Public health views health through the lens of the overall population, the collective health, rather than in terms of the "privately held" health of society's individual members. Hence, public health is inextricably linked to the question of who comprises the population, the community, and the public. What is the nature of this group? Where are its borders? Which ages are included? Which races? Given the interdependence of humans and the ecosystem, the question must also be posed as to which species it extends.

The second question inherent in public health is "What is health"? As defined by the World Health Organization (WHO) in its 1978 Declaration of Alma-Ata, health is a "state of complete physical, mental, and social well-being, not merely the absence of disease or infirmity." The declaration called for the "attainment by all peoples of the world by the year 2000 of a level of health that will permit them to lead a socially and economically productive life," and affirmed health to be "a fundamental human right." Health as a human right was codified in Article 12 of the International Covenant on Economic, Social, and Cultural Rights, adopted by the United Nations General Assembly in 1966 and entered into force in 1978. Article 12 "recognize[s] the right of everyone to the enjoyment of the highest attainable standard of physical and mental health."

The articles within this special issue of Social Justice examine various aspects of how these two questions are being shaped in the wake of rapid economic transformation in a world where the use of military power to adjudicate disputes remains paramount. The profound danger posed to the health of the world community by the relentless momentum of capital accumulation is provocatively explored by John McMurtry in the lead article. McMurtry surveys the precipitous global decline in social well-being and relates it to the creation of a borderless, global financial field yielding unprecedented corporate profits -- a transformation of the world's capital flows into a mutated circuit of "money to more money." In his elaboration of the "social immune system and the cancer stage of capitalism," McMurtry documents that capital growth is increasingly unregulated and divorced from the production of goods and services necessary for the sustenance of the social body, i.e., the public health.

McMurtry's observation of the increasing tendency for profits to be severed from socially beneficial endeavors is borne out by Thomas Bodenheimer's analysis of the evolution of the U.S. health care system. Bodenheimer explains that in contrast to the past when health care profits were retained largely for improvements within the health care sector, with the rise of investor-owned, for-profit health institutions, profits are distributed to investors who are less likely to contribute to health care improvement and community services goals. Such for-profit health maintenance organizations, concerned only with the bottom line, are anticipated to constitute the majority of health care services by the year 2000.

Similarly, Barry Levy documents the dire implications of global economic transformation for environmental and occupational health. He likens these developments to a global embrace of a value system antithetical to public health, while substituting the concept of preventing morbidity and mortality with the battlefield concept of "acceptable losses." Levy's suggestions for turning the tide are compelling in that they proceed from the assumption of a globally defined public.

It is this expansive view of who constitutes the public that informs the models for social change presented by authors Emily Merideth and Garret Brown, and by Janet Gottschalk. In their case study of public health without borders, Merideth and Brown describe a growing cross-border solidarity movement composed of U.S. and Mexican unions, environmental organizations and social justice groups, public health professionals, researchers, and public policy centers, which shares a common goal of safer workplaces, cleaner communities, and just and sustainable development on both sides of the border. Gottschalk's article traces steps in "the long and difficult journey toward a world of equality, development, and peace" and describes the events leading up to and the outcome of the United Nation's Fourth World Conference on Women held in Beijing in 1995. Gottschalk's perspective echoes the theme of a world without borders in her question, "How can the world dream, or even talk, of peace without a clearer understanding of the limits of national sovereignty?"

Also integral to the construction of a less fragmented, more inclusive view of "the public" are efforts that increase citizen participation in scientific and technological decision making affecting public health. A consistent public health theme in the 1990s will be how to balance the often divergent perspectives of governments that are bound to be responsive to all of their citizens, affected communities, and scientists and other experts, to achieve equitable and just solutions that serve the interests of public health in its broadest manifestation. Whether the issue is curing AIDS, destroying chemical weapons stockpiles, or remediating environmental destruction arising out of a half century of nuclear weapons development, democratization of science through citizen participation in scientific and technological decision making is crucial to realizing this goal (see the contributions by Gilbert Elbaz, Velma Campbell and J. Ross Vincent, and Michael Veiluva, respectively).

