaeus and his colleagues
convinced the authorities to start the Tabellverk, an organization for collection and
analysis of yearly tables on mortality by sex, age and causes of death from all of
the country’s about 2500 parishes from 1749 and onwards. The access to vital data,
including the population at risk every fifth year by sex and age, stimulated its use.
As in other European countries epidemiology and ideas how to fight the recurrent
epidemics were born.
Data revealed the connection between social status and mortality, especially in
the cities. One explanation emphasized factors outside the power of the individual,
i.e. one’s health was often a result of being in a situation one could not be blamed
for. The opposite explanation said that poverty and other negative factors were usu-
ally the individual’s own fault. Only a few who had been unfortunate, for instance
being blind since birth, were ‘deserving poor’ with a moral right to be helped. The
rest had to be disciplined with a whip rather than a carrot. These two opposite views
were part of a common debate in western Europe during the nineteenth century.
This discussion was the first example of what was later called the “structural” versus
the “individual” theory in public health. Current medical theories of importance for
the fight against disease and death were, however, not preoccupied with the moral
side of death. The big bulk of mortality was obviously caused by infectious dis-
eases and until the birth of bacteriology during the last decades of the nineteenth
century, these diseases were thought to spread through contagion, particles migrat-
ing from one individual to another, or by miasma, a kind of vapor emerging from
dirty swamps or stench, attacking a person’s lungs and stomach. Although rather
crude from a modern point of view, these theories contributed to better cleanliness
and health. They became an argument for the hygienic era, with social engineers
building pipelines for water, sewage systems and a cleaner and healthier city. Such

1
  For the story before year 2000 see Sundin and Willner (2007).

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was the situation when Robert Koch and Louis Pasteur initiated the revolution of
bacteriology during the last decades of the nineteenth century. It strengthened the
authority of science and the arguments for hygienic reform. Public health science
and policy became a multidisciplinary trade with medicine, epidemiology and engi-
neering serving a healthier society.

Social Hygiene

It did not take long, however, before the prestigious concept was also adopted by
those who presented theories about a population composed of biologically more
or less “valuable” individuals. The Italian Cesare Lombroso’s idea that you could
distinguish criminals by their physical features became widely accepted in forensic
medicine around 1900 and preceded the racial theories of the twentieth century. In
Sweden, it led to the establishment of an institute for race hygiene in 1922 with-
out political opposition. Social medicine, a relatively new discipline, also got its
proponents of “social hygiene”. A well-known representative in Sweden was Olof
Kinberg, professor in forensic psychiatry, influential supporter of the inter-war law
about forced sterilization and supportive of eugenics.
In 1938, the novelist Ludvig Nordström made a famous series of radio reports
and wrote a book about ‘Dirty Sweden”.2 In the spirit of nineteenth century social
engineers, its purpose was to show that many in the countryside lived in deplorable
hygienic conditions. However, putting this observation in a wider context, the author
had adopted more current views. In the final, conclusive radio program, he explained
that much of the dirt was a product of indolence among the poor. They had become
lazy because of too generous subsidies from the State. Generally, there were too
many impregnated by a “relief mentality”,3 a concept that is kept alive in the politi-
cal arguments of today, advocating individual rather than structural policies.

The People’s Home

On the other side of the debate, Per-Albin Hansson (prime minister 1932–1946) gave
a speech in the parliament in 1828, introducing “the People’s Home” as an antithesis
of “relief mentality”: “The good home does not know of privileged or slighted, no
pets and no step children. In the good home is equality, concern, cooperation and
helpfulness—applied on the large people’s and citizen’s home this would mean the
knocking down of all social and economic barriers.”4 The inter-war period was a
political break-through for the social democrats and the social liberals in parliament
and government. However, the prime goal was to fight depressions and unemploy-
ment, and public health as science, policy and practice were not on top of the list.

2
  Ludvig Nordström (1938).
3
 Swedish:”Understödstagaranda”.
4
  Per Albin om Folkhemmet (1989).

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J. Sundin

Instead, the means to realize the goals of the social democrat’s State came after
1945. Swedish economy was excellent, having its infrastructure intact and ready to
export a diversity of goods asked for by other countries that had suffered from the
war. For decades the party managed to stay in power permanently, from 1976 to
2006 sometimes interrupted by middle-right coalitions. Politically, public health was
usually seen as part of the welfare state, accepted by a political majority. The policy
document signed in 2005 illustrates this unity. The “new public health policy” in
2007 meant that the Moderate Party had convinced three other parties in the coali-
tion to change the priorities.

