American public hospitals and health centers are often criticized for their inadequate facilities or for not being patient-centred enough. Financial constraints faced by public institutions are often cited for these impediments, but government regulation also shapes the availability of good health care, with either too much or too little regulation typically impacting disproportionately upon patients whose options are limited by where they live or by the affordability of treatment. Despite the (often undervalued) endeavours of primary health care workers, many activists conclude that the system serves its own ends rather than patients’ needs – or, more polemically, that the ‘medical establishment’ poses a ‘threat to health’, as Ivan Illich famously stated in Limits to Medicine (1976). Conversely, though, health institutions are vital for preserving life and for advancing medical research, spanning a matrix of interpersonal and bureaucratic relationships which, in many ways, reflect broader changes in American society and culture. By addressing these divergent perspectives, the five authors of this section explore the politics undergirding the administration of public health institutions in terms of capacity, finances and regulation, while also reflecting historically on public–private institutional relationships, uneven efforts by authorities to tackle racial segregation in hospitals during the postwar years, and the challenges faced by the Veterans Administration in recognizing and caring for the needs of veterans facing adverse mental health experiences arising from their active service.

In assessing the role and scope of health institutions it is tempting to focus on the pace of change and technological innovations since World War II. Developments in tomography in the late 1970s and the emergence of mobile health services (or mHealth) in the 2010s, to take two examples, have offered new horizons for preserving lives. But whether we see such technological developments as complementing or straining the interpersonal bond between doctors and patients, we should remember that ‘old forms and practices coexist alongside the new’, as the 2000 volume Institutional Change and Healthcare Organizations reminds us. Sometimes owners and governing bodies are resistant to change or their organizations lack the bureaucratic agility to ensure that when change happens it is in the patients’ interest.

Questions of public health hit news headlines on a global scale when in the early months of 2020 the first cases of Covid-19 were reported in Asia, North America and Europe. A wave of earlier twenty-first-century epidemics – Zika, SARS, MERS, Ebola, H1N1 – theoretically should have equipped the global community with the surveillance strategies needed to mitigate the rapid spread of the causal virus SARS-CoV-2, which was distinctive in its high level of transmissibility and mutability, as new variants emerged during the course of 2020–22. Leading US public health officials Anthony Fauci, director of the National Institute of Allergy and Infectious Diseases, Deborah Birx, White House Coronavirus Response Coordinator, and Robert Redfield, director of the Centers for Disease Control and Prevention (CDC), were very visible on television during 2020 in presenting public health advice and data on the pandemic, whereas in other historical phases public health officials have rarely made headline news, especially over such a sustained period. The composition of the White House coronavirus response team did not mean federal agencies were coordinating seamlessly though, or that the Trump administration was fully cognizant of the need to maintain consistent public health messages in the face of a rapidly evolving emergency, caused by what Fauci called one of the most ‘unpredictable’ of viruses.

It is important to remember that the US public health system has a complex infrastructure and a considerable reach in civic life, having expanded over the course of the twentieth century via the governance and surveillance roles of the CDC and the US Public Health Service as agencies within the Department of Health and Human Services. The fact that the responsibilities of public health agencies go well beyond infectious disease control – spanning occupational health, environmental health, bioterrorism defence and health education, among other functions – shows how public health challenges are both widespread in American society and cannot be reduced to a media spectacle at times of national emergency. While sustained congressional funding of public health services to an adequate level is an ongoing concern for the scientific and medical community, the Covid-19 pandemic reveals the functional and ethical importance of such a politically independent community to ensure that health messages are accurately communicated, and to push federal and state authorities to make decisions informed by evidence-based epidemiology and robust scientific data, ideally of an evolving, granular, and comparative nature.

