Public Health Liberation and Federalist No. 10
By Christopher Williams, Founding Director of Public Health Liberation
The general point of Federalist No. 10 was to argue for a republican form of government as opposed to a pure democracy to regulate the harm and excesses of factions, whether majoritarian or not, that threaten political stability and the public good. Madison’s writings more than 230 years ago immediately resonate in light of the January 6th violence on the Capitol and the deepening divide between the two major political parties. This essay will seek to argue that Federalist No. 10 has major public health relevance. Madison’s views on human nature and factionalism can extend to the public health economy and support principles of Public Health Liberation. The following questions will be explored:
1) How is a Madisonian view of factions and the lengths that they will seek to effectuate self-interests relevant to public health?
2) Is the public health economy sufficiently regulated to safeguard public health and the common good à la Madisonian republicanism?
3) What are the “factions” in the public health economy?
4) What is the role of Public Health Liberation?
1) Public Health Relevance to a Madisonian View on Factions
Madison is gravely concerned about factions as he argues for ratification of the US Constitution as a representative democracy. “By a faction, I understand a number of citizens, whether amounting to a majority or a minority of the whole, who are united and actuated by some common impulse of passion, or of interest, adversed to the rights of other citizens, or to the permanent and aggregate interests of the community.” Since political parties had yet to form in 1787, he did not mean political parties at the time of his writing. Madison seeks to secure the longevity of the Union against, “(t)he influence of factious leaders (that) may kindle a flame within their particular States, but will be unable to spread a general conflagration through the other States.”
“The latent causes of faction are thus sown in the nature of man; and we see them everywhere brought into different degrees of activity, according to the different circumstances of civil society. A zeal for different opinions concerning religion, concerning government, and many other points, as well of speculation as of practice; an attachment to different leaders ambitiously contending for pre-eminence and power; or to persons of other descriptions whose fortunes have been interesting to the human passions, have, in turn, divided mankind into parties, inflamed them with mutual animosity, and rendered them much more disposed to vex and oppress each other than to co-operate for their common good.”
Madison’s critique that factionalism is omnipresent in society is relevant to Public Health Liberation. Previously, we defined the public health economy as the totality of human activity within economic, political, and social spheres that explains persistent health inequity. Assumed to be potentially deleterious to democratic integrity, the civil factionalism that occupied Madison in Federal Paper No . 10 can also be found in the public health economy. A competition among special interests groups is no less a threat to the common good and public health. In fact, we have theorized that this economy has not garnered a critical Madisonian appraisal and operates without adequate steering of public health economic activity toward greater gains in health equity. Our theory of public health realism posits six core beliefs about special interests groups in the public health economy. We define later a preliminary list of factions in the public health economy.
Human beings and the institutions within which they operate and represent are inherently egoistic and self-serving. Self-interest overcomes moral imperatives that require deep and sustained work to realize racial health equity.
The lack of common rule-making and an enforcing authority governing racial health inequity reproduction across economic, political, clinical, and social domains create conditions for each agent to be responsible for its own survival and to pursue power and resource accrual. The state of health inequity relies on an anarchy among agents within the public health economy.
The demands of the moral imperative and public health social contract to meaningfully address the social determinants of health and other structural factors such as racism directly compete with self-interest. Human suffering and vulnerability are often used instrumentally to achieve maximum benefits that flow to that agent or class of agents.
The holistic environment that constitutes all sources of health reproduction lacks universal values or interests. Self-interests lead to circular reasoning or self-justification. Purported appeals to universal interests and values are aligned with self-interests and the concomitant perceived or actual material benefits.
There is no order in the public health economy. Order is anarchy defined by power. This power is fundamentally driven by material goals and is undergirded by fierce competition. Morality arises from self-interest in the public health economy, not the other way around. As a general principle, accelerating racial health equity is not sought if “there’s no money in it.”
Dominant powers within the public health economy – these are its principal proponents and benefactors – seek to maintain their power position and hence promote their self-interests through direct or facilitated control of the public health economy. If there is internally - or externally-driven disruption to the public health economy (e.g. calls for redistributive justice and resources), then dominant powers seek to arrange for an efficient return whereby their dominance is preserved.
