The Tyranny of Public Health
Last year, when the tobacco companies said they would no longer cooperate with the effort to pass a federal anti-smoking bill, the Clinton administration said it didn't really matter. "We will get bipartisan legislation this year," Secretary of Health and Human Services Donna Shalala told NBC. "There's no question about it, because it's about public health."(1)
As it turned out, Shalala was a bit overconfident. But her prediction was certainly plausible, given the way politicians usually behave when the term public health is bandied about. The incantation of that phrase is supposed to preempt all questions and erase all doubts. It tells us to turn off our brains and trust experts like Shalala to think for us.
Given that expectation, it may seem rude to ask why, exactly, smoking is a matter of "public health." It's certainly a matter of private health, since it tends to shorten one's life. But lung cancer, heart disease, and emphysema are not contagious, and smoking itself is a pattern of behavior, not an illness. It is something that people choose to do, not something that happens to them against their will.
If smoking is a matter of "public health," and therefore subject to government control, then so is any behavior that might lead to disease or injury. And in fact, public health officials nowadays target a wide range of risky habits, including not just smoking but drinking, overeating, failing to exercise, owning a gun, and riding a bicycle without a helmet. Even gambling, which has no obvious connection to morbidity and mortality, is a matter of interest to public health researchers.(2)
In short, there is no end to the interventions that could be justified in the name of public health, as that concept is currently understood. Although this sweeping approach is a relatively recent development, we can find intimations of it in the public health rhetoric of the 19th century. In the introduction to the first major American book on public health, U.S. Army surgeon John S. Billings explained the field's concerns: "Whatever can cause, or help to cause, discomfort, pain, sickness, death, vice, or crime --- and whatever has a tendency to avert, destroy, or diminish such causes --- are matters of interest to the sanitarian."(3)
Despite this ambitious mandate, and despite the book's impressive length, A Treatise on Hygiene and Public Health had little to say about the issues that occupy today's public health professionals. There were no sections on smoking, alcoholism, drug abuse, obesity, vehicular accidents, mental illness, suicide, homicide, domestic violence, or unwanted pregnancy. Published in 1879, the book was instead concerned with things like compiling vital statistics; preventing the spread of disease; abating public nuisances; and assuring wholesome food, clean drinking water, and sanitary living conditions.
A century later, public health textbooks discuss the control of communicable diseases mainly as history. The field's present and future lie elsewhere. Principles of Community Health explains that "the entire spectrum of 'social ailments,' such as drug abuse, venereal disease, mental illness, suicide, and accidents, includes problems appropriate to public health activity....The greatest potential for improving the health of the American people is to be found in what they do and don't do to and for themselves. Individual decisions about diet, exercise, stress, and smoking are of critical importance."(4) Similarly, Introduction to Public Health notes that the field, which once "had much narrower interests," now "includes the social and behavioral aspects of life --- endangered by contemporary stresses, addictive diseases, and emotional instability."(5)
In the past, public health officials could argue that they were protecting people from external threats: carriers of contagious diseases, fumes from the local glue factory, contaminated water, food poisoning, dangerous quack remedies. By contrast, the new enemies of public health come from within; the aim is to protect people from themselves rather than each other.
In a sense, the change in focus is understandable. After all, Americans are not dying the way they once did. The chapter on infant mortality in A Treatise on Hygiene and Public Health reports that during the late 1860s and early 1870s two-fifths to one-half of children in major American cities died before reaching the age of 5.(6) The major killers included measles, scarlet fever, smallpox, diphtheria, whooping cough, bronchitis, pneumonia, tuberculosis, and "diarrheal diseases." Beginning in the 1870s, the discovery that infectious diseases were caused by specific microorganisms made it possible to control them through vaccination, antibiotics, better sanitation, water purification, and elimination of carriers such as rats and mosquitoes. At the same time, improvements in nutrition and living conditions increased resistance to infection.
Americans no longer live in terror of smallpox or cholera. Despite occasional outbreaks of infectious diseases such as rabies and tuberculosis, the fear of epidemics that was once an accepted part of life is virtually unknown. The one major exception is AIDS, which is not readily transmitted and remains largely confined to a few high-risk groups. For the most part, Americans are dying of things you can't catch: cancer, heart disease, trauma. Accordingly, public health specialists are focusing on those causes and the factors underlying them. Having vanquished most true epidemics, they have turned their attention to metaphorical "epidemics" of unhealthy behavior.