On 20 July 2021, four leading United States health officials addressed a congressional hearing, ‘The Path Forward: A Federal Perspective on the Covid-19 Response’, held by the US Senate Health, Education, Labor and Pensions Committee, twenty months after the novel coronavirus was first identified as a disease event in Wuhan, the capital of Hubei Province in central China. Rather than providing a conclusive review of the highly contagious SARS-CoV-2 virus that swept the United States and over two hundred countries through 2020, the committee recognized that the nation remained in a perilous state, with the Delta variant (first identified in India in December 2020) at that time causing more than 80 per cent of Covid-related illness and death among US citizens. The domestic and global politics of the hearing are evident from these basic facts about viral transmissibility and the framing of two Asian countries by many politicians and reporters as significant international health threats, despite the efforts of the World Health Organization to classify the sequence of Covid-19 variants alphabetically (Alpha to Omicron) so as not to stigmatize particular nations or peoples.

The co-chair, Senator Patty Murray, opened the hearing by highlighting the ‘promise and peril’ of this moment, and then the four health officials spoke in turn about the importance of the federal vaccination program for saving lives and containing viral spread, confirming that the most severe responses to Covid-19 were among unvaccinated Americans. The drama of the otherwise cordial hearing centred on a barbed exchange between Rand Paul, Republican senator from Kentucky and a trained ophthalmologist, and virologist Anthony Fauci, the long-standing director of the National Institute of Allergy and Infectious Diseases, who had been a key figure in the White House Coronavirus Task Force during the final year of the Trump administration and was now President Biden's Chief Medical Advisor. Instead of addressing questions of disease prevention, Rand Paul swerved to the unproven theory that the National Institutes of Health (NIH) directly funded ‘gain of function’ research at the Wuhan Institute of Virology during the 2010s, thereby making SARS-related viruses transmissible between bats and humans. Paul began by reminding Fauci that it is ‘a crime to lie to Congress’, recalling that Fauci had stated to this committee on 11 May 2021 that ‘the NIH has not ever and does not now fund gain of function research’ at the Wuhan laboratory.

The politics of health in the United States often plays out in the charged space where abstract matters of law and constitutional rights collide with the realities of health care delivery, political manoeuvres and everyday life. Health, often presumed to be an uncontroversial good, is in fact a contested label, particularly when it comes to hot button topics at the heart of America's ideological divide: of these, the subjects of abortion, firearms and mass incarceration are all addressed in this section. Claiming any of these cases to be a ‘public health issue’ might be interpreted as a move towards depoliticization, or at least de-escalation, attempting to draw together both sides of a polarized debate in the shared arena of health. However, as these chapters elucidate, the promotion of health is rarely an ideologically neutral project. Enduring debates over whether women's health is promoted or depleted through abortion rights, whether gun violence should be addressed as individual or social pathology, or whether incarceration protects or harms the health of the nation, all demonstrate the folly of seeking common ground by labelling something a ‘health care issue’. Similarly, appeals to statistical evidence or scientific neutrality in practices and discourses of public health often occlude the discriminatory underpinnings of these constructs. The staking of identity claims around race and age is fraught with the violent legacies of historical attempts to find biological bases for social hierarchies. Identity based movements for social justice in the twentieth and twenty-first centuries have had to contend with these legacies while articulating alternative bonds of solidarity and community. In this section, scholars from the fields of law, history, rhetorical studies, sociology and medical anthropology contend, in diverse ways, with the health politics of fraught ethical debates and movements as they seek justice for marginalized subjects.

Legal scholar Mary Ziegler's chapter opens this section by interrogating the shift from rights to health in battles over abortion in the United States. Re-evaluating the widespread understanding that abortion is primarily a question of government, religion and constitutional law in the US, Ziegler argues that, in the years since the 1973 Roe v. Wade US Supreme Court decision secured a limited constitutional right to terminate a pregnancy, both defenders and opponents of this right have frequently turned to arguments about public health rather than to questions of ethics, morals or abstract rights.

Improving the quality and coverage of health care is one of the greatest domestic challenges that the US federal government faces, yet this challenge is usually framed exclusively in fiscal terms. National health expenditure has risen dramatically over the last fifty years, from 6.9 per cent of GDP in 1970 to 18 per cent in 2020, prior to the public health emergency caused by the Covid-19 pandemic. However, despite the United States now spending more on health care than any other developed economy, the federal government is criticized routinely by health advocates – and periodically by the electorate – for failing to meet the basic health needs of US citizens.

