Individualism runs rampant in America. It is the belief that with will, spirit, and effort anyone can rise. This ideal is deeply intertwined with other ideas such as freedom, giving rise to a libertarian ethos that constantly clashes with government power. Libertarians believe that it is up to the individual to take responsibility for their choices. Centralists believe that it is up to the government to organize its citizens’ lives for the better. Structural interventions are tools of the central government to enforce a top-down policy. While it sounds like coercion, often the policies do have some political support and are enacted to improve the general welfare. Indeed structural interventions have the advantage over individual interventions in terms of a wider spread and a clear pathway to a specific goal. Examples of structural interventions can be found in both the Broad Street pump incident and the Prohibition. Unfortunately, the same factors that give structural interventions their strength are also their weakness.
Structural interventions require political will and, in the case of the US history, plays heavily to bipartisan politics. The original fight between libertarians and centralists in the US resulted in government bipartisanship. Federalists, led by Alexander Hamilton, argued for a strong central government with the goal of creating a national bank. Democratic-republicans, lead by Thomas Jefferson, argued for more states rights with the goal of making the US an agricultural economy. Ironically, it would later be the Republicans during the late 19th century Progressive Era that argued for more government involvement. These structural interventions reflected a shift towards more active government involvement in form of trust-busting, labor laws, and sanitation standards.[1] The movement’s success in improving living standards and working conditions highlights the success of structural interventions.
A specific goal provides a clear objective to aim for. In the case of Prohibition, the goal was to ban the production, transport, and sale of alcohol. This singular mission was one that Temperance Societies across the country could support and rally behind. Individual attempts to rehabilitate alcoholics through self-help, medical treatment, and abstinence often failed and the Temperance Societies looked to greater government regulation as the solution.[2] The ratification of the 18th Amendment was the rallying cry that enabled a broad base of supporters to contribute to the “dry” cause. With enough political support, the 18th Amendment was ratified on January 16, 1919, leading to the Prohibition Era.[3] While the era is widely remembered as one of the gangsters, shootouts, and speakeasies, new studies have shown that banning alcohol did succeed in lowering alcohol consumption and lowering liver-related deaths. Therefore, the structural intervention had met some of its goals in the sphere of public health where individual intervention had failed.
Another benefit of structural interventions is widespread reach they have over individual interventions. The famous Broad Street pump situation in London during the 1854 Cholera outbreak is a great example. When an outbreak of Cholera occurred in 1854 physician, John Snow proved through epidemiological study that cholera was being spread via water.[4] Removal of access to the contaminated water reduced incidence of the disease. Individual interventions, in this case, would have relied on physicians and professionals educating citizens not to drink the water or asking for people to avoid inhaling the toxic miasmas (the prevailing theory at the time was that cholera was spread by miasmas in the air). Both such methods would not have had the same rapid effect that structural interventions had of immediately removing the source of the outbreak.
Despite numerous benefits possible with structural interventions, there are also significant drawbacks to its top-down approach to fixing problems. One is that its highly centralized method of implementation often lacks feedback from those on the ground. A perfect example is the Sonagachi Project in India.[5] Prostitutes in the red light district were contracting HIV at a high rate due to their profession and socioeconomic status. The structural approach was to provide the workers with condoms to use, but their socioeconomic status often meant that the workers could not force their clients to use condoms. Leaders of the project were able to steer away from structural approaches and focus more on the complaints of the prostitutes allowing for greater success than previously expected. Second is these interventions often do not account for other possible detriments that may arise. Prohibition, while successful in limiting alcohol consumption, had a negative effect of increasing organized crime. Criminal elements created an underground black market for alcohol in speakeasies that produced moonshine or imported it through rumrunners. The highly profitable industry meant that competition was cutthroat and many criminal syndicates had wars increasing the homicide rate.
Structural interventions achieve success not by individual victories, but by sweeping victories through societal enforcement. The success of such interventions relies on political support and the potential rewards affect the population in a larger scale than individual interventions. However, structural approaches often ignore voices of those at the bottom in favor of specialists or figures of high authority. This often results in disastrous consequences when factors unaccounted for start causing significant harm.
[1] "Legacy of the Progressive Era." 2010, 103-12.
[2] “Did prohibition really work? Alcohol prohibition as a public health innovation” American Journal of Public Health vol. 96,2 (2006): 233-43.
[3] Hall, Wayne. "What Are the Policy Lessons of National Alcohol Prohibition in the United States, 1920-1933?(Report)." Addiction 105, no. 7 (2010): 1164-1173.
[4] "Snow, John." Britannica Online Academic Edition, 2018, Encyclopædia Britannica, Inc.
[5] Marni Sommer, and Richard G. Parker, Structural Approaches in Public Health (New York: Routledge, 2013) Chapter 5.
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