A New Public Health Policy

In August 2007, an article in Göteborgs Tidningen was titled “Shut down the Public
Health Institute”.5 It criticized what it described as restrictions of the individual’s
free choice, recommended by the institute and put in place by the previous govern-
ment. Giving several examples, it concluded that the institute was “part of a bureau-
cracy financed by taxes—the most primitive and uncalled-for stately care, an author-
ity instructed to educate adult citizens”.
The article was not a shot in the dark. One month earlier, the coalition that took
over government after the election 2006 decided to close the Institute for Working
Life (IWL) with about 400 employees on different places in Sweden. IWL’s research
agenda should in the future be handled by the universities but no money was granted
in the budget. Its current form was established by the left-wing government in 1995
but it had a forerunner in the Centre for Working Life, founded in 1777. Two authors
declared in 1778 that the reason was that “the control over research will be a central
issue in the eighties, an important part of the democratization of the working life”.
One of its strongest proponents was the Trade Union Confederation, declaring that it
looked for a policy based on research.6
A report of a committee with representatives of all parliamentary parties had
been published as late as 2005 by the Public Health Institute.7 It defined 13 tar-
get areas for health and was accepted by all parties except the right-wing Moderate
Party. The emphasis was put on structural welfare factors, such as “participation and
influence in society”, economic and social safety” and “a safe and good childhood”.
Individual lifestyle—physical activity, eating habits and drug abuse—came at the
end of the priority list. Three years later, in 2008, “A Renewed Public Health Policy”
was adopted by the political majority, turning the priority list of 2005 upside down.8
The government declared that the foundations of public health policy shall be “the
individual’s need of integrity and freedom of choice”. Concrete reforms should
“strengthen and support parenthood”, “intensify prevention of suicides”, “promote

5
  GöteborgsTidningen (2007).
6
  Lag och Avtal (2006) and Ehn and Sandberg (1978).
7
  Folkhälsopolitisk Rapport (2005).
8
  Regeringsproposition (2007).

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good eating habits and physical activities” and “minimize the use of tobacco”, i.e.
mainly to influence the individual’s knowledge, attitudes and behavior.
The Moderate Party dominated the new government. It also made the most vis-
ible imprints on this public health document. “Social exclusion”9 was used as the
key element defining the over-representation of bad health in groups with low edu-
cation, the unemployed and those on long-term sick-leave. This concept had been
introduced by the winning coalition in the 2006 election campaign. A successful
fight against this exclusion should be based on bringing people back to work and
self-support using whips rather than carrots. It should for instance be tougher to get
paid sick leave, thereby creating “an own, clear responsibility to get back to work”.
Other reforms were also mentioned that should strengthen “The Primacy of Work”
versus exclusion. The message was that the individual, not structural factors beyond
the individual’s reach like wealth, had the fate in her hands.
To “have an influence over everyday life by freedom of choice”, promoted by
privatization of different sectors in healthcare was a strategy shared by all four par-
ties in the coalition. Other coalition parties were also allowed to influence the sum-
mary. Educational reforms were at the heart of the liberals, hence a reference to the
connection between low education and bad health. Voluntary work was emphasized
as good for a healthy social capital, a sense of belonging and fellowship—a declara-
tion close to central issues among the Christian Democrats. “Influence over every-
day life” through free choice and privatization of different sectors of care was also
emphasized. It was very clear that the “renewed public health” was an application of
the general political agenda of the new government.
The implications of the new policy for public health research were considerable.
The institute was not closed, even if it had been a possible option of the minister of
health. The previous government had already decided that the institute should move
from Stockholm to a small town in the north, a deliberate intention to decentralize
and strengthen the labor market in the periphery. Whether it was the decisive factor
or not, a closure had become a political risk. Few researchers did, however, follow
the institute to its new location. The directives of the ministry of health did also limit
the sphere of research. More emphasis was gradually put on medical epidemiology
at the expense of an analysis of social, structural factors related to health. No more
money was for instance granted for publishing a statistical report every fourth year.
In theory, the closure of the Institute for Working Life and the reorganization of
the Public Health Institute would only mean that studies of these two fields should
be conducted and evaluated within the universities. But a considerable part of the
research financed by the institutes had already been conducted at or in collaboration
with universities. When the state delimited its direct support of research to medical
and epidemiological aspects, most social scientists had to look for other research
areas. The change from a left-center to a center-right government and its “renewed”
public health policy meant a delimitation of a research field to “politically neutral”
subjects from ideological points of view. Consequently, social science studies of
structural factors saw its resources shrinking dramatically, further underlined when

9
  ”Utanförskap”, being outside society.

