The governmentalization of living: calculating global health

Abstract

The contemporary global health agenda has shifted emphasis from mapping disease patterns to calculating disease burden in efforts to gauge ‘the state of world health’. In this paper, we account for this shift by showing how a novel epidemiological style of thought emerged in the closing decades of the twentieth century. As is well known, the compilation and tabulation of vital statistics – death-rates, birth-rates, morbidity rates – contributed to the birth of the ‘population’ in the eighteenth and nineteenth centuries. The population is reformatted from the middle of the twentieth century by ‘modified life tables’ made up of disability weightings, health state valuations, quality of life scores, disease burden estimates, etc. The problem of morbid death gives way to that of morbid living, made calculable through a metrics of ‘severity’, ‘disability’ and ‘impairment’. A series of new indices and scales (e.g. the QALY and DALY) has contributed to a governmentalization of living, in the course of which the social and personal consequences of living with disease come to be an object of political concern, and made knowable, calculable and thereby amenable to various strategies of intervention. We conclude by showing how this style of epidemiological thought has generated a new global visibility for brain disorders as their impact on individuals, health care systems and nations are calculated in novel ways.     

A comparative study of representations about disability in primary school children's drawings: a sociosemiotic approach

Over the past few years, perceptions about disability – at least at the theoretical level – have been shifted toward a more progressive approach, which stresses the social aspects of the construction of disability (social model) rather than personal limitations, as supported by the traditional disability approach (medical–individual model). Drawing upon the sociosemiotic approach as developed by Kress and van Leeuwen, the present study examines from a comparative perspective the representations about disability and people with disabilities, as emerging from the drawings produced by 4th grade Greek primary school children. The sample consists of two groups of children. Group A does not share the same school environment with schoolchildren with special education needs, while group B shares the same school surroundings with students attending a special education needs School. The comparative analysis of their drawings indicates that children of both groups reproduce the dominant meanings they receive from their direct social environment.     

Public values and administrative reforms in French health care

Public value appears to be reborn out of the ashes of earlier failed new public management (NPM)‐driven policies in health care. It advocates greater consultation of the civic society and autonomy of public managers in decision‐making. In France, the 2009 Hospital, Patient, Health, and Territory law recentralized the health system and strengthened the central government to restore consistency in policy implementation and address earlier NPM shortcomings. The 2014 Health Project heralds a phase of policy hybridization that not only preserves earlier NPM tools but also seeks to reaffirm the role of the public and the medical profession in the governance of the health system. Copyright © 2016 John Wiley & Sons, Ltd.     

The dynamic political economy of support for Barack Obama during the 2008 presidential election campaign

In recent years, students of voting behavior have become increasingly interested in valence politics models of electoral choice. These models share the core assumption that key issues in electoral politicds typically are ones upon which there is a widespread public consensus on the goals of public policy. The present paper uses latent curve modeling procedures and data from a six-wave national panel survey of the American electorate to investigate the dynamic effects of voters’ concerns with the worsening economy—a valence issue par excellence—in the skein of causal forces at work in the 2008 presidential election campaign. As the campaign developed, the economy became the dominant issue. Although the massively negative public reaction to increasingly perilous economic conditions was not the only factor at work in 2008, dynamic multivariate analyses show that mounting worries about the economy played an important role in fueling Barack Obama’s successful run for the presidency.     

National health insurance: Some lessons from the Canadian experience

In the current American debate over national health insurance an examination of the Canadian governmental experience is very instructive. Canada is enough like the United States to make the effects of Canadian health insurance policies rather like a large natural experiment. The Canadian experience—universal government health insurance administered by the ten provinces with some fiscal and policy variations—can be used to predict the impact in the United States of proposed national health insurance plans on the medical care system, and the reaction of mass publics and national policymakers to these effects.The central purpose of the Canadian national health insurance was to reduce and hopefully eliminate financial barriers to medical care. In this it succeeded. But it also produced results which Canadian policymakers never anticipated: essentially unexpected side-effects on cost, quality, organization, and manpower distribution of the particular national health insurance program adopted. It should be cause for concern, the article concludes, that most of the prominent American national health insurance proposals resemble the Canadian program in failing to provide a single level of government with both the means and incentives to curb the inflationary effects of national health insurance. The lesson from Canada is that unless the system has very strong anti-inflationary mechanisms and incentives built into it, national health insurance will feed the fires of medical inflation despite great formal governmental authority to control it.     

