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The Contingent Power of Experts: Public Health Policy in the United States, Britain, and France

Published online by Cambridge University Press:  27 April 2009

Constance A. Nathanson
Affiliation:
Mailman School of Public Health Columbia University

Extract

Dangers to life and health abound. Even among the subset known to medicine and science, however, there is no guarantee that any particular danger will rise to the level of a recognized public health problem or elicit a response from the makers of public policy. The path from knowledge to policy is not straightforward; scientific consensus does not lead automatically to policy consensus. Judgments of what dangers should be most feared, how to explain them, what to do about them, and even whether they are public health problems at all are the outcome of social processes. A couple of examples may help to clarify these points.

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Copyright © The Pennsylvania State University, University Park, PA. 2007

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References

1. In my approach to this analysis I draw on three theoretical traditions, that of the symbolic interactionists, Herbert Blumer, Joseph Gusfield, and others who have written about the construction of public problems: Blumer, Herbert, “Social Problems as Collective Behavior,” Social Problems 18 (1971): 298307Google Scholar; Gusfield, Joseph R., The Culture of Public Problems: Drinking-Driving and the Symbolic Order (Chicago, 1981)Google Scholar; Conrad, Peter and Schneider, Joseph W., eds., Deviance and Medicalization: From Badness to Sickness (St. Louis, 1980)Google Scholar; social movement scholars' elaboration of framing processes: Snow, David A., Rochford, E. Burke Jr., Worden, Steven K., and Benford, Robert D., “Frame Alignment Process, Micromobilization, and Movement Participation,” American Sociological Review 51 (1986): 464481Google Scholar; McAdam, Doug, “Culture and Social Movements,” in Larana, E., Johnston, H., and Gusfield, J. R., eds., New Social Movements (Philadelphia, 1994), 3657Google Scholar; Tarrow, Sidney, Power in Movement: Social Movements and Contentious Politics, 2d ed. (Cambridge, 1998)Google Scholar; and the work of Mary Douglas and her colleagues and students, who have studied the impact of political cultures on constructions of risks to the environment: Douglas, Mary and Wildavsky, Aaron, Risk and Culture: An Essay on the Selection of Technological and Environmental Dangers (Berkeley and Los Angeles, 1982)Google Scholar; Douglas, Mary, Risk and Blame: Essays in Cultural Theory (London, 1992)Google Scholar; Thompson, Michael, “Postscript: A Cultural Basis for Comparison,” in Risk Analysis and Decision Processes: The Siting of Liquified Energy Gas Facilities in Four Countries, ed. Kunreuther, Howard C. and Linerooth, Joanne, 232262 (Berlin, 1983)Google Scholar; Wynne, Brian, Risk Management and Hazardous Waste: Implementation and the Dialectics of Credibility (Berlin, 1987)Google Scholar. The recent work of Karen Litfin on the science and politics of global environmental risks has been particularly valuable: Litfin, Karen T., Ozone Discourses: Science and Politics in Global Environmental Cooperation (New York, 1994)Google Scholar.

2. Haas, Francois and Haas, Sheila Sperber, “The Origins of Mycobacterium Tuberculosis and the Notion of Its Contagiousness,” in Garay, William N. and Rom, Stuart M., eds., Tuberculosis (Boston, 1996), 319Google ScholarPubMed.

3. Guillaume, Pierre, Du Désespoir Au Salut: Les Tuberculeux Aux 19e et 20e Siécles (Paris, 1986)Google Scholar. Villemin's conclusion that tuberculosis was contagious was rejected first in 1865, as I have stated, and again in 1889 (post Koch). Mandatory notification of tuberculosis cases to public health authorities was rejected by the Academy in 1902 and again in 1913. In 1919 mandatory notification was proposed by Premier Georges Clemenceau and was rejected by the National Assembly.

4. Pidoux, Hermann (1867), cited in David S. Barnes, The Making of a Social Disease: Tuberculosis in Nineteenth-Century France (Berkeley and Los Angeles, 1995), 46Google Scholar.

5. Nowhere (among the four countries I have studied) was mandatory notification uncontested. Nevertheless, New York City implemented notification in 1897 and within ten years eighty-four U.S. cities had followed suit. Notification became law in Britain in 1913.

