Through the 1980s and early 1990s, the course of American health research was increasingly shaped by politically-aggressive activism for two particular diseases, breast cancer and AIDS (Acquired Immunodeficiency Syndrome). Even as national stakes rose, both in dollars spent and growing demands on the medical system, breast cancer and AIDS advocates made government policy-making for research ever more public and controversial. Through skillful cultivation of political strength, interest groups transformed individual health problems into collective demands, winning notable policy influence in federal agencies such as the National Institutes of Health (NIH) and Food and Drug Administration (FDA). Activists directly challenged fundamental principles of both government and medical systems, fighting to affect distribution of research funds and questioning well-established scientific methods and professional values. In the contest for decision-making power, those players achieved remarkable success in influencing and infiltrating (some critics said, undermining) both the politics and science of medical research. Between 1990 and 1995, federal appropriations for breast cancer study rose from $90 million to $465 million, while in that same period, NIH AIDS research rose from $743.53 million to $1,338 billion.

In 1977, the United States Congress forbade the Food and Drug Administration to outlaw use of the food additive saccharin as an artificial sweetener for a period of three years. Subsequent legislation extended the congressional ban. It remains in effect today. Congress's saccharin action neatly represented late twentieth-century federal regulatory policy. The process had become decidedly antibureaucratic and ultimately democratic. Forces both for saccharin's prohibition and for its continued use outlined and debated their positions in public, letting their arguments contend in the marketplace of ideas. Following the conduct of this de facto national plebiscite, duly elected representatives weighed the respective cases and selected the course that their constituents seemed to favor.

In mid-nineteenth century America the asylum became the foundation of public policy. This ubiquitous institution was regarded as a symbol of an enlightened and progressive nation that no longer ignored or mistreated its severely and chronically mentally ill citizens. The faith in an institutional policy was embodied in a vast and costly system of state mental hospitals that by 1940 had an inpatient population of about 450,000. Despite the presence of serious problems, there was little disposition to call into doubt the wisdom of institutional care and treatment. Even though mental health policy was formulated within a decentralized and divided political system, there was no doubt that a holistic and clear consensus prevailed.

In the summer of 1989, an extended strike by the various “Baby Bell” telephone companies, including those of New York, Massachusetts, California, and thirteen other states in the Northeast, Midwest, and West Coast, brought to public attention the importance of health and hospital insurance to the nation's workers. In what the Los Angeles Times headline proclaimed was a “Phone Strike Centered on the Issue of Health Care,” workers at NYNEX, Pacific Bell, and Bell Atlantic went out on strike over management's insistence that the unions pay a greater portion of their hospital insurance premiums. In contrast to their willingness to grant wage concessions throughout most of the 1980s, the unions and their membership struck to protect what was once considered a “fringe” benefit of union membership. What had been a trivial cost to companies in the 1940s and 1950s had risen to 7.9 percent of payroll in 1984 and 13.6 percent by 1989. Unable to control the industry that had formed around hospitals, doctors, drug companies, and insurance, portions of the labor movement redefined its central mission: the fringes of the previous forty years were now central concerns. In the words of one local president engaged in the bitter communication workers strike: “‘It took us 40 years of collective bargaining’ to reach a contract in which the employer contributed [substantially to] the costs of health care, ‘and now they want to go in one fell swoop backward.’”

Sheldon Reed coined the expression “genetic counseling” in 1947, the same year he succeeded Clarence P. Oliver as Director of the University of Minnesota's Dight Institute for Human Genetics. In reflections written more than a quarter-century later, Reed noted that the term had occurred to him “as a kind of genetic social work without eugenic connotations.” Sharply distinguishing the aims of eugenics and counseling, he explained that whereas the former promotes the interests of the larger society, the latter serves the interests of individual families—as families perceive them. Reed never denied that he or other postwar medical geneticists were concerned with population improvement. But he maintained that counseling served a different purpose. Commenting on the history of the Dight Institute, Reed asserted: “There were certainly no attempts to benefit society as a whole in dealing with these families. This was not thought of as a program of eugenics.”

Quackery forms a gaudy thread in the fabric of health care through the course of American history. In the colonial years, the American market for commercial self-dosage was dominated by “patent medicines”—some of them actually patented—shipped overseas from the mother country. Packed in containers of distinctive shape, sealed in wrappers printed with boastful therapeutic claims, advertised in the slender newborn press, these British nostrums far overshadowed occasional American imitators.

By the middle 1990s the recovery movement for personal self-esteem and, thus, mental health for the individual, had reached a new level of penetration into American culture. Many commentators and interpreters of contemporary affairs judged the President of the United States, Bill Clinton, a potential recruit. As the archetypical adult child of an alcoholic parent—the product of a dysfunctional family if there ever was one, according to the movement's clerics-Clinton seemed lacking in selfesteem. His painful childhood was the culprit. And recovery was the solution. In a word, he was too anxious to please his critics—the classic trademark of the adult child of an alcoholic parent. Contemporary therapists taught that such persons were placaters of their critics because of the emotional abuse that their parents had inflicted on them, often for no apparent reason. The damaged child, regardless of his or her chronological age, could not, without appropriate therapy and personal “recovery,” ever get over such incidents, which were seared into their psychological and neurophysiological apparatus.