Variations in appointment delays for physicians' services: Theory and empirical evidence

Waiting times for physician appointments have been used in past studies as a measure of access to, or excess demand pressure on, local ambulatory care systems. This paper offers an alternative view—that short appointment delays are one of several types of amenities produced by physicians in combination with health services. Empirical evidence is presented that illuminates some previously unknown relationships between appointment delays, patient diagnosis, site of care, and family income. A model is developed with the capability of predicting short-run responses to changes in demand for physicians' services. The model and empirical evidence are used as the basis for interpreting recent experience in Canada with its system of national health insurance (NHI) and for predicting potential consequences regarding the production of amenities of NHI in the US.This research has been supported in part by a grant (HS—00825) from the Center for Health Services Research, US Department of Health, Education, and Welfare, to the University of Florida. We are indebted to John B. Wayne and to Paula Sloan for their assistance and to University of Florida colleague Gary Shannon for comments on an earlier draft.     

Are Americans underinvesting in their children?

He has written widely on the Economics of health care. Among his books are The Economics of Physician and Patient Behavior; Economic Aspects of Health; How We Live;and The Health Economy.     

International Power and Local Action – Implications for the Intersectionality of the Rights of Women with Disability

The recent United Nations Convention on the Rights of Persons with Disabilities (CRPD) reframes how policy responds to disability, difference, interdependence and rights. We examine how Australian disability activists used the CRPD to advocate for the intersectional rights of women with disability. We applied a framework from Zwingel's conceptualisation of mutually constituting global norms to analyse the intersectionality of rights represented in three stages of the CRPD process – during the drafting, the wording in the Convention, and the periodic review. We found that disability activists were able to shape the gendering of disability through their targeted representation as people with lived experience. This expertise filled a knowledge gap in the policy process valued by the actors at other policy levels. Extending Zwingel's concept of global discourse translation, it also suggests that the dynamic contribution continues in the international interpretation of the CRPD itself.     

Trade Winds: NAFTA and the Rational Public

The sharp increase in suppport for the North American Free Trade Agreement (NAFTA) poses a challenge to many of our conceptions of public opinion. Most large shifts in public opinion follow major events. Based on models estimated from the September to November NBC News/ Wall Street Journal surveys, I show this was not the case with respect to public opinion on NAFTA. Instead, the increase in support for the pact reflected a slower response to a public debate over the merits of free trade versus protectionism. As the debate proceeded, large segments of the public— including the least interested—developed more highly constrained belief systems. By the end of the public discourse, the most and least interested citizens both linked attitudes on the merits of trade to their positions on NAFTA and to their evaluations of the elites on each side of the issue. People made up their minds on NAFTA on the basis of arguments about trade, not about their own self-interest. The NAFTA case suggests that there may be a rational public at the individual level after all, even among people who may not usually be interested in public affairs.     

Cheap and Dirty: The Effect of Contracting Out Cleaning on Efficiency and Effectiveness

Contracting out of public services, especially ancillary services, has been a key feature of New Public Management since the 1980s. By 2014, more than £100 billion of U.K. public services were being contracted out annually to the private sector. A number of high‐profile cases have prompted a debate about the value for money that these contracts provide. Value for money comprises both the cost and the quality of the services. This article empirically tests the contestability and quality shading hypotheses of contracting out in the context of cleaning services in the English National Health Service. Additionally, a new hypothesis of coupling is presented and tested: the effect of contracting of ancillary services on patient health outcomes, using the hospital‐acquired infection rate as our measure. Using data from 2010–11 to 2013–14 for 130 National Health Service trusts, the study finds that private providers are cheaper but dirtier than their in‐house counterparts.     

The composition of microcosms

Q methodology is employed for purposes of providing an instrumental base to Lasswell's concept of the continuing decision seminar. Policy-making is regarded as essentially subjective and value-laden in nature, hence the use of instruments to assist in the micromodeling of complex decision processes—as embodied in decision seminars—must give centrality to human judgment. The factor-analytic procedures proposed are applied first to a life-history seminar. Suggestions are then made for the extension of these methods to future seminars, decision-making, and to the policy sciences more generally.     