The public health economy is not just a struggle among agents or classes of agents for “pre-eminence and power” that can be diametrically opposed to accelerating health equity. It operates without a set of governing principles and a central authority. The legal and regulatory frameworks in this or that industry are not sufficient to establish that order exists broadly across the public health economy. It does not. The politicization and mainstream denialism of the Covid-19 pandemic are sufficient proof of that. The US officially surpassed one million deaths due to Covid-10 in May of this year, yet the public health economy is no closer to undergoing any fundamental shift in addressing chronic health disparities. These deaths could be viewed as a form of political violence resulting from clashes among classes of agents in the public health economy. On one side, there are health providers, hospitals, scientists, a large number of state legislatures, and an obliging public that follows masks, vaccine, and social distancing recommendations, although less so after the pandemic began to subside. On the other hand, denialism, anti-vaccine campaigns, and other rhetoric, backed by political and economic activities (e.g. forbidding local mask mandates, peddling false cures) were illustrative of anarchy in the public health economy and its tendency for control and violence. Madison warned about this violence in his first sentence in Federal No. 10, “its tendency to break and control the violence of faction,” though he meant “violence” as in direct physical harm. Public health realism and Madisonian factionalism provide a theoretical framework to explain persistent health inequity in the US. To our understanding, this is the first such theory.
Madison did not place full faith is any set of agents within the body politic, including statesmen like himself, “It is in vain to say that enlightened statesmen will be able to adjust these clashing interests, and render them all subservient to the public good. Enlightened statesmen will not always be at the helm.” However, he perceived the threat from below to be much greater than the threat from above - the common people posed a greater danger to the Union than statesmen. We are not persuaded. If Madison furthers universalism about human nature to form cliques, then the logic must extend throughout the whole. Madison had a tendency to engage in such nuisances, especially on the question of US slavery. He posited a diffusion theory that controlled the spread of factionalism through federalism, “A religious sect may degenerate into a political faction in a part of the Confederacy; but the variety of sects dispersed over the entire face of it must secure the national councils against any danger from that source.” At the time of his writing, he did not anticipate that factionalism would soon find a salient source from above. President John Adams signed into law the Alien and Sedition Acts in 1798, which curtailed fundamental freedoms in the US. Madison led efforts in Virginia to invalid these Acts. In other words, the universal principles of factions, parties, or special interest groups proved true.
2) Is the public health economy sufficiently regulated to safeguard public health and the common good?
The fragmented US healthcare system can trace its inability to secure universal healthcare and health equity to Federalist No. 10. Madison sought to resolve the political divide between the North and South and to secure ratification of the US Constitution through a delineation of federal and state powers, “The federal Constitution forms a happy combination in this respect; the great and aggregate interests being referred to the national, the local and particular to the State legislatures.” Later in 1791, Madison supported the Tenth Amendment which said, “The powers not delegated to the United States by the Constitution, nor prohibited by it to the States, are reserved to the States respectively, or to the people”. Of course, all of these contemporary issues on healthcare access, costs, and equity did not figure in 18th century deliberation, but it is important to understand Federalist No. 10 as laying the groundwork for persistent health inequity due to the limitations on the federal government. Again, we extend the logic of Madisonian views of universal factionalism and its tendency to co-opt political processes and to abuse majoritarian rule to oppress others “than to co-operate for their common good.” If the Union should be sufficiently safeguarded against factions, then it would reason that within states, as well as the public health economy, should be as well.
Yet, we find that neither public health theories nor practices sufficiently address anarchy within the public health economy. Individual and community health are driven by political, social, and economic factors that did not work in concert. Even in states that have expanded Medicaid, economic policies and vast inequality are likely to counteract some of the benefits of increased healthcare access and affordability. In Washington, DC, for example, there exists generous social welfare alongside major health disparities, especially by race. The nation’s capital is the most intensely gentrified city in the US in the 21st century and experiencing rapid economic growth. It is simultaneously the site of acute resident displacement, especially among African Americans and having some of the worst mortality rates and disparities among the most industrialized nations. Stark racial differences in life expectancy can be upwards of 16 years between Black and white men in poor and rich neighborhoods, respectively. It is the poor regulation of and anarchy within the public health economy that are to blame.