Repeated attempts to refine the health care and welfare systems, starting during the Roosevelt administration in the 1930s, have met resistance in Congress for a combination of ideological and fiscal reasons. To care for all US citizens via a single-payer system, such as national health insurance in the UK, is thought not only to be too costly but also to strain against American values of freedom, market choice and low taxation. At best, US health care is a flexible structure that marries shared responsibility at federal, state and local levels with a decentralized mix of public and private provision. At worst, it is a patchwork of services that comprise what progressive reformer Edward Kennedy derided in 1972 as ‘a medical maze’ or what forty-five years later Elizabeth Rosenthal called a ‘system in disarray’.

While it is easy to overplay the failures of the US federal government to meet the health needs of an expanding and diversifying population (rising from just shy of 140 million in 1945 to over 330 million in 2020), the five authors of this section each consider the ways in which presidential and congressional politics have grappled with insistent calls to reform health care provision and entitlements. The five chapters are structured in chronological order, from the 1940s to the 2010s, with the first, second and fifth chapters forming a tight sequence in addressing the efforts at executive and legislative level to expand health insurance during the administrations of Harry Truman (1945–53), Lyndon Johnson (1963–69) and Barack Obama (2009–17).

In a March 2021 essay on the Covid-19 crisis and ‘crip time’, the literary theorist Elizabeth Freeman suggests that the pandemic had expanded to the masses the distinctive, non-normative experiences of time engendered by disability and chronic illness. For Freeman, crip time describes not only foreshortened lifespans or the ‘lost time’ in everyday experiences of disability, but also forms of transhistorical solidarity. Freeman writes:

Freeman's essay exemplifies the political value of analysing health conditions in historical perspective and of drawing attention to the social and cultural dimensions of illness across space and time. If government responses to the Covid-19 pandemic have often seemed to naturalize the connections between chronic illness or disability and isolation, this vision of ‘crip time’ emphasizes the inescapable collectivity of illness. As such, it is an apposite way to introduce the five essays in this section, which all work to unveil the social and political worlds that shape definitions and experiences of critical health conditions, moving beyond the disease conception of illness by attending to the material contexts that are often rendered invisible by the focus on the individual patient in discourses of critical health. Whether looking at the twentieth-century epidemics of polio and AIDS, the emergence of ‘obesity’ and major depressive disorder as contested diagnoses or the production of cancer under capitalism, these chapters open up the various economic, cultural, industrial, legal and emotional forces that shape the politics of critical health conditions.

In the first chapter of this section, Stephen Mawdsley tracks the history of anti-vaccination attitudes during the polio epidemics of the twentieth century.

In October 2011, at a summit in Rio de Janeiro, Brazil, the World Health Organization (WHO) released the Rio Political Declaration on Social Determinants of Health, its strongest statement yet of the need to tackle health inequities both ‘within and between countries’. Focusing on the WHO's commitment to health as a fundamental right rather than a privilege, the Rio Declaration recognized that to eliminate inequities would require the sustained ‘engagement of all sectors of government, of all segments of society, and of all members of the international community’. By viewing social determinants in both economic and psychosocial terms, the declaration made three policy recommendations: ‘to improve daily living conditions; to tackle the inequitable distribution of power, money and resources; and to measure and understand the problem and assess the impact of action’. Set against the World Health Assembly's adoption of this policy framework in 2012, the five essays of this volume's opening section explore the material conditions and distribution of resources that underpin the health challenges facing diverse communities within the United States.

The focus on geography, immigration and race in this section calls for what the Rio Declaration termed ‘an intersectoral approach’ to analysing how social groups are classified with respect to life expectancy, comorbidities and access to health care. Ensuring that health data is adequately granular is often the most significant challenge for assessing how inequities are shaped by locality, citizenship and identity. With this in mind, the five essays adopt intersectoral approaches – historical, sociological, geographical, legal and community-based – and offer different kinds of evidence to highlight how US health care at a systemic level routinely fails to serve poor and less advantaged communities. As well as drawing correlations between environmental pressures and health challenges in localities ranging from Black communities living in South Side Chicago to poor isolated places in the Rocky Mountain West to the immigrant communities of Los Angeles County and Miami, these five chapters address the ways in which health activism can ‘close the gap’ (to evoke the title of a 2008 WHO report) by exposing health inequities and stimulating legislative and operational changes that might redress historically ingrained and newly emerging exclusions.

