The circular structure of policy failure and learning. Danish and American public health policy 1975-2005

The literature on policy learning has focused our attention on how governments ’puzzle’ over society’s great problems and foster solutions based on the experience of previous policy as well as new knowledge and ideas. While policy learning is often seen as a linear process, this article aims to show how the learning process can also be circular in the sense that the previous policy from which a given new policy departs is constructed over and over again, which should not be confused with actual past policy. The argument is backed by a comparative policy analysis of lifestyle-focused public health policy in Denmark and the United States over the past three decades. While downplaying their belief in traditional medical treatment technology, most Western nations shifted their health policy objectives in the mid-1970s in order to get into what one report termed ’the business of modifying behaviour’, i.e. to counter lifestyle diseases by getting citizens to exercise more, but eat, drink, and smoke less. Based on a study of three decades of Danish and American public health programs, the article shows how two very different health care systems experienced a similar pattern of policy failure. While both systems continually experience that citizens fail to live by what they know is healthy, public health policies always seem to able to generate strong optimism for each new policy program, because the values responsible for policy failure are associated with the medical treatment paradigm that the policies depart from, but never with prevention itself.