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J. Sundin

it was merged with The Swedish Institute for Disease Control in 2014 under a new
name, The Public Health Agency.

Regional Marmot Commissions

The political benefits seemed obvious from the point of view of the new govern-
ment. However, history tells us that public health policy is formulated in an inter-
action between ideologies, science and manifested realities. A dominant political
hegemony might decide which “science” should be funded and listened to. But
social realities and scientific perspectives can change quickly, sometimes more rap-
idly than expected. Within less than four years and before the next election, the tar-
gets of public health in the media and political debate were once more seen as some-
thing more than epidemics and individual behavior.
Several events contributed to the change. An economic crisis in the western world
begun to have negative impacts on unemployment and other social problems. Inter-
national research on the connection between economic inequality and health differ-
ences had been going on for more than a decade.10 Michael Marmot, a British peer
and professor in medicine, published several studies, for instance on the connection
between social status, heart disease and life expectancy. He became the leader a
WHO Commission on the Social Determinants of Health. Some studies for the com-
mission were made by Swedish researchers.11 They were met with skepticism by the
ministry of health. At the same time, the Swedish translation of Michael Marmot’s
book in 2006 on “the status syndrome” was praised by the media.12 Their coverage
was also intensive when the WHO commission delivered its final report “Closing
the Gap in a Generation” in 2008.13 One of the commission’s conclusions was the
growing importance of psychosocial factors for increased health differentials in pop-
ulations. This came at the same time as epidemiologists and medical agents referred
to statistics about widening social differentials and a significant increase of mental
health problems in Sweden.
Regional health boards were the first to respond and started several “Marmot
commissions” in 2011–2013. Their data illustrated the social differentials for heart
disease and other serious health problems in the regions. It had for instance been
known before that there was a difference in life expectancy between the richest
versus the poorest communities in the Stockholm region. However, it had not been
understood that the magnitude of the difference was almost 10  years in the worst
cases. The regional commission for the county of Östergötland, among others, dis-
covered that the health differential showed itself stepwise among its 13 communi-
ties.14 The commissions delivered joint recommendations on how to integrate the

10
  Wilkinson and Marmot (2001) and Putnam (2001).
11
  Lundberg et al. (2008).
12
  Marmot (2006).
13
  Marmot (2008).
14
  Region Östergötland (2014).

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idea of equality and health in every political sphere. Politicians from all parties had
participated in these commissions, one way or the other. It meant that the conclu-
sions were followed by formal policy declarations with little resistance.
After 2013, public health research was theoretically and methodologically in a
favorable position in Sweden. There had been a fruitful merge between biomedicine,
psychology and social science. A general theory was accepted about the connection
between society and health, whilst many of its implications had yet to be understood.
However, 4 years later, Sweden is facing another election. Social determinants and
health are sometimes mentioned in political fora but usually from a new angle. How
to make the immigrants become Swedes is the most acute agenda, by political par-
ties as well as in opinion polls among the voters. Health is also a priority, but the
main concern is how to get rid of the queues for care of serious medical needs. New
medical technologies, particularly new drugs tend to increase costs. Hence, the inter-
est in research is directed towards economy and administration. Social determinants
of health are commonly accepted but the general policy documents are thought to
have settled the issue.

Conclusion

As an interdisciplinary arena, the funding of public health research has depended

largely on public money—at specific institutes or from sources open to any
researcher. The Swedish Council for Planning and Co-ordination of Research was
led by researchers and specifically designed to support interdisciplinary projects.
But the golden era of interdisciplinary research in Sweden was in the 1980s and
consequently a new minister of education decided to close it in 1992. Public health
has been a target of political interest and dispute from its very birth during the eight-
eenth century and onwards. The central question was already in the nineteenth cen-
tury whether individual, free choice or structural forces beyond the power of the
individual, was the predominant factor causing the observed social differentials of
health in a population. Conservatives and adherents of laissez-faire tended to believe
in the individual’s behavior and own responsibility. Social liberals and politicians
on the left side have emphasized the structural explanation. There has of course
not been any open censorship regulating what, how and to which extent academic
research should be engaged in trying to increase the knowledge and understanding
of relationships between health and society. But a great deal of funding has come
through politically controlled channels. The latest Swedish example of the impact of
political goals on public health research and practical policy came after a change of
political majority in parliament in 2007.

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J. Sundin

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