6. Litfin, Ozone Discourses.

7. Intergovernmental Panel on Climate Change (1990), cited in ibid., 193 and 191.

8. The Constance Nathanson, A., Disease Prevention as Social Change: The State, Society, and Public Health in the U.S., France, Great Britain, and Canada (New York, 2007)Google Scholar.

9. Senator James Inhofe of Oklahoma has gone so far as to claim that “there is scientific evidence that global warming is a ‘hoax.’” Cited in Silver, Howard J., “Science and Politics: The Uneasy Relationship,” Open Spaces Quarterly 8, no. 1 (2005)Google Scholar.

10. I have borrowed the useful concept of “knowledge brokers” from Karen Litfin. Knowledge brokers are “intermediaries between the original researchers, or the producers of knowledge, and the policymakers who consume that knowledge but lack the time andtraining necessary to absorb the original research” (Ozone Discourses, 4). Knowledge brokers usually represent state or nonstate agencies or organizations with interests at stake in the matter at hand: civil servants, lobbyists, and activists of various stripes.

11. These case studies are based on detailed interviews with participants in the policy process in each country, on extensive archival research in primary sources, and on the large volume of secondary literature on smoking and HIV/AIDS policies.

12. Royal College of Physicians of London, “Smoking and Health” (London, 1962)Google Scholar; U.S. Department of Health, Education, and Welfare, “Smoking and Health: Report of the Advisory Committee to the Surgeon General of the Public Health Service,” Public Health Service publication no. 1103 (Washington, D.C., 1964)Google Scholar.

13. Brandt comments on the social and cultural meanings attached to the different labels for other people's smoking: “‘passive smoking’ contrasted with active smoking; ‘secondhand smoke’ contained the ominous implication that someone else had used it first; involuntary smoking indicated that the practice of smoking was indeed a voluntary act.” “Environmental tobacco smoke,” or ETS, identifies tobacco smoke as an environmental hazard and, I would add, lends to it the aura of medicine and science attached to other acronyms like STD or DNA. Brandt, Allan M., “Blow Some My Way: Passive Smoking, Risk, and American Culture,” in Lock, S., Reynolds, L. A., and Tansy, E. M., eds., Ashes to Ashes: the History of Smoking and Health (Amsterdam, 1998), 164180Google Scholar.

14. Royal College of Physicians of London, “Smoking and Health,” S6–7.

15. National Research Council, Environmental Tobacco Smoke: Measuring Exposures and Assessing Health Effects (Washington, D.C., 1986)Google ScholarPubMed; U.S. Department of Health and Human Services, “The Health Consequences of Involuntary Smoking: A Report of the Surgeon General,” DHHS publication no. (CDC) 87–8398. U.S. Department of Health and Human Services, Public Health Service, Centers for Disease Control, Center for Health Promotion and Education, Office on Smoking and Health (Rockville, Md., 1986).

16. Berridge, Virginia, “Passive Smoking and Its Pre-History in Britain: Policy Speaks to Science?Social Science and Medicine 49 (1999): 11831195CrossRefGoogle Scholar. The “Frogatt report” was the fourth report of the Independent Committee on Smoking and Health, a committee of “scientists and public health interests” appointed in 1973 by then Secretary of State for Health and Social Services, Sir Keith Joseph (ibid., 1187).

17. Tubiana, Maurice, “Tabagisme Passif: Rapport et Voeu de L'Académie Nationale de Médicine,” Bulletin de L'Académie Nationale de Médicine 181, no. 4 (1997): 343Google Scholar.

18. See, for example, Kluger, Richard, Ashes to Ashes: America's Hundred-Year Cigarette War, the Public Health, and the Unabashed Triumph of Philip Morris (New York, 1996)Google Scholar. Scientific controversy over the health effects of passive smoking continues to this day. In what was clearly intended as a definitive blow to the credibility of skeptics, Barnes and Bero stated that “the only factor associated with concluding that passive smoking is not harmful was whether an author was affiliated with the tobacco industry.” Barnes, D. E. and Bero, L., “Why Review Articles on the Health Effects of Passive Smoking Reach Different Conclusions,” Journal of the American Medical Association 279, no. 19 (1998): 15661570Google Scholar; 1566. An updated Surgeon General's report on The Health Consequences of Involuntary Exposure to Tobacco Smoke reviews evidence published since 1986 (when the first such report came out) and concludes that “secondhand smoke is a major cause of disease, including lung cancer and coronary heart disease, in healthy nonsmokers” (U.S. Department of Health and Human Services. The Health Consequences of Involuntary Exposure to Tobacco Smoke: A Report to the Surgeon General. Atlanta: U.S. Department of Health and Human Service, Centers for Disease Control and Prevention, Coordinating Center for Health Promotion, National Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health, 2006, i).