In 1979, Surgeon General Julius Richmond released Healthy People: The Surgeon General's Report on Health Promotion and Disease Prevention, which broke new ground by setting specific goals for reductions in mortality. "We are killing ourselves by our own careless habits," Secretary of Health, Education, and Welfare Joseph Califano wrote in the introduction. Califano called for "a second public health revolution" (the first being the triumph over infectious diseases). Healthy People, which estimated that "perhaps as much as half of the U.S. mortality in 1976 was due to unhealthy behavior or lifestyle," advised Americans to quit smoking, drink less, exercise more, fasten their seat belts, stop driving so fast, and cut down on fat, salt, and sugar. It also recommended motorcycle helmet laws and gun control to improve public health.(7)
Healthy People drew on a "national prevention strategy" developed by what is now the U.S. Centers for Disease Control and Prevention. Established during World War II as a unit of the U.S. Public Health Service charged with fighting malaria in the South, the CDC today includes seven different centers, only one of which deals with its original mission, the control of infectious disease.
The CDC's growth can be seen as a classic example of bureaucratic empire building. More generally, it is easy to dismiss public health's ever-expanding agenda as a bid for funding, power, and status. Yet the field's practitioners argue, with evident sincerity, that they are simply adapting to changing patterns of morbidity and mortality. In doing so, however, they are treating behavior as if it were a communicable disease, which obscures some important distinctions. Behavior cannot be transmitted to other people against their will. People do not choose to be sick, but they do choose to engage in risky behavior. The choice implies that the behavior, unlike a viral or bacterial infection, has value. It also implies that attempts to control the behavior will be resisted.
Healthy People noted that "formidable obstacles" stand in the way of improved public health. "Prominent among them," it said, "are individual attitudes toward the changes necessary for better health. Though opinion polls note greater interest in healthier lifestyles, many people remain apathetic and unmotivated....Some consider activities to promote health moralistic rather than scientific; still others are wary of measures which they feel may infringe on personal liberties. However, the scientific basis for suggested measures has grown so compelling, it is likely that such biases will begin to shift."(8) In other words, people engage in risky behavior because they don't know any better. Once they realize the risks they are taking, they will change their ways.
But what if they don't? Public health specialists are used to dictating from on high, because their field developed in response to deadly threats that spread from person to person and place to place. Writing in 1879, John Billings put it this way: "All admit that the State should extend special protection to those who are incapable of judging their own best interests, or of taking care of themselves, such as the insane, persons of feeble intellect, or children; and we have seen that in sanitary matters the public at large are thus incompetent."(9)
Billings was defending traditional public health measures aimed at preventing the spread of infectious diseases and controlling hazards such as toxic fumes. It's reasonable to expect that such measures will be welcomed by the intended beneficiaries, once they understand the aim. The same cannot be said of public health's new targets. Even after the public is informed about the relevant hazards (and assuming the information is accurate), many people will continue to smoke, drink, take illegal drugs, eat fatty foods, buy guns, eschew seat belts and motorcycle helmets, and otherwise behave in ways frowned upon by the public health establishment. This is not because they misunderstood; it's because, for the sake of pleasure, utility, or convenience, they are prepared to accept the risks. When public health experts assume these decisions are wrong, they are indeed treating adults like children.
The dangers of basing government policy on this attitude are clear, especially given the broad concerns of the public health movement. According to the textbook Public Health Administration and Practice, "public health is dedicated to the common attainment of the highest levels of physical, mental, and social well-being and longevity consistent with available knowledge and resources at a given time and place."(10) Principles of Community Health tells us that "the most widely accepted definition of individual health is that of the World Health Organization: 'Health is a state of complete physical, mental, and social well-being and not merely the absence of disease or infirmity.' "(11) A government empowered to maximize health, then, is a totalitarian government.