However, the conditional and arduous nature of the calculus between government, citizen, and scientific participation in public health decision making -- essentially the contradictory and precarious nature of democracy -- also resonates within these case studies. The balance of forces suggested by these articles includes those between activist-driven science and the equally compelling need to create and preserve objective research methods, and between the rights of a community directly affected by environmental hazards and the rights of the larger population to realize a public health goal such as disarmament. The relative benefits of local, national, and international jurisdiction over public health choices are also examined.

Opportunities afforded by transcending the public health limitations of a "NIMBY" (not in my backyard) organizing strategy and the successes of activist participation in biomedical research are illustrated by these case studies. However, as Veiluva notes in reference to the current, more democratic inclusion of citizen "stakeholders" in Department of Energy's processes related to nuclear cleanup, "good process is not the equivalent of good results on the ground." Placing responsibility for cleanup of the nuclear weapons complex in the hands of the very agency that retains responsibility for maintaining and developing future nuclear weapons may represent an untenable conflict of priorities.

Department of Energy plans to spend ever more billions of dollars to construct and operate a system of new high-tech laboratory facilities to preserve its capacity to maintain, test, modify, design, and produce new nuclear weapons, with or without underground tests, are analyzed by Jacqueline Cabasso and Patrice Sutton. Having squandered more than four trillion dollars on nuclear weapons over the last 50 years, and with continuing expenditures of some $25 billion a year on nuclear forces, the U.S. commitment to these weapons is unceasing. The ongoing production and strategic deployment of nuclear weapons, by the U.S. and other nuclear powers, conflict with their obligation under Article VI of the Nuclear Non-Proliferation Treaty to work toward disarmament. Mexican Ambassador Miguel Marin-Bosch has noted that this apparent unwillingness of the nuclear powers to give up nuclear weapons in the foreseeable future does not bode well for efforts to halt the global spread of nuclear weapons.

The public health effects posed by the persistence of a global commitment to weapons and violence in conducting international relations -- militarism -- are presented in contributions by Jody Williams and by Victor W. Sidel and Robert Wesley, Jr. By forcefully splintering the worldwide social fabric and directly and indirectly forestalling the achievement of universal social and economic well-being, militarism is dually destructive of the "public" and "health." These authors vividly demonstrate in their respective articles the legacy of militarism's deleterious effects on global health in all of its dimensions -- the direct killing and maiming resulting from weapons use, the environmental havoc caused by production and detonation of weapons of mass destruction, including landmines, and the social and economic dislocations and disparities in the wake of warfare and drained budgets that in turn fuel new cycles of violence. Drs. Sidel and Wesley link such patterns of global violence to the experience of U.S. communities consumed by gun violence and devastated by draconian budget cuts.

One can only expect accelerated deterioration of U.S. health and social indicators with austerity-driven block grants. By terminating federally mandated entitlement programs that grow according to the size of the population in need, during times of increasing impoverishment, families and individuals could no longer depend on block grants to provide safety-net programs and services. Block grants will also lead to heightened competition for scarce resources; programs with weaker constituencies, such as the poor, or that challenge well-organized political groups, such as sexually explicit AIDS prevention campaigns, are expected to lose out. However, unconstrained by the lack of a Cold War cloak, there has now been wrought an extraordinary consensus of Republicans and Democrats on balancing the budget without reducing military expenditures. Current U.S. military expenditures, discounted for inflation, are higher than they were at the peak of the Cold War in 1980, with no serious debate between the Clinton administration and the Republican Congress over how much to spend over the next five years. The multitrillion dollar expenditures to date have left the U.S. with a crumbling health and social infrastructure at odds with any reasonable "national security."

Taken together, the articles in this issue of Social Justice suggest the need for public health activism that is informed by a globally defined and mobilized public. Absent such activism, given the implications of the unregulated, "cancer stage of capitalism" posited at the beginning of this issue, coupled with the dogged devotion to nuclear and conventional weapons noted in later contributions, one can anticipate a dark shadow to be cast over public health in the 1990s and thereafter.