19. U.S. Department of Health and Human Services, “Reducing the Health Consequences of Smoking: Twenty-Five Years of Progress. A Report of the Surgeon General,” U.S. Department of Health and Human Services publication no. (CDC) 89–8411 (Rockville, Md., 1989), 189Google Scholar.

20. Steinfeld, Jesse L., “Women and Children Last? Attitudes Toward Cigarette Smoking and Nonsmokers' Rights, 1971,” New York State Journal of Medicine 83, no. 13 (1983): 12571258; 1258Google ScholarPubMed.

21. Unless otherwise noted, all the narrative accounts that follow are drawn from my own research. See, for example, Social Movements as Catalysts for Policy Change: The Case of Smoking and Guns,” Journal of Health Politics, Policy and Law 24, no. 3 (1999)Google ScholarPubMed.

22. The Ventilator (1971), 1.

23. The concept of “organizational field,” meaning“those organizations that, in the aggregate, constitute a recognized area of institutional life,” was introduced by DiMaggio and Powell in 1983: DiMaggio, Paul J. and Powell, Walter W., “The Iron Cage Revisited: Institutional Isomorphism and Collective Rationality in Organizational Fields,” American Sociological Review 48 (04 1983): 148CrossRefGoogle Scholar.

24. Clara Gouin, “Nonsmokers and Social Action,”Proceedings of the ACS/NCI Conference (DHEW publication no.[NIH] 77–1413), 353–56(Washington, D.C.,1977), 355Google Scholar.

25. Hanauer, P., Barr, G., and Glantz, S., Legislative Approaches to a Smoke-Free Society (Berkeley and Los Angeles, 1986)Google Scholar.

26. Warner, Kenneth E., “Cigarette Smoking in the 1970s: The Impact of the Antismoking Campaign,” Science 211, no. 4483 (1981): 729731CrossRefGoogle Scholar.

27. Ibid., 730.

28. Slade, J., Glantz, S. A., Barnes, D. E., Bero, L., and Hanauer, P., “Nicotine and Addiction: The Brown and Williamson Documents,” Journal of the American Medical Association 274, no. 3 (1995): 225233CrossRefGoogle Scholar.

29. It is unclear to what extent the smoker-drug addict linkage is accepted by the general public. It is pervasive in public health circles, however, as evidenced by a marked increase over the past decade in the number of articles in the American Journal of Public Health associating tobacco with alcohol and drugs, by the naming of an APHA section “Alcohol, tobacco, and other drugs,” and by foundation requests for funding applications that link tobacco with narcotic drugs. It is equally popular in legal arguments against the tobacco industry (e.g., Brief for the State of Maryland at 52, State of Maryland v. Philip Morris et al.) and in antismoking messages focused on the industry's alleged targeting of children.

30. Koop, C. Everett, Preface to “Reducing the Health Consequences of Smoking: Twenty-Five Years of Progress. A Report of the Surgeon General,” U.S. Department of Health and Human Services. U.S. Department of Health and Human Services publication no. (CDC) 89–8411 (Rockville, Md., 1989), vGoogle Scholar.

31. British official publications refer to “passive smoking,” the French to “tabagisme passif.” Neither countries' publications use a label comparable to the scientific and somewhat more fearsome-sounding “ETS.”

32. Roy Porter, “Concluding Remarks,” in Ashes to Ashes, ed. S. Lock, L. A. Reynolds, and E. M. Tansey, 221–28; David Simpson, “ASH: Witness on Smoking,” in Ashes to Ashes, ed. S. Lock, L. A. Reynolds, and E. M. Tansey, 208–12.