The “Perverse Result” of Disability Rights: Deregulating Care Workers’ Labor Unions in the Supreme Court

In Harris v. Quinn (2014), the United States Supreme Court used disability rights rhetoric of independence and control to argue that disabled people—not the State—are the real employers of in-home care workers. Consequently, the State cannot force care workers to pay labor union fees. Justice Alito’s majority decision interprets the employment contract as a capacity contract: a device that uses the recognition of equal cognitive capacity to obscure domination. Alito ignored the vulnerability of disabled people and in-home care workers to legitimize neoliberal cutbacks. In her dissent, Justice Kagan argued that disabled people, care workers, and the State forge multiple and iterative contracts. Using Kagan’s dissent, Charles Mills’s critique of ideal theory, and Susan Burgess and Christine Keating’s participatory social contract, I argue that an emancipatory contract must replace cognitive capacity as the condition of membership with the recognition of shared human vulnerability amid oppressive conditions.     

A note on crime and punishment

The models developed here are intended to convince the reader that Tsebelis' results — that increased punishment leaves the equilibrium level of crime unchanged — is an example of what is possible rather than a general result. To recap the argument in words: it is true that raising the penalty on a crime may cause the enforcing agency to divert attention away to other matters, so that theexpected penalty facing the prospective criminal is not as high as it would have been had the agency not adjusted; but it is not generally true that enforcing agencies will choose to lower their probabilities of enforcement just enough to exactly offset the increased penalty, leaving the expected penalty unchanged, hence the equilibrium level of crime unchanged.⁸ this result sounds unusual when stated in words and it is when modelled using the theory of games too.This work was supported by NSF grant SES-9022882.     

Avian influenza, ‘viral sovereignty’, and the politics of health security in Indonesia

Abstract

In December 2006, Indonesian Health Minister, Siti Fadilah Supari, shocked the world when announcing her government would no longer be sharing samples of the H5N1 avian flu virus, collected from Indonesian patients, with the World Health Organization, at a time when global fears of a deadly influenza pandemic were running high. For observers of Southeast Asian politics, the decision reinforced the view of the region as made up of states determined to protect their national sovereignty, at almost all costs. This established view of the region, however, generally neglects the variable and selective manner in which sovereignty has been invoked by Southeast Asian governments, or parts thereof, and fails to identify the conditions shaping the deployment of sovereignty. In this paper, it is argued that Siti's action was designed to harness claims of sovereignty to a domestic political struggle. It was a response to the growing fragmentation and, in some cases, denationalisation of the governance apparatus dealing with public health in Indonesia, along with the ‘securitisation’ of H5N1 internationally. The examination of the virus-sharing dispute demonstrates that in Southeast Asia sovereignty is not so much the ends of government action, but the means utilised by government actors for advancing particular political goals.     

On the strategy of social planning

Social planning deals centrally with human values—values which are important even though they do not appear as explicit factors in the classical problems of social welfare.The philosophical question as to whether facts can provide a logical basis for values need not be considered by the planner. He focuses, rather, on the specific interplay of values and facts in the concrete context of his concern.In the analysis of this interplay we can distinguish a number ofprinciples, criteria for the specification of social ends; for instance, the maximin principle, that improvements in a value distribution consisting in cutting off the bottom of the distribution have priority over raising the top.Social ends, in turn, are analysable intoideals, goals, andobjectives—directions, regions and points, respectively, in the value space.Cutting across these are the desiredqualities of the experience of pursuing those ends, qualities allowing for the assessment of planned alternatives by configurational judgment, rather than by a presumed summation of component values.A report submitted to the Social Planning Group of the Planning Board of Puerto Rico in 1958, not previously published.     

Health planning rationality

Health planning theory has failed to operationalize the concept of rationality into terms useful for theory building. The concept of rationality has also generally not been translated into a useful tool for the health planning practitioner. In order to decrease the mystique associated with rationality and to aid in refinement of the concept, four attributes of health planning rationality are proposed:

1. Health planning rationality is “bounded” due to the magnitude of problems and man's limited problem-solving abilities;
2. Health planning rationality has multiple dimensions (technical, social, legal, political and economic);
3. The multiple dimensions of health planning rationality interact as complements and substitutes; and
4. Health planning rationality may be conceived of as the exposure of problems to cognitive processes.