In the first chapter, Andrew Highsmith traces how racial and economic fault lines of the urban experience shaped post-World War II health disparities.

On the afternoon of 20 July 1993, the body of Vincent Foster, Deputy White House Counsel and close childhood friend of President Bill Clinton, was discovered in Fort Marcy Park, a former Civil War fortification up the Potomac River from Washington DC. Foster was lying on an embankment behind a Civil War cannon with a shot to the head and a revolver in his hand, making him ‘the highest-ranking White House official who had ever taken his own life’, as the Baltimore Sun described it. Only six months into the Clinton administration, Foster's death was a devastating shock to the Foster and Clinton families. It was also an opportunity for the president's adversaries to argue that something was deeply wrong in the White House, even when the FBI and an independent council concluded that the cause of death was suicide. Conspiracy theories were rife over the following months, including the right-wing radio host Rush Limbaugh, who suggested, without evidence, that Foster was murdered in Hillary Clinton's apartment and then carried to Fort Marcy Park.

The reality was both more tragic and more mundane. Vince Foster had worked in Clinton's transition team in late 1992 and moved to the White House following the January inauguration, leaving his family behind in Little Rock for schooling. Foster felt burdened by work pressures, leading to bouts of insomnia following long days of administration; he lost weight and his concentration wavered, took the antidepressant Desyrel and may have consulted a psychiatrist in his final days. Occupational health reforms of the late twentieth century did little to address the pressures faced by federal workers, and Foster, a trained Arkansas trial litigator, struggled with the political and media scrutiny of Washington DC. Right-wing critics sought to discredit a torn-up suicide note found in Foster's briefcase six days later in an effort to expose ‘the Clinton crowd’, even though the fragments of Foster's letter confirmed the workplace as the source of his depression – ‘I was not meant for the job or the spotlight of public life in Washington. Here ruining people is considered sport’ – and in spite of independent experts concluding that this was an act of suicide.

In 1946, Dr Benjamin Spock published The Common Sense Book of Baby and Child Care, a new kind of parenting manual for the masses. Renowned for transforming the field of parental advice by encouraging parents to trust their instincts, Spock's ostensibly permissive approach was underpinned by the authority of his paediatrician's white coat that symbolized the privileged role of science during the Cold War. By the late 1960s and the publication of the third edition of Baby and Child Care, Spock's interventions in global politics, as an activist against nuclear proliferation and the Vietnam War, projected his image outside the realm of the nuclear family, pointing to the broader political struggles that shape the world in which children's health will either decline or flourish. As a 2011 profile of Spock in American Journal of Public Health notes, this purveyor of parental advice was also ‘committed to securing a healthy future for the young patients he saw in his practice’. These two aspects of Spock's career exemplify a tension at the heart of the politics of children's health in post-1945 America. The notion that the health of children is the product of prudent parental decision-making within the confines of the nuclear family, on the one hand, and embedded in global struggles for the transformation of society, on the other, ani-mates all five chapters in this section, spanning the fields of political science, gender and cultural studies, history, political theory and human ecology.

In the first chapter of this section, Alice Sardell investigates the expansion of children's health insurance coverage since the 1980s. Drawing on archival evidence and interviews with key policy actors, Sardell tracks the incremental process through which the federal funding of children's health insurance in the US was secured. Building on her 2014 book Insuring Children's Health, Sardell contextualizes the question of health insurance for children within the broader field of US health insurance, in which support is predicated on membership of a population deemed ‘deserving’, in lieu of a universal health care system. As such, the expansion of health insurance to children in the 1990s involved a community of advocates for child health from both inside and outside of the federal government.