“It is clear,” write the authors, “that the public health system in the U.S. has suffered from political neglect in the last 50 years or so, and the revitalization of the U.S. public health system will necessitate confronting many of the challenges facing it in the twenty-first century” (p. 7). Kent Patel and Mark Rushefsky's survey of the politics of American public health argues that our system emphasizes curative treatment of existing illnesses at the expense of activities aimed at preventing them. Although the United States spends more per capita on health care than any other country, public health activities account for only about 2% to 3% of such expenditures. The low priority given public health, they argue, accounts for America's poor performance relative to other industrialized countries on measures of life expectancy and infant mortality.

According to the authors, the sources of our nation's relative neglect of public health are largely those associated with conservatism. The medical profession resists measures, such as universal health insurance, that may infringe on its ability to treat patients and set fees. Corporations, particularly tobacco companies, resist environmental and health measures to protect profit margins. Religious groups oppose needle-exchange programs and underfund AIDS prevention programs on moral grounds. These groups are assisted by political allies in the White House, particularly the current Bush administration, which disregards true science in favor of ideology.

By contrast, proponents of a greater governmental role in public health are undermined by a fragmented governmental system where coordination and cooperation are difficult. Also culpable, say Patel and Rushefsky, are public health professionals themselves, who decline to become involved in political debates because they fear that such activities contradict their positions as objective, neutral scientists. The authors believe that these reservations must be set aside in favor of advocacy if public health is to attain a higher priority on the nation's political agenda.

Patel and Rushefsky are correct that public health is undervalued in the United States. Because the benefits of such programs are public goods, they will almost inevitably be underfunded in the absence of government intervention. This is particularly likely to occur in a country with a political culture that values individualism and private property while harboring a deep skepticism of government action. Further, the authors make sensible arguments that increased government action in a number of areas would benefit its citizens. One such area involves environmental regulation, where they argue for policies based on the precautionary principle: If threats of serious or irreversible damage exist, the absence of scientific certainty should not be used as a rationale for cost-saving measures that will not preserve the environment. Thus, for example, although the link between greenhouse gas emissions and global warming is “correlational or associational … so that causal linkages are not entirely clear” (p. 230), the authors argue that the evidence is strong enough and the potential hazards significant enough to make increased government regulation desirable.

By contrast, Patel and Rushefsky appear to be largely unaware of or unconcerned about the potential for government overregulation in the area of public health. While they mention threats to privacy posed by genetic research, they have little to say about the potential for too much government regulation undermining economic growth or personal choice. Where to draw the line in such instances is crucial, but the authors instead appear content to permit the public health profession to dominate the decision-making process. Although they mention the argument of two critics that public health officials, like government bureaucrats generally, seek to increase their budgets and political power, they do not take such concerns seriously. Nor do they worry that politically liberal interests, such as the sizable environmental lobby, might push government too far in the direction of regulation.

Such concerns about burdensome, meddling government are increasingly plausible given that many of today's public health problems involve matters of personal behavior. As Rushefsky and Patel themselves point out, virtually half of all deaths in the United States are attributable to an “unhealthy lifestyle” (p. 7). Such vices as overeating and smoking increasingly constitute significant threats to societal health and well-being. Given the means, public health officials could significantly lower the prevalence of these activities. But at what cost? Cognizant of the threat posed by secondhand smoke, New York City Mayor Michael Bloomberg has successfully banned smoking in bars, establishments where, it might be argued, individuals expect to smoke. Fast-food chains increasingly fear lawsuits from obese customers while government officials contemplate junk-food taxes. One does not have to smoke or own a McDonald's franchise to be disturbed by the increasing propensity of government officials to behave as finger-wagging nannies in the name of public health. Unfortunately, Patel and Rushefsky appear too convinced of the desirability of increasing the power of public health officials to consider how much government intervention is too much.