33. The British aversion to the issue of passive smoking is well illustrated by the fact that in 1985 at the annual meeting of the British Medical Association a motion calling for a Tobacco Act to ban all advertising and sponsorship passed by “a massive majority,” while a motion to ban smoking on National Health Service property failed by 20 votes out of 194 on the grounds that such a ban would be cruel to smokers in mental hospitals. British Medical Association, Smoking Out the Barons: The Campaign Against the Tobacco Industry (Chichester, 1986), 69Google Scholar.

34. Berridge, “Passive Smoking and Its Pre-History in Britain,”1190. On Valentine's Day 2006, Parliament voted 453 to 125 in favor of a total ban on smoking inside “virtually every enclosed public place and workplace” throughout England. Michael White, “MPs Vote to Stub Out Smoking in Public,” The Guardian, 24 February 2006, 13. Despite similarities in the discourse around passive smoking, there were striking differences in British as compared to U.S. policy approaches. For example, consistent with the British aversion to legislative regulation, until the newly instituted ban (which will not come into force until the summer of 2007), nonsmoking policies tended to be issued in the form of suggested“guidelines.” Furthermore, there was relatively greater emphasis on smoking in the workplace than in spaces open to the public, on the ground that presence in public venues was a matter of choice, whereas presence in the workplace was not. Indoor Pollution; Restricting Smoking,” British Medical Journal 303 (1991): 669670Google Scholar.

35. Note that the “liberty” issue here is not that of nonsmokers to breathe clean air but of smokers to smoke. Nonsmokers are not a significant force in their own right in France. The conflict is not defined as smokers vs. nonsmokers (indeed this is an antagonism that the government and most antitobacco advocates are very concerned to avoid), but the government's responsibility to protect potential victims of involuntary smoking vs. the liberty of smokers.

36. The first paper on the harmful effects of passive smoking generally recognized as being scientifically “authoritative” appeared in the British Medical Journal in 1981. Hirayama, T., “Non-Smoking Wives of Heavy Smokers Have a Higher Risk of Lung Cancer: A Study From Japan,” British Medical Journal 282 (1981): 183185CrossRefGoogle ScholarPubMed.

37. Virginia Berridge, “Science and Policy: The Case of Postwar British Smoking Policy,” in S. Lock, L. A. Reynolds, and E. M. Tansey, eds., Ashes to Ashes, 157.

38. In principle, the incidence of HIV infection would better measure the progress of the epidemic. However, HIV reporting has been highly controversial and has only recently begun to be implemented on any scale. In none of these three countries are reports of HIV infection sufficiently complete or reliable over time to make them useful measures for comparative purposes.

39. Normand, Jacques, Vlahov, David, and Moses, Lincoln E., Preventing HIV Transmission: The Role of Sterile Needles and Bleach (Washington, D.C., 1995)Google Scholar.

40. As early as 1986 an elite committee of the National Academy of Sciences, in its first report on the AIDS epidemic, urged the expansion of drug treatment and “experimenting with removing legal barriers to the sale and possession of sterile, disposable needles and syringes.” Institute of Medicine/National Academy of Sciences, Confronting AIDS: Directions for Public Health, Health Care, and Research (Washington, D.C., 1986)Google ScholarPubMed.

41. Among the consequences of this construction are, first, to assign primary responsibility for HIV/AIDS in injection drug users to large and bureaucratically powerful drug enforcement and drug treatment bureaucracies. The latter are unsympathetic to any program that assigns priority to disease prevention over the treatment of drug dependence. Second, and not unrelated, designation of HIV/AIDS in injection drug users as a moral issue renders expert “knowledge” irrelevant. Morality policies, as Meier points out, “permit little role for expertise; information that challenges the position of one party or another is often ignored.” Meier, Kenneth J., The Politics of Sin: Drugs, Alcohol, and Public Policy (Armonk, N.Y., 1994)Google Scholar, 4. Federal discountenancing of needle exchange and methadone maintenance has not prevented a range of local initiatives, particularly in the large urban areas most affected by HIV/AIDS.

42. Scottish Home and Health Department, “HIV Infection in Scotland: Report of the Scottish Committee on HIV Infection and Intravenous Drug Misuse,” Scottish Home and Health Department (Edinburgh, 1986)Google Scholar.

43. Ibid., 4.

44. U.K. Department of Health and Social Security, “AIDS and Drug Misuse: Report by the Advisory Council on the Misuse of Drugs” (London, 1988), 1Google ScholarPubMed.