     

Lessons in suffering: Greek tragedy’s teachings on disability through Sophocles’ Philoctetes

Political theory often sees disability through the negative language of abnormality and inability, which perceives disability as a deficiency that deviates from the able-bodied. However, critical disability studies strives to transform the disabling language of political theory into an enabling project that sees the ability, unique perspectives, capacities, and contributions of people with disabilities. Through Sophocles’ Philoctetes, this article examines the negative ways in which disability is conceptualized, socially constructed, and (dis)valued, as well as the possibilities for a positive and enabling theory of disability. The character of Philoctetes exposes the negative social construction of disability as well as the extraordinary ability of those who live with chronic impairments. The Philoctetes meditates on the status of the disabled who are unfairly isolated from human community and who are often unfairly seen in an instrumental fashion that fails to recognize their fundamental status as human beings who are capable, valuable, and essential for the success of human endeavors and community. For political theory, the Philoctetes demonstrates the ability in disability, and shines brightly on the essential contributions that people with disabilities make in our societies. Philoctetes shows that the lives of people who live daily with chronic impairments need not be seen as necessarily tragic. Instead, these modes of being speak to human diversity, ingenuity, and triumph.     

Unmet Need for Workplace Accommodation

We use experimental survey methods in a nationally representative survey to test alternative ways of identifying (1) individuals in the population who would be better able to work if they received workplace accommodation for a health condition; (2) the rate at which these individuals receive workplace accommodation; and (3) the rate at which accommodated workers are still working four years later, compared to similar workers who were not accommodated. We find that question order in disability surveys matters. We present suggestive evidence of priming effects that lead people to understate accommodation when first asked about very severe disabilities. We also find a sizeable fraction of workers who report they receive a workplace accommodation for a health problem but do not report work limitations per se. Our preferred estimate of the size of the accommodation‐sensitive population is 22.8 percent of all working‐age adults. We find that 47 to 58 percent of accommodation‐sensitive individuals lack accommodation and would benefit from some kind of employer accommodation to either sustain or commence work. Finally, among accommodation‐sensitive individuals, workers who were accommodated for a health problem in 2014 were 13.2 percentage points more likely to work in 2018 than those who were not accommodated in 2014.     

A tax by any other name: The donor directed automatic percentage contribution bonus,a budget alternative for financing governmental support of charity

Our paper analyzes the merits of four alternatives for providing governmental support to charity—the existing tax write-off, a tax credit, a sliding matching grant, and a percentage contribution bonus. After searching for an appropriate budget mechanism (a five-year fixed-sum authorization and appropriation), we apply a wide-ranging set of criteria—equity, legitimacy, efficiency, reciprocity, controllability, etc.—to each of the four alternatives. In brief, the existing tax write-off is grossly inequitable among donors, poorly controlled by government, and is part of a tax system increasingly viewed as illegitimate by citizens. The advantages of the write-off are that it produces predictable amounts of income at low administrative cost without overtly raising questions of constitutionality. Its disadvantages would be mitigated by a tax credit in proportion to the amounts contributed by taxpayers. But the credit does not reach people who do not file returns and may significantly decrease income to charitable agencies. The sliding matching grant (under which the government pays to charity in proportion as the individual gives of his income) provides a particular form of equity for taxpayers but is deficient in other respects. The contribution bonus—a percentage of each dollar contributed paid to charity by government—is wholly equitable, includes all givers, sustains reciprocity with recipients, is controllable by government, and is legitimate in treating expenditures as expenditures and not as tax dodges. It also raises the possibility of increasing the government's contribution. The defects of the bonus are higher administrative costs and potential doubt about constitutionality. We conclude in favor of a percentage contribution bonus set high enough to provide marginally more income for charity and reduce financial uncertainties during the transition. Appraisal of political feasibility suggests that supporters of charity are likely to be worse off unless they come up with a more defensible approach, such as the contribution bonus. To help resolve doubts, we suggest adding on a small percentage contribution bonus to the present tax write-off for three years so as to test constitutionality and assess more precisely administrative costs. While there is no one proposal that will make everyone better off, the contribution bonus is far superior on most criteria to the alternatives.The paper was written for The Commission on Private Philanthropy and Public Needs. For their criticisms and constructive comments, including those with which we disagreed, we express our appreciation to Professors John McNulty and Lawrence Stone, Law School, and Professors Arnold Meltsner and William Niskanen, Graduate School of Public Policy, all of the University of California (Berkeley).