3) What are the “factions” in the public health economy?
This presents an incomplete list of “factions” within the public health economy. Some are more aligned with safeguarding common good while other pursue aggrandizing self-interested agenda. Even within classes of agents or factions, there are considerable differences. We leave it up to you to reflect on each “faction”.
Housing developers and owners who supply and maintain housing
Large commercial site developers
Small business owners
Water authorities
Housing authorities
Administrators of workforce development
Enforcers of housing codes and quality standards
Distributors of community health grants and support
Elected officials - local, state, and federal
Regulators - local, state, and federal
Health departments
Distributors of public and private health research funding
Gun manufacturers
Gun owners or someone who takes control over a gun
Hospitals
Health care providers
Academic public health
Non-profit sector
Political parties
Industrial polluters
Community advocacy groups
Informal and unorganized community groups
Certified independent health professions
Non-certified health professionals
City and state economic planners
Public-private business groups
Employers
Farmers and cattle ranchers
“Food product” manufacturers
4) What is the role of Public Health Liberation?
Public Health Liberation is a nascent public health transdiscipline that calls attention to the public health economy. For all that is accepted about the economic, political and social determinants of health, public health training and practice have yet to evolve a transdiscipline capable of centralizing cross-disciplinary expertise and community lived experiences under one tent. Health inequity is reproduced by the public health economy and must be the basis for theory-building, resource allocation, and intervention to keep the excesses of factionalism at bay. To our understanding, there is no single entity or discipline that is monitoring the public health economy as a whole or that seeks internal consistency throughout the system. While we assume as a matter of philosophical principle that there is “propensity of mankind to fall into mutual animosities” and become “more disposed to vex and oppress each other than to co-operate for their common good,” as Madison puts it, public health must seek a Madisonian perspective of “that relief is only to be sought in the means of controlling its effects.”
It starts with several basic principles and approaches. First, the public health economy must be acknowledged as a field of scientific inquiry and advancement. We should evolve public health to align with the complexity of the modern world to anticipate and respond to threats to community health. As we discuss at the end of the main story in our latest newsletter, the Flint water crisis could have been prevented if we had a more proactive public health discipline. The errant and damaging policies of municipal water authorities were known to be a major source of public health harm. See our article on “Before Flint, Washington, DC had Lead Crisis “20 to 30 Times Larger” in Early 2000s”.
Second, if we accept the competitive nature within the public health economy, then we must encourage liberation expression of affected populations and ally-ship to counterbalance the strength and solidarity of other classes of agents that may be adverse to the common good and who engage in structural violence. The state of public health is a perpetual struggle between factions or special interest groups. To intervene, we rely on a rich body of literature to support this approach. The notion of "human development" has deep philosophical roots. For example, Adam Smith, a prominent Scottish economist and philosopher, "It is not at all utopian or unrealistic to hope that continuous endeavour towards human development in the Smithian sense would make common people more and more conscious of their power. This is likely to exert increasing pressure on the State (especially, in a democratic framework) to abide by the laws of morality rather than the interests of the well-to-do class." (Ratan Lal Basu, 2007).
Emancipatory theory also informs investment in liberation, which recognizes the inherent resources, talents, and self-actualization of affected populations. Collective self-help and striving are necessary for an inclusive public health agenda. In our Health Equity Terms Dictionary, we discussed the Mary Church Terrell and the National Association of Colored Women, to establish the importance of intrinsic sources of applied health equity. In our recent newsletter, we discussed at length the Poor People’s Campaign - a grassroots movement among low-income communities across the US to push for economic and health justice.
Finally, public health has benefited from applied hegemonic theory at the expense of realizing health equity for all. It makes the existing order appear as extrinsic (beyond the control or ownership of any single agent or class of agents) or inevitable through coercion and consent that is reflective of Madisonian factionalism and public health realism. The theory of hegemonic rule relies on a false appearance of unity of interests between the elite and non-elite or striving classes. In fact, health inequity reproduction is sustained by human activity throughout the public health economy. The Poor People’s Campaign indirectly criticizes the hegemonizing effects on the public health agenda. Public Health Liberation seeks holism in pursuit of an inclusive public agenda by drawing attention to factionalism in the public health economy.
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