45. Ibid., 2. “Prescribing” in this context refers to the medical prescription of narcotic drugs, primarily-although not limited to-oral methadone.

46. Stimson, Gerry V., “AIDS and Injecting Drug Use in the United Kingdom, 1987–1993: The Policy Response and the Prevention of the Epidemic,” Social Science and Medicine 41, no. 5 (1995): 699716CrossRefGoogle ScholarPubMed; 704. “Pilot” is in quotes because this designation was intended to take the heat off arguments against syringe exchange. “We knew they really weren't,” commented a civil servant intimately involved with this activity at the time. Exchange of sterile for used needles and syringes is labeled “syringe-exchange” in Britain. In the United States, “needle” and “syringe” exchange are used interchangeably.

47. Parsons, J., Hickman, M., Turnball, P., McSweeney, T., Stimson, G. V., Judd, A., and Roberts, K., “Over a Decade of Syringe Exchange: Results from 1997 UK Survey,” Addiction 97, no. 7 (2002): 845850CrossRefGoogle Scholar; 845. Syringe-exchange programs were a major policy innovation. To complete the picture of HIV-prevention facilities available to injection-drug users in Britain, it is important to point out that there are no legal barriers either to over-the-counter sales of syringes or to the prescription of oral or injectable methadone.

48. MacGregor, Susanne, “The Public Debate in the 1980s,” in MacGregor, Susanne, ed., Drugs and British Society (London, 1989)Google Scholar.

49. Street, John and Weale, Albert, “Britain: Policy-Making in a Hermetically Sealed System,” in Kirp, David L. and Bayer, Ronald, eds., AIDS in the Industrialized Democracies: Passions, Politics, and Policies (New Brunswick, N.J., 1992), 185220Google Scholar.

50. Stimson, Gerry V. and Lart, Rachel, “The Relationship Between the State and Local Practice in the Development of National Policy on Drugs Between 1920 and 1990,” in Strang, J., and Gossop, M., eds., Heroin Addiction and Drug Policy: The British System (Oxford, 1994), 331341Google Scholar.

51. “Ultimately,” Berridge observes, “both the tabloid press and public opinion had no effect on policy.” Berridge, Virginia, “AIDS, the Media and Health Policy,” Health Education Journal 50, no. 4 (1991): 184CrossRefGoogle Scholar.

52. My account of French drug treatment professionals' ideology and its implications for their confrontation with AIDS is based on published sources and on my interviews with several of the actors involved. Published sources include: Coppel, Anne, “Les Intervenants en Toxicomanie, le Sida et la Réduction des Risques en France,” in Vivre avec les Drogues (Paris, 1996), 75108Google Scholar; Ehrenberg, Alain, L'Individu Incertain (Paris, 1995)Google Scholar; Henrion, Roger, Rapport de la Comission de Réflexion sur la Drogue et la Toxicomanie (Paris, 1995)Google Scholar; Malet, Emile, ed., Santé Publique et Libertés Individuelles (Paris, 1993)Google Scholar.

53. It may be worth noting that the job of public health authorities is made easier when disease prevention and drug-use prevention are synonymous, as in the case of tobacco smoking. “Safe” drug use is a harder sell.

54. French drug treatment specialists had a particular horror of what they saw as “American-style” methadone maintenance programs, requiring daily visits for medication and monitoring of patients' urine to ensure compliance. It is striking that these specialists found it far easier to accept syringe exchange-which they saw as an autonomous act by the drug user-than methadone maintenance, which (in their eyes) implicated the physician in the user's actions. At least one prominent drug-treatment specialist suggested that it might be preferable to sell methadone like cigarettes than for it to be prescribed.

55. The quote is from my interview with a longtime civil servant in the drug policy arena.

56. The point was frequently called to my attention that two figures who played a major role in shifting France's drugs policies in response to HIV/AIDS, Michelle Barzach and Simone Veil, were both on the Right.

57. Among many examples of and reflections on this ideological perspective, see the compilation of articles and brief statements from a symposium titled Santé publique et libertés individuelles and a lengthy interview with Claude Got that appeared in Le Monde on 17 June 1992.