In response to such fears, the public health establishment argues that government intervention is justified because individual decisions about risk affect other people. "Motorcyclists often contend that helmet laws infringe on personal liberties," noted Healthy People, the 1979 surgeon general's report. "Opponents of mandatory [helmet] laws argue that since other people usually are not endangered, the individual motorcyclist should be allowed personal responsibility for risk. But the high cost of disabling and fatal injuries, the burden on families, and the demands on medical care resources are borne by society as a whole."(12) This line of reasoning, which is also used to justify taxes on tobacco and alcohol, implies that all resources --- including not just taxpayer-funded welfare and health care but private savings, insurance coverage, and charity --- are part of a common pool owned by "society as a whole" and guarded by the government.
As Robert Meenan, a professor at the University of California School of Medicine in San Francisco, noted in The New England Journal of Medicine two decades ago, "virtually all aspects of life style could be said to have an effect on the health or well-being of society, and the decision reached that personal health choices should be closely regulated."(13) Writing 18 years later in the same journal, Faith Fitzgerald, a professor at the University of California at Davis Medical Center, observed: "Both health care providers and the commonweal now have a vested interest in certain forms of behavior, previously considered a person's private business, if the behavior impairs a person's 'health.' Certain failures of self-care have become, in a sense, crimes against society, because society has to pay for their consequences."(14)
Most public health practitioners would presumably recoil at the full implications of the argument that government should override individual decisions affecting health because such decisions have an impact on "society as a whole." But some defenders of the public health movement have explicitly recognized that its aims are fundamen-tally collectivist and cannot be reconciled with the American tradition of limited government. In 1975, Dan E. Beauchamp, then an assistant professor of public health at the University of North Carolina, presented a paper at the annual meeting of the American Public Health Association in which he argued that "the radical individualism inherent in the market model" is the biggest obstacle to improving public health.
"The historic dream of public health that preventable death and disability ought to be minimized is a dream of social justice," Beauchamp said. "We are far from recognizing the principle that death and disability are collective problems and that all persons are entitled to health protection." He rejected "the ultimately arbitrary distinction between voluntary and involuntary hazards" and complained that "the primary duty to avert disease and injury still rests with the individual." Beauchamp called upon public health practitioners to challenge "the powerful sway market-justice holds over our imagination, granting fundamental freedom to all individuals to be left alone."(15)
Public health, in other words, is inconsistent with the right to be left alone. Of all the risk factors for disease or injury, it seems, freedom is the most pernicious.
1. Associated Press. Both sides vow a tough fight over tobacco. The New
York Times, April 13, 1998.
2. See, e.g., Feigelman W., Wallisch LS, Lesicur HR. Problem gamblers, problem substance users and dual-problem individuals: an epidemiological study. American Journal of Public Health 1998;88(3):467.
3. Buck AH (ed.) A Treatise on Hygiene and Public Health, New York, Arno Press, 1977 (originally published 1879), pp. 3-4.
4. Smolensky J. Principles of Community Health, Philadelphia, W.B. Saunders, 1977, p. iii.
5. Wilner DM, et al. Introduction to Public Health, New York, MacMillan, 1978, pp. 5-6.
6. Buck, op. cit., p. 269.
7. U.S. Department of Health, Education, and Welfare, Healthy People: The Surgeon General's Report on Health Promotion and Disease Prevention, U.S. Public Health Service, 1979, pp. 1-9.
8. Ibid., pp. 11-22.
9. Buck, op. cit., p. 38.
10. Hanlon JJ. Public Health Administration and Practice, St. Louis, Mosby, 1974.
11. Smolensky, op. cit., p. 5.
12. HEW, op. cit., pp. 9-20.
13. Meenan, RF. Improving the public's health: some further reflections. New Engl J Med 1976;294(1):45-46.
14. Fitzgerald FT. The tyranny of health. New Engl J Med 1994;331(3):196-198.
15. Beauchamp DE. Public health as social justice. Inquiry 1976;13(March):3-14.
Mr. Sullum, a senior editor at Reason magazine, is the author of For Your Own Good: The Anti-Smoking Crusade and the Tyranny of Public Health (The Free Press).
This article was published in the Medical Sentinel, Volume 4, Number 3, May/June 1999, pp. 100-102.