58. Steffen, Monika, “France: Social Solidarity and Scientific Expertise,” in Kirp, David L. and Bayer, Ronald, eds., AIDS in the Industrialized Democracies: Passions, Politics, and Policies (New Brunswick, N.J., 1992), 221251Google Scholar; Morelle, Aquilino, La Défaite de la Santé Publique (Paris, 1996)Google Scholar.

59. Mary Douglas, Risk and Blame, 32.

60. Jasanoff, Sheila, “American Exceptionalism and the Political Acknowledgment of Risk,” Daedalus (Fall 1990): 6181; 76Google Scholar.

61. Brint, Stephen G., In an Age of Experts: The Changing Role of Professionals in Politics and Public Life (Princeton, 1994), 200Google Scholar.

62. Brian Wynne, Risk Management and Hazardous Waste, 421.

63. Decisions to appoint a committee of the “great and the good” and the choice of committee members are not, of course, made in a political vacuum, nor are the deliberations and decisions of these committees apolitical. For an excellent account of their use to suppress and distort “knowledge” in the case of mad cow disease, see: Miller, David., “Risk, Science and Policy: Definitional Struggles, Information Management, the Media and BSE,” Social Science and Medicine 49 (1999): 12391255CrossRefGoogle ScholarPubMed.

64. Brint, In an Age of Experts, 195.

65. Suleiman, Ezra N., Elites in French Society: The Politics of Survival (Princeton, 1978), 4Google Scholar.

66. Lamont, Michèle, Money, Morals, and Manners: The Culture of the French and American Upper-Middle Class (Chicago, 1992)CrossRefGoogle Scholar.

67. Jobert, Bruno, “Mobilisation Politique et Système de Santé en France,” in Les Politiques de Santé en France et en Allemagne, ed. Jobert, Bruno and Steffen, Monika, 7381 (Paris, 1994)Google Scholar.

68. See, for example, Feldman, Eric A. and Bayer, Ronald, eds., Blood Feuds: AIDS, Blood, and the Politics of Medical Disaster (New York, 1999)Google Scholar.

69. Litfin, Ozone Discourses, 37.

70. It is a measure of the tobacco-control movement's success in the United States that, at least in recent years, the tobacco industry has largely disappeared from the media as a credible source on questions of smoking and health.

71. Nathanson, Constance A., “Disease Prevention as Social Change: Toward a Theory of Public Health,” Population and Development Review 22, no. 4 (1996): 609637Google Scholar; Social Movements as Catalysts for Policy Change: The Case of Smoking and Guns,” Journal of Health Politics, Policy and Law 24, no. 3 (1999)Google Scholar.

72. One of many paradoxes in a comparison between American society's current constructions of nicotine and heroin as addictive drugs is the relatively benign connotation of “addiction” in the former as compared to the latter case.

73. This difference in the importance of “innocent victim” rhetoric is strikingly reflected in American and French legal briefs against the tobacco industry. A major reason for plaintiffs' failure to recover in U.S. tobacco litigation until very recently was that individuals who became sick from smoking were regarded as responsible for their own fate. Claimants simply did “not qualify as ‘deserving’ victims.” Kagan, Robert A. and Vogel, David, “The Politics of Smoking Regulation: Canada, France, the United States,” Smoking Policy: Law, Politics, and Culture, ed. Rabin, Robert L. and Sugarman, Stephen D., 22–48 (New York, 1994), 126Google Scholar. Given this history, plaintiffs' tobacco litigation experts were understandably concerned that individuals bringing suit be portrayable, and be portrayed, as “innocent” of responsibility for their claimed injuries. Daynard, Richard A., “Catastrophe Theory and Tobacco Litigation,” Tobacco Control 3 (1994): 62Google Scholar. In France, the state, through its official organs, determined that smoking was a danger to the public's health. The guilt or innocence of smoking victims was simply not a legally cognizable issue. More generally, “fault” has a relatively attenuated role in the French equivalent of tort law but is central to legal determinations of guilt or innocence in the United States.

74. The New School, “Science & Politics.” Web page, February 2006 [accessed 10 March 2006]. Available at http://www.socres.org/polsci; see also Silver, Howard J., “Science and Politics: The Uneasy Relationship,” Open Spaces Quarterly 8, no. 1 (2005)Google Scholar.

75. Silver, “Science and Politics” (n.p.). Silver has been the executive director of COSSA (Consortium of Social Science Associations), the principal lobbying group for social science, since 1988.

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